Brief discussion of inflammatory conditions of the urinary bladder from pathological point of view

1. Cystitis
The acute and chronic form
Made easy

3. THE CASE
• 55 yrs old poorly controlled diabetic
female presented with burning pain
at micturition , excessive need to
urinate but each time she goes , she
was passing only small amount of
cloudy coloured urine that has a fishy
odour

4. Case highlights
• 55 yrs old poorly contolled diabetic
female presented with burning pain
at micturition , excessive need to
urinate but each time she goes , she
was passing only small amount of
cloudy coloured urine that has a
fishy odour

5. So what to do
• Extended history
• Physical examination including the vital
signs ( fever , tachycardia ) and searching
for suprapubic tenderness
• Urinalysis to look for the microorganism
that caused the trouble
• Complete blood picture will reveal
leukocytosis
• Urine culture that takes a day or two

6. What can cause the trouble ?
• Bacterial cystitis :
1. E.coli
2. Proteus
3. Klebsiella
• Tuberculous cystitis
• Fungal cystitis ( candida albicans)
Immunesuppressed and those on long term ABCs
• Schistosomal cystitis
• Viruses , chlamydia , mycoplasma
• Other non infectious causes : drugs (cyclophosphamide)
and radiation ( radiation cystitis)

7. Predisposing factors5
• Urinary obstruction ( BPH , bladder calculi
and tumors )
• Cystocele or diverticula
• D.M
• Instrumentation
• Immune defeciency

8. Grossly , what to see ?
• Hyperemia of the mucosa
• Hemorrhagic cystitis : (after Radio,Chemo or Adeno)
• Suppurative cystitis : large amounts of suppurative
exudate
• Ulcerative cystitis : large mucosal ulcers and
sometimes ulceration of entire bladder mucosa !
• IF the infection persists Chronic cystitis that’s
seen as Red , Friable , Granular mucosa ANOTHER
association is the fibrosing thickening and inelasticity
of bladder wall

9. Post-radiotherapy hemorragic cystitis

10. Fibrous thickening of bladder wall

11. Microscopically there is :
• acute cystitis acute infammation
• chronic cystitis chronic inflammatory
cells ( ? ) with fibrosis
• two variants of
chronic cystitis :
1. Follicular cystitis
2. Eosinophilic cystitis

12. Schistosomal cystitis
• Caused by S. Hematobuim
• Eggs (by anastomosis) travel from sup. Rect. V.
to the veins of bladder wall , these eggs are
irritating so causing granulomatous cystitis
with eosinphilic infiltrate and fibrosis
• These granulomas are seen as minute
granules hence the name (sand grain cystitis)
• The eggs die and calcify

13. What are the complications ?
• extensive fibrosis ( that may impinge on
ureteric orifices to cause hydronephrosis
• CA bladder (squamous type) :
Schistosomal
cystitis
Squamous
metaplasia
Carcinoma

17. Special forms of cystitis
1. Interstitial cystitis (Hunner ulcer) :
• painful form of chronic cystitis (very painful)
• most frequently in women
• Cystoscopy shows : fissures and punctate
hemorrhages in the mucosa , sometimes with
chronic mucosal ulcers
• mast cell infiltrate is characteristic
• Maybe of autoimmune origin

19. Special forms of cystitis
2. Malakoplakia :
• Macroscopically : soft , yellow , slightly raised
mucosal plaques 3-4 cm in diameter
• Microscopically : infiltration by large foamy
macrophages with debris of bacterial origin
(E.coli)
• Michaelis – Gutmann bodies (laminated
mineralized concretions) are typically present
• Occurs in increased frequency in immune
suppressed transplant recipients

21. Special forms of cystitis
3. Polypoid cystitis :
• Results from irritation of bladder mucosa by
indwelling catheters
• Submucosal Edema causes broad , bulbous ,
polypoid projections

22. Review
• cystitis is either infectious or non infectious
• 5 predisposing factors for cystitis
• The acute form seen grossly : hyperemia,
hemorrhagic cystitis , suppurative cystitis and
ulcerative cystitis microscopically : acute
inflammation.
• The chronic form grossly : red , friable , granular
ulcerated mucosa, and fibrous thickening and
inelasticity of wall , microscopically : chronic cell
infiltrate and fibrosis

23. Review
• schistosomal cystitis : S. hematobium
• Eggs in the walls causing granulomas,
eosinophilic infiltrate, fibrosis
• granulomas look like sand grains
• 2 complications ( extensive fibrosis impenge
ureters causing hydronephosis , and squamous
metaplasia and carcinoma of bladder )