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