1. Non-malignant diseases of urinary bladder and urethra
Urologická klinika 3. LF UK a FNKV
Non-malignant diseases of urinary bladder and urethra
MUDr. Zuzana Kachlířová

2. Acute cystitis
Recurrent cystitis
Interstitial cystitis
Fistulas
Uretritis
Urethral strictures
Cystolithiasis

3. Acute cystitis

4. Acute cystitis
Infection of lower urinary tract, principally the bladder
More commonly in women than in men
Primarly mode: ascendent infection from the periurethral/vaginal and faecal flora
Diagnosis is made clinically

5. Presentation and findings
Irritative voiding symptoms – dysuria, frequency, urgency
Low back and suprapubic pain
Haematuria, cloudly/foul-smelling urine
Fever and systemic symptoms are rare
E. coli
Other gram-negative (klebsiella, proteus) or gram-positive (staph. saprophyticus, enterococci) pathogens

6. Risk factors
Diabetes mellitus
Lifetime history of UTI
Intercourse

7. Managemet Short course of oral antibiotics 3-5 days
Single dose therapy for treatment of recurrent cystitis less effective

8. Antibiotics TMP-SMX Nitrofurantoin Fluorochinolones
Penicillins and aminopenicillins not recommended (high resistance)

9. Recurrent cystitis

10. Recurrent cystitis
Caused either by bacterial persistence or reinfection with another organism
Bacterial persistence: removal of infected source
Reinfection:preventive therapy

11. Bacterial persistence
Suspected cause – radiological imaging indicated:
- US – screening evaluation of the genitourinary tract
- intravenous pyelogram
- cystoscopy
- CT

12. Frequent, recurrent UTI
Bacterial localisation studies
More extensive radiologic evaluation (retrograde pyelogram)
Evaluation for evidence of vesico-vaginal or vesico-enteric fistulas

13. Management Surgical removal of the infected source (urinary calculi)
Surgical repair of the fistula
Medical management with prophylactic antibiotics – reduce recurrence of UTI by 95%
Alternatively – intermittent self-start antibiotic therapy (in some women)
Relation to sexual intercourse – frequent emptying of the bladder + single-dose ATB

14. Alternatives to antibiotic therapy
Intravaginal estriol
Lactobacillus vagina suppositories
Cranberries / cranberry juice orally taken

15. Interstitial cystitis

16. Interstitial cystitis
Hunner´s ulcer, submucous fibrosis
Primarly a disease of middle-aged women
Characterised by fibrosis of the vesical wall with consequent loss of bladder capacity
Neuro-immuno-endocrine disorder
Principal symptoms: frequency, urgency, pelvic pain with bladder distension

17. Pathogenesis Urine usually normal
Fibrosis due to obstruction of vesical lymphatics secondary to infection or pelvic surgery
Or neuropathic origin
Endocrinologic factors suggested

18. Interstitial cystitis

19. Interstitial cystitis

20. Interstitial cystitis

21. Pathology
Primary change is fibrosis in the deeper layers of the bladder – muscle replaced by fibrous tissue
Mucosa is thinned
Small ulcers or cracks in the mucous membrane
Signs of inflammation
Normal mechanism of the UV-junction is destroyed - VUR
Hydroureteronephrosis and pyelonephritis may ensue

22. Clinical findings Symptoms Signs Laboratory findings X-ray findings
Instrumental examination

23. Symptoms of interstitial cystitis
Slowly progressive frequency and nocturia
History does not suggest infection
Suprapubic pain when bladder full
Pain experienced in urethra or perineum – relieved on voiding
Gross haematuria occasionally (following bladder overdistension)

24. Signs Physical examination usually normal
Tenderness in suprapubic area
Tenderness in the region of the bladder when palpated through the vagina

25. Laboratory findings Urine free of infection Microscopic haematuria
Renal function failure in vesical fibrosis and VUR

26. X-ray findings Excretory urogram – normal VUR
Cystogram: small capacity bladder, VUR

27. Instrumental examination
Cystoscopy
- increase suprapubic pain during the bladder fills
- vesical capacity may be as low as 60ml
- second hydrodistension: punctate haemorrhagic areas may appear, arcuate split in the mucosa, profusely bleeding
- difffuse mucosal changes
- congestion, edematous reaction, petechial haemorrhages
Biopsy

28. Differential diagnosis
TBC
Vesical ulcers due to schistosomiasis

29. Treatment NO definitive treatment
Hydraulic overdistension to improve the bladder capacity
Instillation of 50ml of 50% dimethyl sulfoxide (DMSO) intravesically for 15 minutes every 2 weeks
Vesical irrigation of 0,4% oxychlorosene sodium
Cortisone acetat or prednisone
Antihistamines
Heparine sodium
New treatments: resiniferotoxin, gene therapy, neuromodulation

30. Surgical treatment
In fibrotic bladder, small capacity, VUR, renal failure
- ceco- or ileocystoplasty to augment vesical capacity
- urinary diversion
Denervation by presacral and sacral neurectomy and perivesical procedures (cystolysis, cystoplasty, transvaginal neurotomy) – rarely of lasting benefit

31. Fistulas

32. Fistulas Vesico-vaginal Vesico-rectal Vesico-intestinal Vesico-adnexal
Urethro-vaginal
Urethro-scrotal
Urethro-rectal
Retrovesical

33. Vesical fistulas Common
Bladder may communicate with the skin, intestinal tract, female reproductive organs
Primary disease NOT urologic

34. Causes Primary intestinal disease - diverticulitis 50-60%
- colon cancer 20-25%
- Crohn disease 10%
Primary gynaecologic disease
- pressure necrosis during difficult labor
- cervix cancer
Treatment for gynaecologic disease
- hysterectomy
- low cesarean section
- radiotherapy for tumor
Trauma

35. Vesico-intestinal fistula
Symptoms: vesical irritability, passage of feces and gas through the urethra, change in bowel habits
Examination: barium enema, upper gastrointestinal series, sigmoidoscopy
Cystogram – gas in bladder or reflux into bowel
Cystoscopy
Cathetrisation of the fistulous tract

36. Vesico-intestinal fistula

37. Vesico-vaginal fistula
Relatively common
Secondary to obstetric, surgical or radiation injury or invasive cervix cancer
Constant leackage of urine
Pelvic examination
Cystoscopy
Vaginography

38. Vesico-vaginal fistula

39. Vesico-vaginal fistula

40. Treatment of fistulas Vesico-intestinal fistula - proximal colostomy
- resection of the bowel + closure of the blader
Vesico-vaginal fistula
- coagulation of the fistula
- indwelling catheter
- surgical repair through vagina or transvesically

41. Uretritis

42. Uretritis Infection / inflammation of the urethra 2 types:
- caused by Neisseria gonorrhoeae
- caused by other organisms (chlamydia trachomatis, ureaplasma urealyticum, trichomonas vaginalis)

43. Neisseria gonorrhoeae

44. Trichomonas vaginalis Chlamydia trachomatis

45. Symptoms Urethral discharge, dysuria
Obstructive voiding symptoms in recurrent infection
40% of gonococcal urethritis are asymptomatic

46. Findings Development of urethral strictures
Examination and culture of the urethra
30% of men infected with N. gonorrhoeae have concomitant infection with Chlamydia trachomatis

47. Management Pathogen-directed antibiotic therapy
- gonococcal: fluoroquinolones, norfloxacin
- non-gonococcal: tetracycline, erythromycine, doxycycline
Treatment of all sexual partners
Prevention !, protective sexual practices

48. Urethral strictures

49. Urethral strictures Congenital - uncommon in infant boys
- fossa navicularis, membranous urethra
Acquired
- common in men, rare in women
- due to infection or trauma
- long-term use of indwelling catheters

50. Urethral strictures
Fibrotic narrowings composed of dense collagen and fibroblasts
Fibrosis usually extends into the surrounding corpus spongiosum, causing spongiofibrosis
Narrowings restrict urine flow and cause dilatation of the proximal urethta and prostatic ducts

51. Symptoms and signs Initial complaints: frequency and mild dysuria
Decrease in urinary stream
Spraying or double stream
Postvoiding dribbling
Acute urinary retention
Palpable induration in the area of the stricture
Urethrocutaneous fistula
Chronic retention of urine – enlarged bladder

52. Examination Urethrogram
Voiding cystourethrogram – location and extent of the stricture
Ultrasonography
Urethroscopy

53. Urethral strictures

54. Urethral strictures

55. Differential diagnosis
Benign or malignant prostatic obstruction
Bladder neck contracture after prostatic surgery
Urethral carcinoma
Obstruction by a concrement or blood clot

56. Complications Chronic prostatitis Cystitis Chronic urinary infection
Diverticula
Urethrocutaneous fistula
Periurethral abscess
Urethral carcinoma
Vesical calculi due to chronic urine stasis
Detrusor-muscle hypertrophy
Hydronephrosis

57. Treatment Dilatation - lubrication of the urethra - silicone catheters
Urethrotomy under endoscopic direct vision
- sharp knife attached to an endoscope
- multiple incisions
Surgical reconstruction
- excision and primary anastomosis
- patch graft urethroplasty

58. Cystolithiasis

59. Cystolithiasis = bladder stones
Manifestation of an underlaying pathologic condition including voiding dysfunction or a foreign body
Voiding dysfunction due to:
Urethral stricture
BHP
Bladder neck contracture
Flaccid or spastic neurogenic bladder
Foreign bodies
- indwelling catheters
- forgotten double J-stents
- bladder erosion by a sling

60. Stone analysis
Ammonium urate
Uric acid
Calcium oxalate

61. Symptoms Irritative voiding Intermitent urinary stream
Urinary tract infection
Haematuria
Pelvic pain

62. Findings
Most of the stones are radiolucent
Ultrasound
Cystoscopy

63. Treatment Endoscopy - crushing - cystolitholapaxy
- electrohydraulic, ultrasonic, laser, pneumatic lithotripsy
Open surgery
- cystolithotomy

64. Cystolithiasis