LOWER URINARY TRACT.
URETER, BLADDER & URETHRA.
By: Abiodun Mark Akanmode
LOWER URINARY TRACT.
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The lower urinary tracts
consists of the ureters,
urinary bladder and the
urethra.
These organs are involved
in the involuntary storage of
urine produced in the upper
urinary tract and the
voluntary expulsion of urine
at an appropriate time and
place.
LOWER URINARY TRACT
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There are considerable variations in the
anatomy of the male and female urinary
tract but we focus our attention on the male
lower urinary tract.
A thorough knowledge and understanding of
the relevant anatomy is essential in
understanding the various
pathophysiological mechanisms of LUT
disorders and their appropriate management
URETER.
The ureter is a tubular structure ,30cm in length
and 0.5cm in diameter.
 It extends from the renal pelvis to the urinary
bladder.
 The ureters enter the bladder in an obliquely, so
that its compressed during micturition to prevent
vesico-ureteric reflux.
 The ureter is lined by transitional epithelium
internally and by a fibrous layer which ensheaths
the muscular layers.

DOUBLE &BIFID
URETER.
This is a condition in
which the upper or the
entire part of the
ureter is duplicated.
 Double ureter is
associated with double
renal pelvis.
 Most cases are
unilateral & of no
clinical significance.

URETERIC DIVERTICULAR.
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This is a very rare
congenital disorder of
the ureter.
It is characterized by
the presence of
saccular
outpouchings of the
ureteral wall.
URETERAL TUMORS & TUMOR LIKE
LESIONS
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Primary tumors of the ureter are very rare.
However the malignant tumors of the ureter
resemble those arising from the renal pelvis,
calyces and bladder.
Most of the malignant lesions of the ureter are
urothelial carcinomas.
Urothelial carcinomas are predominant between
the 6th and 7th decades.
OBSTRUCTIVE LESIONS OF THE URETER.
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Various pathologic lesions can lead to ureteral obstruction
thus giving rise to hydroureter, hydronephrosis and
occasionally pylelonephritis.
Sclerosing retroperitoneal fibrosis(RPF):This is an
uncommon cause of ureteral narrowing/obstruction
characterized by a fibrous proliferation around
retroperitoneal structures eventually leading to
hydronephrosis.
The idiopathic variant of this disease i.e. idiopathic
retroperitoneal fibrosis is also called Ormond's disease.
OTHER CAUSES OF
URETERAL OBSTRUCTION.
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
Intrinsic causes:
-calculi/stone.
-Strictures.
-Blood clots.
Extrinsic causes:
-Pregnancy.
-Endometriosis.
-Tumors.
URINARY BLADDER.
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The urinary bladder is the organ that
collects urine excreted by the kidneys before
disposal by urination.
The bladder lies extraperitoneally and the
peritoneal surface is reflected on its superior
surface.
The greater part of the bladder wall is made up of
dextrusor muscles while the bladder trigone is a
prolongation of the muscle layers from each
ureter.
CONGENITAL BLADDER ANOMALIES.
Bladder or vessical diverticulum: This consists of
a pouch-like evagination of the bladder wall.
 Diverticulum could be acquired or congenital.
 Congenital diverticulum is mostly ascribed to
focal failure in the normal musculature
development.
 Acquired diverticulum is associated with
prostatic enlargement & obstruction to urine
flow.
 Although most diverticulum are small are
insignificant they might constitute a site of
stasis(urine), hence infection and sepsis.

BLADDER
EXTROPHY.
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In bladder extrophy
developmental defects
in the anterior
abdominal wall allows
for a communication
of the bladder with
the exterior.
The exposed bladder
is highly susceptible
to infections.
CYSTITIS.
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This refers to the inflammation of the urinary
bladder.
The common etiologic agents implicated in
cystitis are E.coli, proteus, klebsiella and
enterobacter.
Women are more predisposed to developing
cystitis as compare to males because of their
shorter urethras.
Triad of cystitis is: frequency, lower abdominal
pain and dysuria.
MORPHOLOGY: ACUTE CYSTITIS.
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Grossly: Acute cystitis is
characterized by a swollen,
red and hemorrhagic
bladder mucosa.
There may be suppurative
exudates or ulcer also on
the bladder mucosa.
Microscopically acute
cystitis is characterized by
intense neutrophilic
exudation admixed with
lymphocytes and
macrophages.
MORPHOLOGY: CHRONIC CYSTITIS.
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Repeated attacks of acute cystitis lead to chronic
cystitis.
Grossly: The mucosal epithelium is thickened, red
and granular with polypoid masses. long standing
cases gives rise to a thickened bladder wall and
shrunken cavity.
Microscopically: There is a patchy ulceration of the
mucosa with the formation of granulation tissue.
FOLLICULAR CYSTITIS.
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This is a type of
cystitis
characterized by
the aggregation of
lymphocytes into
lymphoid follicles
within the bladder
mucosa and wall.
Follicular cystitis is
not necessarily
associated with a
bacterial infection.
SPECIAL TYPES OF
CYSTITIS:
INTERSTITIAL CYSTITIS.
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Interstitial cystitis(chronic pelvic pain
syndrome):This is a persistent, painful
form of chronic cystitis occurring mostly
in women.
The etiology of which is unknown.
Some pt with this condition show chronic
mucosal ulcers (Hunner ulcers).
Late in this disease, there is transmural
fibrosis leading to a contracted bladder .
Interstitial cystitis is characterized by
suprapubic pain, hematuria, dysuria,
frequency without evidence of bacterial
infection.
INTERSTITIAL CYSTITIS

Interstitial cystitis
giving rise to a
contracted bladder
appearance.
SPECIAL TYPES OF CYSTITIS:
MALACOPLAKIA.
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This are soft ,flat yellowish lesions
found on the surface of the bladder
mucosa.
They tend to vary from 0.5-5cm in
diameter.
They are composed of large amounts
of foam macrophages, multinucleated
giant cells and lymphocytes.
Malacoplakia is also characterized by
the presence of Michaelis-Gutmann
bodies.
SPECIAL TYPES OF CYSTITIS:
POLYPOID CYSTITIS.
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This is usually secondary to the irritation of the
bladder wall.
Its characterized by papillary projections on the
bladder mucosa.
Indwelling catheters are usually responsible for
this variant of cystitis.
Polypoid cystitis may be confused for papillary
urothelial carcinoma clinically & histologically.
METAPLASTIC LESIONS OF THE
BLADDER.
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Cystitis glandularis & cystitis cystica:
Here nest (Brunn nests) of transitional
epithelium grows downwards into the
laminar propria and undergoes
transformation into cubiodal or
columnar epithelium lining(c.
glandularis) or cystic spaces (c.cystica)
Both variants are common microscopic
findings in a relatively normal bladder.
Squamous Metaplasia: injury to the
urothelium is often replaced by
squamous epithelium.
BLADDER NEOPLASM'S.
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Bladder cancer accounts for 7% of cancer in the
US.
About 95% of bladder cancers are of the epithelial
origin with the rest been of the mesenchymal
origin.
Most epithelial bladder cancers are of the
urothelial (transitional)origin.
UROTHELIAL/TRANSITIONAL TUMORS.
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They account for 90% of all bladder cancers.
The 2 major precursor lesions to invasive
urothelial carcinoma are:
-non-invasive papillary tumors.
-flat non invasive urothelial carcinoma(CIS).
In about 1/3rd of pt with bladder ca, the cancer
has already invaded the bladder wall at the time
of presentation and no precursor lesion would be
seen.
MORPHOLOGY
OF UROTHELIAL
TUMORS. :
The gross pattern of
urothelial tumors
tends to vary from
papillary to nodular or
flat.
 90% of all urothelial
tumors are papillary.
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Most papillary tumors
are low grade and
arise from the lateral
or posterior wall of the
bladder.
LOW GRADE PAPILLARY UROTHELIAL
CARCINOMA
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Low grade papillary
urothelial carcinoma:
characterized by orderly
appearance
architecturally and
cytologically.
They tend to recur and
they seldomly invade.
A
B
HIGH GRADE PAPILLARY
UROTHELIAL CANCER:
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This variant contains
cells that are more
architecturally in
disarray, areas of larges
hyperchromasia seen,
abundant mitotic figures
etc.
80% of high grade
tumors are invasive.
BLADDER CANCER EPIDEMIOLOGY.

Several factors have been implicated in the
etiology of urothelial cancers such as:
-Cigarette smoking.
-Industrial exposure to napthalamine.
-Parasitic infection with shistosoma hematobium.
-Drugs: cyclophosphamide etc.
-Diet.
-Local lesions.
-Prior exposure to radiation.
-Long term analgesic use.
CLINICAL FEATURES OF BLADDER TUMORS.
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Bladder tumors classically produces painless
hematuria.
Urgency, frequency and dysuria occasionally
accompany the hematuria.
Treatment for bladder tumors depends on the
stage and whether it’s a flat of papillary lesion.
Chemotherapy and radical cystectomy are both
proven ways to manage bladder tumors.
BLADDER OBSTRUCTION.
Obstruction of the bladder neck eventually
causes problems with the kidney.
 Bladder obstruction in males is mostly due to
nodular prostatic hyperplasia.
 Other causes of bladder obstruction include:

-Congenital urethral stricture.
-Inflammatory urethral strictures.
-Bladder tumors.
-Mechanical obstruction by foreign body or
calculi.
-Neurogenic bladder.
MORPHOLOGY OF BLADDER
OBSTRUCTION.

There is
hypertrophy
& thickening
of the smooth
muscle of the
bladder wall.
URETHRA.
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The urethra runs from the bladder up to the
external meatus.
The male urethra has 3 major parts-prostatic,
membranous and penile.
The female urethra is much shorter than the
male urethra.
The urethra functions to convey urine from the
bladder and also as a passage way for various
secretions from reproductive organs.
URETHRITIS.
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This is the inflammation of the urethra.
Urethritis is divided into gonococcal and non
gonococcal urethritis.
The bacteria's involved in NGU include E.coli,
Chlamydia etc.
Urethritis is a component of the REITER’S
SYDROME which comprises of arthritis,
conjuctivitis and urethritis.
TUMORS & TUMOR-LIKE LESIONS OF THE
URETHRA.

URETHRAL
CARUNCLE: this is an
inflammatory lesion
that presents as a
small painful mass
around the urethral
meatus. its common
in older females.

PRIMARY CARCINOMA
OF THE URETHRA: this
is an uncommon lesion,
but are mostly of
squamous cell origin.