Subject: Pathology Topic: Diseases of Lower Urinary Tract Lecturer: Dra.

Cagampan Date of Lecture: January 30, 2012 Transcriptionist: Gluttonoids Editor: Gluttonoids Pages: 4

DISEASEs OF THE LOWER URINARY TRACT

Lower Urinary Tract:
Ureters Urinary Bladder Urethra

Congenital hydroureter reflect some neurogenic defect in the inndervation of the ureteral musculature Makes ureter more prone to kinking and obstruction

URETERS
I. CONGENITAL ANOMALIES (2%-3%)
Main Significance: may contribute to obstruction

1. Double Ureters or Bifid Ureters:

Associated with totally distinct double renal pelvis or a large kidney with bifid terminating in separate ureters. Usually joined within the bladder with a single ureteral orifice No clinical significance unless obstruction occurs Most are unilateral

5. Megaloureter Massive enlargement of the ureter May be due to a functional defect of ereteral mmuscle My also occur in severe cases of obstruction

II. URETERITIS: Usually not associated with

infections Findings in long-standing ureteritis: a. Ureteritis follicularis lymphocytic aggregates in the subepithelial region

2. Ureteropelvic junction obstruction Congentiital disorder

Most common cause of hydronephrosis in infants and children; In infants- more common in boys, usually on the left ureter and more commonly unilteral In adults, more common among women and most often unilateral Abnormal organization of smooth muscle bundles excess collagen deposition between smooth muscle bundles ureteropelvic junction becomes small obstruction hydronephrosis of the involved kidney

appear as protrusions or undulations on the surface of the ureteral mucosa and produce a fine granular mucosal surface b. Ureteritis cystica small cysts on the surface of the ureter

III. TUMORS & TUMOR-LIKE LESIONS

Primary tumors of the ureter are rare Small benign tumors of the ureter are generally mesenchymal origin Primary malignant tumors of the ureter are similar to those arising from the renal pelvis, clyces, and bladder 1. FIbroepithelial polyp Very common benign tumor of the ureter Tumor-like lesion that grossly presents as a small mass projecting into the lumen, often in children

3. Diverticula Congenital or acquired

Outpouchings of the ureteral wall stasis of urine infection

4. Dilatation, elongation & tortuosity ( assoc w/ ectopic kidney Congenital or acquired

SY 2011-2012

 composed of loose vascularized connective tissue mass beneath the mucosa may also appear in the bladder, urethra, and renal pelvis

2. Leiomyoma - another
very common benign tumor of the ureter 3. Urothelial carcinoma

6 - 7th decades of life

Can cause obstruction in ureteral lumen Multiple and ocuaassionaly occur concurrently with similar neoplasms in the bladder or renal pelvis

th

pouchlike evangination of the bladder wall <1 cm 10 cm Congenital: focal failure of development of normal musculature Urinary tract obstruction during fetal development Acquired: Seen with prostatic enlargement Obstruction to urine outflow and muscle thickening in urinary bladder intravesical pressure formation of outpouchings or divertucula Clinical significance:

IV. OBSTRUCTIVE LESIONS

May be due to extrinsic or intrinsic causes Instrinsic Causes Calculi Strictures Tumors Blood clots Neurogenic Extrinsic Causes Pregnancy Periureteral inflammation Endometriosis Tumors Involvement of the kidneys is of clinical significance

Sites of urinary stasis infection Impinge on the ureter & cause vesivulo-ureteral reflux May give rise to cancers

2. Exstrophy
Anterior wall of the abdomen fails to develop bladder communicates directly with the surface of the body or it lies as an open sac Exposed mucosa undergoes metaplasia More prone to infection Increased risk of developing adenocarcinoma Amenable to surgeical correction

Leads to
hydroureter/hydronephro sis and sometime pyelonephritis Unilateral obstruction results from proximal causes Bilateral obstruction arises from distal causes (e.g. nodular hyperplasia of the prostate)

II. URINARY BLADDER INFLAMMATION (CYSTITIS)

Etiologic agents: E. coli (primary causing agent) Protesus, Klebsiella Enterobacter Candida albicans in immunosuppressed Others: viruses, Chlamydia, Mycoplasma, Schistosoma Predisposing factors: Bladder calculi Obstructions DM Instrumentation Immunodeficiency Women shorter urethra

Sclerosing
Retroperitoneal Fibrosis

uncommon cause of ureteral

obstruction Fibrous proliferative inflammatory process encasing the retroperitoneal structures and causing hydronephrosis

Forms of Cystitis:

URINARY BLADDER
I. CONGENITAL ANOMALIES 1. Diverticula

1. Acute Cystitis Morphology: Hyperemic mucosa; may have exudates

 Non-specific acute (&chronic) inflammation Types: a. Hemorrhagic cystitis after radiation treatment or antitumor treatment b. Suppurative cystitis c. Ulcerative cystitis 2. Chronic Cystitis Morphology: Predominance of chronic inflammatory cells Heaping up of the epithelium & granular surface Fibrous thickening of the muscularis propria bladder wall become less elastic Morphologic variants: a. Follicular cystitis ~ lymphoid follicles within the bladder mucosa and wall ~ not necessarily associated with infection b. Eosinophilic cystitis ~ submucosal eosinophils, fibrosis, occasionally giant cells ~ nonspecific subacute inflamamtion

Fibrosis may ensue, leading to a contracted bladder Unknown etiology Early Phase(nonclassic, non-ulcerative) ~ recent submucosal haemorrhages

Late Phase(classic, ulcerative) ~ Hunner ulcer Chronic mucosal ulcers

~ Inflammation & granulation tissue in mucosa, lamina propria & muscularis ~ Mast cells may be prominent

b.

Malacoplakia Vesical inflammatory reaction 3 cm 4cm slightly raised, soft, yellow, mucosal plaques Large foamy macrophages with occ. Multinucleated giant cells, interspersed with lymphocytes Michaelis-Gutmannbodies laminated mineralized concretions (calcium) in macrophages and between cells

Clinical Manifestation of cystitis

(TRIAD):

a. Frequency urination
every 15 to 20 minutes b. Lower abdominal Pain over the bladder region or in the suprapubic region c. Dysuria pain 0r rburning urination Systemic Manifestation: fever, chills body malaise 3. Cystitis Special variants a. Interstitial Cystitis (Chronic pelvic pain syndrome) Persistent, painful chronic cystitis associated with inflammation and fibrosis of all layers of the bladder wall Fissures and punctuate haemorrhages (cystoscopy) Most frequent among women Intermittent, severe suprapubic pain, urinary frequency, urgency, hematuria, dysuria

Related to chronic bacterial infection (E.coli, occasionally Proteus)

c. Polypoid Cystitis

Irritation of the bladder

mucosa (catheterization) marked submucosal edema urothelium is thrown into broad polypoid projections Maybe confused with papillary urothelial carcinoma

III. METAPLASTIC LESIONS

1. Cystitis Glandularis & Cystitis Cystica Brunn nestsNests of transitional epithelium go down into the lamina propria and

undego transformation of central epithelial cells Central epithelial cells become Cystitis glanduralis cuboidal or columnar

If untreated, 50% - 70% invade the underlying muscle b. Invasive Urothelial Cancer Extent of invasion is of prognostic significance

Cystitis cystica cystic spaces lined by urothelium 2. Squamous Metaplasia As a response to injury, the urothelium converts to a squamous epithelium which is a more durable lining. 3. Nephrogenic Adenoma Shed renal tubular cells implant at sites of injured urothelium Resembles renal tubules histologically Overlying urothelium may become cuboidal and papillary Tubular proliferation in the lamina propria

c.

Papilloma (1% or fewer) Small; superficially attached to the mucosa (exophythic papilloma) Lining is similar to normal urothelium Inverted papilloma extends into the lamina propria

IV. NEOPLASM (7% of cancers, 95%

epithelial in origin)

d. Papillary Urothelial Neoplasm of Low Malignant Potential (PUNLMP) Histologically similar to papilloma but with thicker urothelium OR with diffuse nuclear enlargement Larger than papillomas; may grossly look like the low-grade & high-grade lesions

A. Urothelial (transitional Cell) Tumors 90% of bladder tumors Benign to malignant Precursor lesions of invasive urothelial carcinoma a. Non-invasive papillary tumors most common precursor which originates from papillary urothelial hyperplasia b. Carcinoma-in-situ Flat non-invasive urothelial carcinoma
Morphologi c patterns: Papilloma Invcasive papillary carcinoma Flat non-invasive carcinoma Flat invasive carcinoma Classificati on Carcinoma-in-situ

e.

Low-Grade Papillary Urothelial Carcinoma Cells are orderly and cohesive Mild nuclear atypia Infrequent mitosis High-Grade Papillary Urothelial Carcinoma Dyscohesive cells with large, hyperchromatic nuclei Loss of polarity (disorganized architecture) Frequent mitotic figures 80% are invasive

f.

B. Other Epethelial Tumors 1. Squamous Cell Carcinoma (3% - 7%) Pure or Mixed (Urothelial + squamous cell) Usually invasive and fungating or ulcerative Usually seen in cases of schistosoma haematobium infection

2. Adenocarcinoma Rare
Identical to adenocarcinomas seen in GIT Some arise from urachal remnants or in association with extensive intestinal metaplasia 3. Small-cell carcinoma

a. (CIS) Cytologically malignant cells in a flat epithelium Often multifocal

 Indstinguihshable fom lung small cell carcinoma Arise in the bladder Associated with urothelial, squamous, or adenocarcinoma

V. OBSTRUCTION In the bladder neck

More common in males. M>F Clinical significance:: Morphologic changes in the bladder Effects on the kidneys Causes:

Causative Factors of Urinary

Bladder Carcinoma/ Urothelial carcinoma: Cigarette-smoking most important Exposure to arylamines Schistosoma haematobium (squamous cell carcinoma) Long-term use of analgesics Heavy, long-term intake of cyclophosphamide Prior radiation of the bladder Genetic alteration: deletion of chromosome 9 & 17 Clinical Manifestation and Course: Painless hematuria Tendency to develop new tumors Important prognostic factors: Grade3 and Stage

Prostatic enlargement (men) Cystocele of the bladder (women) Urethral narrowing or stricture Inflammatory fibrosis and contractions in the bladder after cystitis Bladder tumors Calculi or other foreign bodies Neurogenic bladder

Morphology: Muscle hypertrophy trabeculations Diverticula

Dilated bladder with markedly thinned-out wall

URETHRA
I. Urethritis
Gonococcal or Non-gonococcal

Pathologic staging: Ta non-invasive, papillary

TIS carcinoma-in-situ T1 lamina propria invasion T2 muscularis propria invasion T3a microscopic extravesicle invasion T3b grossly apparent extravesicle invasion T4 invasion of adjacent structures

II. TUMORS AND TUMOR LIKE LESIONS 1. Urethral carcuncle

Inflammatory small, red, painful mass at the urethral meatus in females Highly-vascularized, fibroblastic connective tissue with lymphocytes Intact mucosa but is extremely friable (slightest trauma can cause ulcer and bleeding)

C. Mesenchymal Tumors: a. Leiomyoma b. Sarcomas uncommon in the bladder

2. Benign epithelial tumors

a. squamous and urothelial papillomas b. Inverted urothelial papillomas c.Condyloma

Embryonal rhabdomyosarcoma n ~ most common sarcoma in the bladder in infants and children ~ Manifest asa sarcoma botyroides (polypoid grapelike mass) Leiomyosarcoma most common sarcoma in the bladder adults

3. Peyronie disease
Fibrous bands involving corpus cavenosum of the penis

4. Urethral carccinoma
primary urethral carcinoma is uncommon Proximal urothelial

Distal squamous ***End of Transcription**