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Flashcards in Lower urinary tract Deck (27):
1

Ureter Congenital Anomalies

-Double and Bifed ureters

-Ureteropelvic junction (UPJ) obstruction
Most common cause of hydronephrosis in infants and children
1 in 500 live births
20% bilateral

-Diverticula

2

Ureteropelvic Junction Obstruction (UPJ)

Most cases are thought to be due to partial obstruction, because complete obstruction results in rapid destruction of the kidney

symptoms might include:

Abdominal mass
Urinary tract infection with fever
Kidney infection
Back or flank pain
Bloody urine
Vomiting

3

Inflammation of the Ureter

Ureteritis, though associated with inflammation, is typically not associated with infection and is of little clinical consequence.

4

Tumors of the Ureters

Primary tumors of the ureter are rare
- Fibroepithelial polyp (Benign mesenchymal neoplasm)

* Urothelial carcinoma (Majority of ureter malignant tumors)
6th – 7th decades
Multifocal (dysplasia – carcinoma-in-situ field effect)
Associated bladder or renal pelvis neoplasms

5

Obstructive Lesions of the Ureters

- Obstruction of the ureter can lead to hydroureter, hydronephrosis and pyelonephritis

-Unilateral obstruction typically results from proximal causes

- Bilateral obstruction typically arises from distal causes such as prostatic hyperplasia

6

Sclerosing Retroperitoneal Fibrosis

Fibrosis encasing the retroperitoneal structures occurring in middle to late age
Associated with IgG4 related disease (Rich in IgG4 secreting plasma cells)
Multifocal fibroinflammatory disorder
Ergot alkaloids (methysergide for migraine headaches, vasoconstriction)
Crohn’s disease
Malignancies (lymphomas)
*** Most have no obvious cause (Idiopathic)

7

Key Concepts: Disorders of the Ureters

Ureteral obstruction is clinically significant because it can subsequently involve the kidney (hydronephrosis or even pyelonephritis), compromising renal function.

In children, congenital ureteropelvic junction (UPJ) obstruction is the most common obstructive lesion in the ureter.

In adults, ureteral obstruction may be acute (e.g., due to obstructing calculi), or chronic (e.g., due to intrinsic or extrinsic tumors or rarely idiopathic conditions such as sclerosing retroperitoneal fibrosis).

8

Urinary Bladder Congenital Anomalies

Vesicoureteral reflux
- Most common and clinically significant anomaly

Diverticula
- Congenital or Acquired

Exstrophy
- Failure of anterior abdominal wall and bladder development with herniation of urinary bladder through abdominal wall defect

- Urachal anomalies
Urachus persists --> fistula between bladder and umbilicus
***vIncreased risk for bladder adenocarcinoma

9

Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is a condition in which urine from the bladder has retrograde flow back into the ureter and kidney, usually related to “valve” malfunction.

Most commonly diagnosed in infancy/childhood. About 1/3 of children with recurrent UTI are found to have VUR.

The likelihood of vesicoureteral reflux is related to the length of the ureteral tunnel in the bladder.

10

Urinary Bladder Diverticula

A pouchlike evagination of the bladder wall
May arise as congenital anomalies but more commonly are acquired due to persistent urethral obstruction
Congenital form may be due to a focal failure of development of the normal musculature or to some urinary tract obstruction during fetal development
Acquired form most often seen with prostatic enlargement producing obstruction to urine outflow and thickening of the bladder wall

11

Bladder Exstrophy

A developmental failure in the anterior wall of the abdomen and the bladder. The latter either projects directly through a large defect to the body surface or lies as an unopened sac. M=F, W>>B

Exposed mucosa may undergo colonic glandular metaplasia and is subject to infections that can spread to the upper GU tract

Patients have an increased risk of adenocarcinoma arising in the bladder remnant

12

Patent Urachus/Urachal Cysts

Urachus (the canal that connects the fetal bladder with the allantois) is normally obliterated after birth, but it sometimes remains patent in part or in whole

Fistula  connecting the bladder with the umbilicus

Central region of the Urachus persists, giving rise to Urachal Cysts

Urachal cysts lined by metaplastic glandular epithelium can give rise to adenocarcinoma

13

Interpretation of Negative Urine Cultures

Urine is usually sterile. However, contamination with urethral, vaginal or skin flora at the time of collection, and growth of organisms prior to plating, are always concerns (false positive)
Negative – No/few organisms present: Usually indicates that bacterial cystitis is unlikely.***

*** Exceptions include:
Patients on antimicrobial therapy when culture obtained
Patients with mycobacterial or other unusual infectious cystitidies


14

Interpretation of positive urine cultures

Positive - Clinical interpretation of urine culture isolates depends on:
Specimen Collection Method & Handling: mid-stream clean catch, supra-pubic, etc.
Number of Isolates: Multiple organisms are rarely the cause of cystitis except in patients with chronic indwelling catheters or abnormalities of the urinary tract.
Specific Organisms: Escherichia coli & other coliforms make up 75-90%
Quantity: The dogma > 105 bacteria/mL as evidence of bacterial cystitis has been broadened in recent years.

15

Acute Cystitis predisposing factors

Bladder calculi
Urinary obstruction/structural abnormalities
Diabetes mellitus
Instrumentation
Immune deficiency
Institutionalization or hospitalization

16

Bladder InflammationAcute and Chronic Cystitis

Urinary tract infections are considered to be the most common bacterial infection
Bacteria that generally ascend from the rectal reservoir may cause urinary tract infections
More common in younger women than younger men (30:1)
Clinical manifestations can vary from
Asymptomatic
* Frequency
* Lower abdominal pain
* Dysuria (pain/burning on urination)

17

Uncommon Important Causes of Infectious Cystitis

Tuberculosis cystitis (Mycobacterium tuberculosis)
Fungal cystitis (Candida albicans)
Viral cystitis (Immunocompromised and children)
- BK polyomavavirus
- Adenovirus

Parasite cystitis
- Schistosomiasis

18

Tuberculosis Cystitis

From pulmonary focus, bacillemia leads to bacillus implantation in other organs
Latent period between pulmonary infection and clinical urogenital tuberculosis is 22 years on average
Mycobacterium tuberculosis is an acid-fast aerobic bacillus
Granulomatous inflammatory reaction

19

Fungal Cystitis

Most fungal cystitis occurs in debilitated patients or those receiving antibiotic therapy.

Many patients are diabetic, and most are women.

Most caused by candida albicans

20

Viral Cystitis

Uncommon in immunocompetent adults and children
Adenovirus most common but rare cause of hemorrhagic cystitis in healthy child
Adenovirus, cytomegalovirus, and polyomaviruses (BK, JC) may cause cystitis in children who have undergone hematopoietic cell or solid organ transplant (immunosuppressed)

21

Schistosomiasis Cystitis

Schistosomiasis is the fourth most prevalent disease in the world and the leading cause of hematuria

In humans, the trematode Schistosoma haematobium commonly resides in the paravesical veins and causes urinary schistosomiasis, which also is known as bilharziasis

Process begins with the deposition of eggs in small veins and venule -> bladder wall --> produce a granulomatous response

22

Polypoid Cystitis

Nonspecific mucosal reaction secondary to chronically inflamed bladder
Seen commonly in patients with indwelling catheter and vesical fistula
Reactive process with inflamed background and urothelium of normal thickness
Mimic papillary urothelial neoplasms

23

Interstitial cystitisChronic Pelvic Pain Syndrome

90% of patients are women (middle and old age)
Urinary frequency, urgency and pelvic pain of unknown etiology
Nonspecific histologic findings
Diffusely reddened mucosa often associated with one or more ulcerative patches (Hunner ulcer)
Chronic condition with variable course and no effective treatment

histologic findings: There is a dense infiltrate of lymphocytes, mast cells and plasma cells

24

Eosinophilic Cystitis

Infiltration of ** all layers ** of the urinary bladder wall with numerous eosinophils
Urinary frequency, dysuria, hematuria and suprapubic pain
Cystoscopic examination appearance is variable with ulcers, exudates, edematous bullae, or polyps.
Diagnosis confirmed by biopsy
Associated with a variety of systemic triggers (food allergens, systemic allergy, allergic gastroenteritis, parasites, systemic drugs and prior transurethral resection)
Nonsteroidal anti-inflammatory agents, steroids, cyclosporine may help

25

Malakoplakia (Chronic Cystitis)

* Chronic inflammatory reaction that can occur in any organ particularly common in GU tract in response to gram-negative coliforms (E. coli)
Distinctive histology with abundant macrophages filled with undigested bacterial products (defective phagocytosis) **
Associated with immunosuppression (HIV, renal transplant)
Treatment can involve antibiotics and/or surgery
** Michaelis-Gutmann body- calcium laminated phagolysosomes

26

Metaplastic Lesions

Cystitis glandularis and cystitis cystica


Non-keratinizing squamous metaplasia

Keratinizing squamous metaplasia
- ***Associated with schistosomiasis and squamous cell carcinoma

Nephrogenic adenoma

27

Nephrogenic Adenoma

Results from implantation of shed renal tubular cells
90% are found in adults (most incidental)
66% less than 1 cm; 25% 1-4 cm

Sometimes can be confused with bladder carcinoma