Nonneoplastic Conditions

Bacterial cystitis: this, the most common cause of cystitis, is usually due to coliform organisms (e.g., E. coli) ascending the urethra. Underlying structural (diverticula, fistulae, malformations, stones) or medical (diabetes mellitus, chronic renal failure, immunosuppression) conditions predispose. Recurrent infections, especially in men, should trigger investigation for an underlying cause.

Malakoplakia: is caused by a defect in the host macrophage response to bacterial infection and can affect practically any organ in the genitourinary system or indeed elsewhere. It is seen primarily in middle-aged women and presents as multiple soft, yellow mucosal plaques on cystoscopy, sometimes mistaken for carcinoma. Biopsy reveals collections of granular histiocytes in the lamina propria, some with characteristic intracytoplasmic concentrically laminated inclusions (Michaelis-Gutmann bodies).

Polypoid/papillary cystitis: these closely related conditions describe localised non-specific inflammation and oedema of the bladder mucosa commonly seen in association with indwelling urinary catheters and less often with vesical fistulae. They may be difficult to differentiate endo-scopically and microscopically from papillary urothelial carcinoma, which tends to have finer stromal papillary cores, more urothelial atypia and less associated inflammation.

Nephrogenic adenoma: often associated with previous surgery, stones or infection, these are small, usually polypoid lesions of metaplastic origin and, although most commonly found in the bladder (75%), can be seen anywhere in the urinary tract.

Interstitial cystitis: usually in middle-aged women, the aetiology is obscure and the diagnosis essentially one of exclusion. Symptoms may be extremely severe. On cystoscopy the typical appearances of diffuse punctate haemorrhage with or without ulceration can closely mimic carcinoma in situ. The histological appearances are non-specific, with lamina propria congestion, oedema and inflammation featuring lymphocytes, plasma cells and variable numbers of mast cells (best seen histologically if sample submitted in alcohol rather than formalin). Urine cytology to exclude malignancy and culture for infection are other important investigations. Treatment is initially medical for symptom relief (amitriptyline, antihistamines, analgesics) with intravesical therapy an alternative and eventually surgical intervention, in the form of urinary diversion with or without cystourethrectomy, as a last resort.

Bladder stones: most commonly seen in men with bladder outlet obstruction, and associated with renal or ureteric stones. Rarely result in surgical material.

Diverticula: most are seen in elderly males and attributed to increased luminal pressure secondary to prostatic enlargement causing outlet obstruction. Few cause symptoms or require surgical treatment. Most are located close to the ureteric orifices. Possible complications include ureteric obstruction, infection, stone formation and rarely malignancy (urothelial, adeno- or squamous cell carcinoma).

Urachal-related lesions: persistence of the urachus can result in a completely patent tract from bladder to umbilicus, a blind-ended sinus opening onto the bladder mucosa or umbilical skin, or an enclosed sinus blind at both ends. The lining epithelium may be of urothelial or columnar type. Presentation is usually in childhood. Stasis of urine and epithelial debris predispose to infection, abscesses and rarely stones. Cysts may occur at any point within the urachal remnant.

Neurogenic bladder: a wide range of neuromuscular conditions (e.g., cerebrovascular accident, multiple sclerosis, spinal cord trauma, diabetes mellitus) can cause voiding dysfunction by interfering with bladder wall compliance, detrusor muscle activity or sphincter function, resulting eventually in either a tightly contracted or flaccid bladder. These are usually treated by behavioural, pharmacological or electrophysiological means but occasionally surgical intervention may be indicated, e.g., augmentation cystoplasty to increase capacity in a contracted bladder, where a segment of stomach or intestine is isolated and anastomosed to the native bladder. Rarely, adenocarcinoma may supervene later in the augmented bladder.

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