Bladder Disease

Question 1

Describe ways men and women differ in terms of bladder anatomy?

Answer 1

men - longer urethra, prostate

women - short urethra, no prostate

Question 2

What’s the bottom part of the bladder called? Upper part?

Answer 2

lower = trigone
upper = dome

Question 3

WHat are urinary diverticula?

Answer 3

outpouchings of the bladder due to increased pressure pushing urine out into weak parts of the wall near where the vessels or ureters leave

Question 4

What cyst can form in the dome of the bladder?

Answer 4

if a urachus remains patent after birth, you can get a urachal cyst

Question 5

What’s the cancer concern with the a urachal cyst?

Answer 5

20-40% will have adenocarcinoma

Question 6

What happens when there’s failure of development of the anterior abdominal wall?

Answer 6

exstrophy of the bladder

Question 7

What cancer is associated with exstrophy of the bladder?

Answer 7

adenocarcinoma again

Question 8

What type of tissue is an adenocarcinoma made of? Why is this unusual in the bladder?

Answer 8

it’s made of glandular mucosa - unusual because the bladder is transitilonal epithelia

Question 9

Are diverticula of the bladder more often congenital or acquired?

Answer 9

acquired

Question 10

What is a common cause of diverticuli?

Answer 10

benign prostatic hypertrophy increases the pressure in the bladder, promoting the formation of diverticula

Question 11

What happens to the wall of the bladder with benign prostatic hypertrophsy?

Answer 11

the wall gets a trabeculated appearance due to pressure-induced hypertrophy

Question 12

What two things can form in diverticula that will be hard to see on cytoscopy?

Answer 12

bladder stones or carcinoma

Question 13

There are tons of things that can predispose to bladder inflammation. One is a fistula. Where do fistulas often form from?

Answer 13

the colon and the rectum

Question 14

What is a very common cause of a colon-bladder fistula?

Answer 14

Crohn’s disease

the inflammation goes right through the wall of the colon into the bladder and the fibrosis that occurs afterwards forms a fistula

Question 15

What is a cystocele and who is most likely to get them?

Answer 15

It’s when the bladder gets pushed down (along with the rectum) by a prolapsing uterus

most common in multi-partum women starting around age 50

Question 16

What is the symptom triad for cystitis?

Answer 16

frequency
pain
dysuria

Question 17

What is an important systemic effect of cystitis in the elderly population that doesn’t really occur in the young?

Answer 17

altered mentation

Question 18

What are some other infectious causes of cystitic other than e coli, proteus or enterococcus that this guy talked about?

Answer 18

fungal: candida, cryptococcus (in immunosuppressed or post ABx)

chlamydia

mycoplasma

Question 19

What are three causes of non-infectious cystitis?

Answer 19

radiation
chemotherapy agents - esp cyclophosphamide
interstitial cystitis (hunner ulcer)

Question 20

How do acute and chronic cystitic differ pathologically?

Answer 20

acute - PMNs with suppurative exudate

chronic - lyphocyte hyperemia, epithelial hyperplasia, fibrosis, may be follicular or eosinophilic

Question 21

What are the three thgins that can cause hemorrhagic cystitis?

Answer 21

radiation
chemo drugs - cyclosphophamide
adenovirus

Question 22

What is a Hunner Ulcer and who gets them

Answer 22

it’s a persistent and very painful full thickness inflammation with fibrosis and fissures

more in women

Question 23

what is the likely cause of a hunner ulcer?

Answer 23

probably autoimmune but we’re not sure

Question 24

What is cystitis glandularis?

Answer 24

when the inflammation from cystitis induced metaplasic changes from transitional epithelia to glandular mucosa

Question 25

What is malacoplaki? WHat's it usually in response to?

Answer 25

when you get formation of soft yellow raised plaques in the bladder - usually in response to E coli and proteus

Question 26

What cells will you see with malacoplakia? How do they form?

Answer 26

Michaelis-Gutman bodies - they're macrophages that have an abnormality in their lysosomal enzymes so the e coli and proteus they gobble up don't get broken down and they calcify within the lysosome. it makes the cell look like a bullseye.

Question 27

What is cystitis cystica?

Answer 27

Sometimes instead of glandular metaplasia you just see cysts forming in the mucosa

Question 28

What is by far the most common bladder neoplasm?

Answer 28

transistional cell carcinoma | others rarely: squamous cell carc, adenocarc, sarcoma, papillomas

Question 29

Who is the most likely person to get a bladder cancer? WHY?

Answer 29

male aged 50-80 living in an urban setting because they're more likely to smoke! Tobacco is the number 1 contributor to bladder cancer

Question 30

Where in the bladder do you see transitional cell carcinoma?

Answer 30

trick question - the whole uroepithelial lining is predisposed in a high risk patient, so they can be anywhere from the renal pelvis down to the urethra

Question 31

Which is better to have: a papillary type or sessile type?

Answer 31

papillary! A sessile type is much more likely to infiltrate and metastasize

Question 32

Besides tobacco use, what are some other factors that can contribute to bladder neoplasia?

Answer 32

aromatic amines/azo dyes like aniline dye from the rubber industry chronic shistosomiasis in Africa long term analgesic use long term cytoxan exposure possibly saccharin sweetener

Question 33

WHat are the common symptoms of bladder neoplasia?

Answer 33

some will have fequency and dysuria only 15% will have painless gross hematuria

Question 34

Otherwise unexplained gross hematuria in a patient over 40 is what until proven otherwise?

Answer 34

urothelial carcinoma

Question 35

What are some ways to evaluate a hematuria?

Answer 35

1. urinalysis 2. cytourethroscopy 3. urinary cytology (beter for high grade carcinoma than low grade) 4. evaluatoin of upper tracts with IV pyelogram with US or helical CT with urography

Question 36

How do you grade transitional cell carcinoma?

Answer 36

Grade 1 - some cytologic and arch. atypia, but closely resemble normal trans. cells grade 2 - still recognizable as transitional cells, but with mitoses and great loss of polarity grade 3 - hard to tell they were ever transitional - disarray, loosening, fragmentation, mitoses, nuclear pleomorphism, tumor giant cells

Question 37

How do you stage a bladder cancer?

Answer 37

``` Ta - papillary in mucosa TIS - flat in mucosa (worse) T1 - invades lamina propria T2a- invades superficial muscle T2b - invades deep muscle T3 - invades perivesical fat T4 - invades adjacent structures - through the bladder completely ```

Question 38

What does N1, N2 and N3 mean for stagin bladder cancer?

Answer 38

Affecting nodes or not? N1 is less than 2 cm N2 is 2-5 cm N3 is over 5 cm

Question 39

What does M1 mean for staging bladder cancer?

Answer 39

has distant metastases

Question 40

What is the most important factor in determining prognosis for bladder cancer?

Answer 40

``` stage Ta - 5 yr survival 90% T2 - 80% 5ys T3- 50-60% 5ys M1 - less than 10% 5ys ```

Question 41

What is the treamtnet for a low stage transistional cell carcinoma?

Answer 41

transurethral resection fulguration (cauterize the base) intravesicular BCG to induce an inflammatory response for 6 weeks

Question 42

What is the treatment of a high stage T2/T3?

Answer 42

cystectomy with node dissection little benefit form post-surgical chemo

Question 43

What is the treatment of a high stage/metastatic in a non-surgical patient?

Answer 43

chemotherapy - gemcitabine, cisplatin, methotraxate, vinblast, adriamycin ,cytoxan

Question 44

Is screening reommended for bladder cancer in asymptomatic adults?

Answer 44

nope

Question 45

What are the surveillance recommendations after a TURBT with or without BCG?

Answer 45

urine cytology and cytoscopy 3 months afterwards periodic screening thereafter every 3-6 months

Question 46

What is the general prognosis for a squamous cell carcinoma of the bladder and why?

Answer 46

70% 1year mortality! Terrible! because they ofen cover a large area and are already deeply invasive at diagnosis

Question 47

Again, what will predispose a bladder to adenocarcinoma?

Answer 47

urachal remnants or glandular metaplasia from chronic inflammation

Question 48

Chronic shistosomiasis predisposes you to what cancer of the bladder? Why?

Answer 48

squamous cell - the shisto will penetrate the skin from contaminated water and enter venous circulation. it sets up shop in the portal system and the eggs are deposited in the wall of the bladder. cause a HUGE inflammation that sets up the milieu for squamous cancer down the line.

Question 49

What are some common bacteria that cause urethritis?

Answer 49

neiseeria gonorrhea chlamydia (M>F) E coli and other enterics

Question 50

What are the symptoms of urethritis?

Answer 50

pain, itchiness, frequency

Question 51

What are two benign neoplasia or the urethra?

Answer 51

caruncles and papillomas

Question 52

Who gets caruncles? What are they like?

Answer 52

females | red painful mass about 102 m in size at the urethral meatus

Question 53

What is a papilloma associated with?

Answer 53

HPV

Question 54

What is the most common malignant urethral neoplasia? Who gets it?

Answer 54

squamous cell carcinoma elderly women