Ureters
-muscular tubes
25-30cm long, 5-10mm diameter
-leading from renal pelvis to urinary bladder
1. mucosa
2. muscularis
3. adventitia
-not passive, peristaltic contraction of muscle layer propels the urine
Obstructive Lesions of Ureter: Intrinsic
- calculi (stones)
- strictures
- neoplasms
- blood clots
- neurogenic causes
- vesicoureteral reflux
Obstructive Lesions of Ureter: Extrinsic
- pregnancy
- periureteral inflammation
- sclerosing retroperitoneal fibrosis
- endometriosis
- neoplasms
Can pregnancy cause partial obstruction of the ureter?
yes
Hydronephrosis
- obstruction of ureter, results in obstruction is interruption of normal outflow of urine from renal pelvis which creates distention of pelvis and increased pressure on parenchyma of kidney
- results in hydronephrosis and possibly pyelonephritis
Periureteral Inflammation
- salpingitis
- diverticulitis
- peritonitis
- sclerosing retroperitoneal fibrosis
Salpingitis
-inflammation of fallopian tube
Diverticulitis
-inflammation of intestinal diverticulum and surrounding ttissues
Peritonitis
inflammation of peritoneum
sclerosing retroperitoneal fibrosis
- fibrous proliferative inflammatory process encasing retroperitoneal structures including ureter & causing compressing of ureter
- rare,middle-late age
- 70% no obvious cause (drugs, Crohn’s disease, malignant disease)
Cells of Urinary Bladder
- basal cell
- intermediate cell
- umbrella cell
- basement membrane
- subepithelial connective tissue (lamina propria)
Endometriosis
- presence of endometrial tissue (ectopic) outside of uterus
- found on surface of organs adjacent to uterus, fallopian tubes, ovaries; sometimes adj to ureters, urinary bladder or intestines
- tissue is functionally active, responds to stimulation by hormones
- proliferation followed by bleeding & scarring can cause ureter compression
Ureteritis Cystica
- may dev. as component of urinary tract infections
- sig. morphologic changes arise in longstanding ureteritis
- assumulation of lymphocytes in subepithelial region of ureter in chronic ureteritis may produce fine granularity of mucosa (ureteritis follicularis)
- cystica in which mucosa of ureter shows fine cysts (1-5mm) filled with clear yellow fluid
Congenital Anomalies of Ureters: Double
-usually accompanied by partial or complete duplication of renal pelvis
Congenital Anomalies of Ureters: Ureteropelvic Junction Obstruction
- usually present in infants/children, boys>girls, more on left
- abnormal organization of excess stromal depositison of collagen b/w smooth muscle bundles
- causes hydronephrosis
Congenital Anomalies of Ureters: Diverticula
- saccular outpouchings of ureteral wall (uncommon)
- appear as congenital/acquired (due to increased pressure secondary to obstruction of urine flow) important as pockets of stasis and secondary infection
Congenital Anomalies of Ureters
2-3% of all autopsies
Urinary Bladder: Congenital & Acquired Anomalies
- obstruction to the bladder neck
- diverticula
- exstrophy
- urachus
- cystocele
- vesicoureteral reflux
Urinary Bladder Anomalies Causes
- enlarged prostate
- cystocele of bladder
- post inflammatory fibrosis & contraction of bladder after varying types of cystitis
- bladder tumors
- sec. invasion of bladder neck by growths arising in perivesicule structures (cervix, vagina, prostate, rectum)
- mechanical obs. caused by calculi
- injury to innervation of bladder causing neurogenic or cord bladder
Diverticuli
- pouch-like evaginations of bladder wall
- sites of urinary stasis, with potential for infection
Congential Diverticuli
-caused by focal muscular defect
Acquired Diverticuli
- more common
- arise following persistent urethral obstruction
Exstrophy
- developmental defect of closure of anterior wall of the abdomen and the bladder so the bladder communicates with the exterior of the body through a large defect or open sac
- often associated with other abnormalities of GU tract
- increased incidence of malignancy (adenocarcinoma)
Urachus
-5-6cm vestigial structure located b/w apex of bladder and umbilicus
Cystocele
- protrusion of bladder into the vagina, creating a pouch
- caused by relaxation of pelvic support in females, leading to uterine prolapse (pulls bladder floor downward)
- frequently turn into bladder adenocarcinomas
Inflammations of Urinary Bladder
-acute/chronic cystitis
-special forms of cystitis
interstital cystitis (Hunner Ulcer)
malakoplaki
cystitis glandularis
cystitis cystica
Malakoplaki
- soft, yellow 3-4cm mucosal plaques composed of closely packed, large, foamy macrophages with occasional giant cells and interspersed lymphocytes
- macrophages contain PAS+ granules filled with bacterial debris
- Michaelis-Gutmann bodes: laminated mineralized concretions within and b/w macrophages
- most likely represents a defective host response to bacterial infections, usually from gram - bacilli
Bladder Tumors
- 95% in epithelial origin, rest are mesenchymal
- epithelial composed of urothelial (transitional) type
Most common to cause Cystitis?
-E coli.»_space;> then Proteus, Klebsiella, Enterobacter, TB, candida, cryptococcus, schistosoma, virus, chlamydia, mycoplasm - cytotoxic drugs, radiation, trauma
Cystitis Glandularis
- cysts are 0.1-1cm, filled with clear fluid, lined by cuboidal or urothelial cells
- MAY predispose to adenocarcinoma of bladder
Interstitial Cystitis
Hunner Ulcer -Persistent, Chronic Cystitis -most frequent in middle aged women feamale>male 10:1 -intermittent, severe suprapubic pain, urinary frequency, urgency, hematuria, dysuria without bacterial infection
Majority of Bladder Cancers
- high-grade
- most arise from the lateral or posterior walls at the bladder base, partial or complete ureteral obstruction commonly occures
- most >50, male to female 3:1
Squamous Carcinoma of the Bladder
-nonsmoker, Egyptian, Nile River Delta
Adenocarcinoma of Bladder
- rare (2% of primary bladder cancer)
- develops in setting of cystitis glandularis, exstrophy or in urachal remnant
- unlike TCC, solitary lesion
- generally deeply invasive
- like colon cancer (therapy?)
- poor prognosis
Non-gonococcal Urethritis
-E. coli, chlamydia, mycoplasm
Urethral Caruncle
tumor
-inflammatory lesion presenting as small, red, painful, friable mass about the external urethral meatus in female patient
-at any age, more common in later life
Histologically: highly vascular, young, fibroblastic connective tissue heavily infiltrated with leukocytes
Papillomas
tumor
- occur usually on the external meatus
- viral origin, similar to those affecting the vulva
Carcinoma of the urethra
tumor
- rare
- advanced age, women
- arises in external meatus or immediately surrounding structures, most of these are squamous cell carcinomas
- more aggressive than bladder cancers