Inflammatory Bladder Lesions

Question 1

What is CCEG, and what causes it?

Answer 1

CCEG (Cystitis Cystica et Glandularis) is a chronic reaction in the bladder.
Often caused by bladder irritation from recurrent UTIs, tumors, stones, or outlet obstruction.
It forms single or multiple submucosal nodules in the bladder.

Question 2

What are the symptoms and common locations of CCEG?

Answer 2

Common in adults; can also occur in children.
Typical symptoms: irritative LUTS and hematuria.
Common locations: trigone, bladder neck, lateral bladder walls, posterior urethra.

Question 3

Is CCEG associated with urothelial malignancy, and what’s the follow-up?

Answer 3

Unclear association with malignancy; retrospective reviews indicate higher risk.
Cystoscopic follow-up recommended, but timing and duration are unclear.
Continued surveillance if bladder irritation is ongoing.

Question 4

What are the treatment options for CCEG?

Answer 4

Remove the source of irritation.
Administer antibiotics, nonsteroidal anti-inflammatory drugs, steroid pulse therapy, antihistamines.
Transurethral resection and fulguration for symptomatic lesions.
Newer therapies like sodium hyaluronate.

Question 5

What is the mechanism of action of sodium hyaluronate in treating CCEG?

Answer 5

Sodium hyaluronate repopulates the glycosaminoglycans layer (GAG) of the urothelium.
In animal models, shown to block the effects of interleukin-6 (IL-6) and downregulate the JAK2/Stat3 pathway.
Leads to decreased inflammation and helps resolve CCEG.

Question 6

What is EC, and what does it look like?

Answer 6

EC presents as diffuse inflammation or pseudotumor (20% of cases).
Lesions appear inflammatory, edematous, ulcerated, or necrotic.
Characterized by inflammation of the lamina propria with eosinophilic component.
Common mutation: BRAF mutation; potential serum marker.

Question 7

Who does EC affect, and what are the symptoms?

Answer 7

Rare disease; around 200 cases described.
Affects children/young women and middle-aged men.
Symptoms: hematuria and irritative LUTS.
May show hydronephrosis on imaging; bladder lesions or wall thickening.

Question 8

What are the treatment options for EC?

Answer 8

Diffuse EC: oral corticosteroids, nonsteroidal anti-inflammatory drugs, antihistamines, azathioprine.
Pseudotumoral form requires different protocols; removal of allergens.
Transurethral resection or cystectomy in refractory cases.
Successful therapy with benralizamab, an interleukin-5 inhibitor.

Question 9

What is Polypoid Cystitis, and what causes it?

Answer 9

Polypoid Cystitis is an inflammatory reaction to bladder injury.
Typical causes: indwelling catheters, stones, fistulae, pelvic abscess, or bladder outlet obstruction.
Lesions appear papillary, broad, and edematous; can be large (up to 6 cm).
Microscopically lacks complex branching and true fibrovascular cores; may show urothelial hyperplasia, inflammation, and reactive atypia.

Question 10

Who does Polypoid Cystitis affect, and what are the symptoms?

Answer 10

No specific age preference; reported even in neonates.
More common in males; often linked to a history of catheterization.
Symptoms may include irritative LUTS or hematuria.
Imaging may show a bladder mass; hydronephrosis/ureteral obstruction described.

Question 11

What are the treatment options for Polypoid Cystitis?

Answer 11

Treatment usually involves transurethral resection of the mass.
Treatment of the underlying condition, if possible.
Short-term corticosteroids have been used successfully.

Question 12

What is HL IC, and what does it look like?

Answer 12

HL IC presents as a reddened area with small vessels radiating toward a central scar.
Two categories: inflamed (friable, red) and noninflamed (white, scarred).
Microscopically shows ulceration, inflammation, granulation, fibrosis, edema, and mast cell infiltrate.
Associated with higher urinary levels of pro-inflammatory cytokines and nitric oxide.

Question 13

Who does HL IC affect, and what are the symptoms?

Answer 13

Mostly affects females; 5%–57% of patients with interstitial cystitis have HL variant.
Symptoms: older age, more frequency, reduced bladder capacity, sharp and stabbing pain.
Co-existence with autoimmune disorders like Sjogren’s syndrome, lupus, rheumatoid arthritis.
Larger lesions correlate with worse symptoms.

Question 14

What are the treatment options for HL IC?

Answer 14

Responds well to endoscopic treatments: triamcinolone injection, fulguration.
Hydrodistension recommended to delineate lesion borders.
Up to 90% have symptom relief; 40% lasting up to 3 years.
Oral cyclosporine A effective; nitric oxide pathway may offer a new treatment.
Rarely, urinary diversion needed; risks include bladder perforation (rare).

Question 15

What is Polyomavirus Cystitis, and what does it look like?

Answer 15

Polyomavirus Cystitis is linked to urothelial lining damage by oncologic conditioning regimens.
Microscopically shows urothelial cells with viral inclusions; “decoy cells” can mimic urothelial carcinoma.
May lead to denuding of urothelium, inflammation, and hemorrhage.
Cystoscopically shows diffusely inflamed bladder with hemorrhage and erosion.

Question 16

Who does Polyomavirus Cystitis affect, and what are the symptoms?

Answer 16

BK virus is one type; seroprevalence rates of 80%–90% by adulthood.
Reactivated in 2%–66% of patients receiving allogeneic hematopoietic stem cell transplant.
Mean time to cystitis after transplantation: 34 days.
Symptoms: gross hematuria, bladder/pelvic pain, viruria; may increase mortality risk.

Question 17

What are the treatment options for Polyomavirus Cystitis?

Answer 17

Prevention: hyperhydration; fluoroquinolones as prophylaxis (last resort).
Treatment for gross hematuria: continuous bladder irrigation (not reducing risk).
Successful use of Cidofovir, hyperbaric oxygen, intravenous leflunomide, vidarabine, topical hemostatic agents, factor VIII concentrate, estrogens.
Cystectomy is rare; reduction in immunosuppressive meds not shown to improve.

Question 18

What is Malakoplakia, and what does it look like?

Answer 18

Malakoplakia: yellow to tan plaque, later grey/tan with central depression.
Associated with poor bacterial phagocytosis; multiple bacteria associated.
Microscopically shows histiocytes (von Hansemann cells), Michaelis-Guttman bodies.
May be mistaken for or accompany transitional cell carcinoma.

Question 19

Who does Malakoplakia affect, and what are the symptoms?

Answer 19

Male-to-female ratio 1:4; often in immunosuppressed individuals.
Can involve any organ of the genitourinary tract; symptoms include bladder pain, urgency, frequency, flank pain.
Associated with autoimmune disorders, neoplastic processes, tuberculosis, alcohol abuse, diabetes, ulcerative colitis, malnutrition.
Can cause hydronephrosis and renal failure.

Question 20

What are the treatment options for Malakoplakia?

Answer 20

Treatment depends on extent; hydronephrosis addressed with stents or nephrostomy drainage.
Bladder lesion needs biopsy and resection if possible.
Medical management with antibiotics like quinolones and sulfonamides.
Long-term use of fluoroquinolones with caution; minimize immunosuppression if possible.

Question 21

What is Nephrogenic Adenoma, and what does it look like?

Answer 21

Relatively rare lesion from renal cells implanting in the bladder.
Cystoscopically, appears papillary; can be confused for urothelial carcinoma.
Microscopically shows cuboidal/flat epithelial cells; can mimic prostatic adenocarcinoma.
Immunoreactive for cytokeratin, PAX-2, PAX-8; low proliferation rate.

Question 22

Who does Nephrogenic Adenoma affect, and what are the symptoms?

Answer 22

More common in males (2:1, male:female).
Symptoms include hematuria and/or LUTS.
Risk factors: prior bacillus Calmette-Guérin therapy, recurrent UTI, chronic catheterization.
Most commonly affects bladder neck, urethra, ureter, renal pelvis.

Question 23

What are the treatment options for Nephrogenic Adenoma?

Answer 23

Treatment: surgical (transurethral resection, cystectomy, diverticulectomy).
Sodium hyaluronate used for multifocal disease, decreasing bladder inflammation.
Benign but has a 3%–67% recurrence rate; surveillance cystoscopy recommended.
Urine cytology used for surveillance, depending on PAX-8 staining.

Question 24

What is Follicular Cystitis, and what are its characteristics?

Answer 24

Unknown cause but associated with inflammatory conditions and infections.
Cystoscopically appears flat, papillary, nodular, erythematous, velvety.
Microscopically shows lymphoid aggregates with germinal centers in bladder lamina propria.

Question 25

Who is affected by Follicular Cystitis, and what are the symptoms?

Answer 25

More common in women over 50.
Symptoms: frequent urination, dysuria, hematuria, recurrent UTI.
Risk factors: bladder stones, bladder malignancy, history of bacillus Calmette-Guérin therapy.
Urine cytology may reveal lymphocytic aggregates.

Question 26

What are the treatment options for Follicular Cystitis?

Answer 26

Treatment: removal of infectious or inflammatory processes.
Long-term suppressive antibiotics or urinary antisepsis; anti-inflammatory meds, corticosteroids, vitamin A.
Other treatments: diethylcarbamazine, pentosan polysulfate sodium, dimethyl sulfoxide, amitriptyline, duloxetine, radiotherapy.
For bulky disease: transurethral resection or palliative cystectomy.