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Non-malignant diseases of urinary bladder and urethra

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Presentation on theme: "Non-malignant diseases of urinary bladder and urethra"— Presentation transcript:

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

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