Non-malignant diseases of urinary bladder and urethra
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Transcript 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
Acute cystitis
Recurrent cystitis
Interstitial cystitis
Fistulas
Uretritis
Urethral strictures
Cystolithiasis
Acute cystitis
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
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
Risk factors
Diabetes mellitus
Lifetime history of UTI
Intercourse
Managemet
Short course of oral antibiotics
3-5 days
Single dose therapy for treatment of
recurrent cystitis less effective
Antibiotics
TMP-SMX
Nitrofurantoin
Fluorochinolones
Penicillins and aminopenicillins not
recommended (high resistance)
Recurrent cystitis
Recurrent cystitis
Caused either by bacterial persistence or
reinfection with another organism
Bacterial persistence: removal of infected
source
Reinfection:preventive therapy
Bacterial persistence
Suspected cause – radiological imaging
indicated:
- US – screening evaluation of the
genitourinary tract
- intravenous pyelogram
- cystoscopy
- CT
Frequent, recurrent UTI
Bacterial localisation studies
More extensive radiologic evaluation
(retrograde pyelogram)
Evaluation for evidence of vesico-vaginal or
vesico-enteric fistulas
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
Alternatives to antibiotic therapy
Intravaginal estriol
Lactobacillus vagina suppositories
Cranberries / cranberry juice orally taken
Interstitial cystitis
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
Pathogenesis
Urine usually normal
Fibrosis due to obstruction of vesical
lymphatics secondary to infection or pelvic
surgery
Or neuropathic origin
Endocrinologic factors suggested
Interstitial cystitis
Interstitial cystitis
Interstitial cystitis
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
Clinical findings
Symptoms
Signs
Laboratory findings
X-ray findings
Instrumental examination
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)
Signs
Physical examination usually normal
Tenderness in suprapubic area
Tenderness in the region of the bladder
when palpated through the vagina
Laboratory findings
Urine free of infection
Microscopic haematuria
Renal function failure in vesical fibrosis and
VUR
X-ray findings
Excretory urogram – normal
VUR
Cystogram: small capacity bladder, VUR
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
Differential diagnosis
TBC
Vesical ulcers due to schistosomiasis
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
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
Fistulas
Fistulas
Vesico-vaginal
Vesico-rectal
Vesico-intestinal
Vesico-adnexal
Urethro-vaginal
Urethro-scrotal
Urethro-rectal
Retrovesical
Vesical fistulas
Common
Bladder may communicate with the skin,
intestinal tract, female reproductive organs
Primary disease NOT urologic
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
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
Vesico-intestinal fistula
Vesico-vaginal fistula
Relatively common
Secondary to obstetric, surgical or radiation
injury or invasive cervix cancer
Constant leackage of urine
Pelvic examination
Cystoscopy
Vaginography
Vesico-vaginal fistula
Vesico-vaginal fistula
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
Uretritis
Uretritis
Infection / inflammation of the urethra
2 types:
- caused by Neisseria gonorrhoeae
- caused by other organisms (chlamydia
trachomatis, ureaplasma urealyticum,
trichomonas vaginalis)
Neisseria gonorrhoeae
Trichomonas vaginalis
Chlamydia trachomatis
Symptoms
Urethral discharge, dysuria
Obstructive voiding symptoms in recurrent
infection
40% of gonococcal urethritis are
asymptomatic
Findings
Development of urethral strictures
Examination and culture of the urethra
30% of men infected with N. gonorrhoeae
have concomitant infection with Chlamydia
trachomatis
Management
Pathogen-directed antibiotic therapy
- gonococcal: fluoroquinolones, norfloxacin
- non-gonococcal: tetracycline, erythromycine,
doxycycline
Treatment of all sexual partners
Prevention !, protective sexual practices
Urethral strictures
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
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
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
Examination
Urethrogram
Voiding cystourethrogram – location and
extent of the stricture
Ultrasonography
Urethroscopy
Urethral strictures
Urethral strictures
Differential diagnosis
Benign or malignant prostatic obstruction
Bladder neck contracture after prostatic
surgery
Urethral carcinoma
Obstruction by a concrement or blood clot
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
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
Cystolithiasis
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
Stone analysis
Ammonium urate
Uric acid
Calcium oxalate
Symptoms
Irritative voiding
Intermitent urinary stream
Urinary tract infection
Haematuria
Pelvic pain
Findings
Most of the stones are radiolucent
Ultrasound
Cystoscopy
Treatment
Endoscopy
- crushing
- cystolitholapaxy
- electrohydraulic, ultrasonic, laser,
pneumatic lithotripsy
Open surgery
- cystolithotomy
Cystolithiasis