Page 715 - Textbook of Pathology, 6th Edition

Cystitis get repeated attacks of severe and excruciating pain on 699
distension of the bladder, frequency of micturition and great
Inflammation of the urinary bladder is called cystitis. Primary decrease in bladder capacity. Cystoscopy often reveals a
cystitis is rare since the normal bladder epithelium is quite localised ulcer. The etiology of the condition is unknown but
resistant to infection. Cystitis may occur by spread of it is thought to be neurogenic in origin.
infection from upper urinary tract as seen following renal
tuberculosis, or may spread from the urethra such as in Microscopically, the submucosa and muscle coat show
instrumentation. Cystitis is caused by a variety of bacterial increased fibrosis and chronic inflammatory infiltrate,
and fungal infections as discussed in the etiology of chiefly lymphocytes, plasma cells and eosinophils.
pyelonephritis (page 682). The most common pathogenic
organism in UTI is E. coli, followed in decreasing frequency CYSTITIS CYSTICA. As a result of long-standing chronic
by Enterobacter, Klebsiella, Pseudomonas and Proteus. Infection inflammation, there occurs a downward projection of
with Candida albicans may occur in the bladder in immuno- epithelial nests known as Brunn’s nests from the deeper layer
suppressed patients. Besides bacterial and fungal organisms, of bladder mucosa. These epithelial cells may appear as small
parasitic infestations such as with Schistosoma haematobium cystic inclusions in the bladder wall, or may actually develop
is common in the Middle-East countries, particularly in columnar metaplasia with secretions in the lumen of cysts.
Egypt. Chlamydia and Mycoplasma may occasionally cause MALAKOPLAKIA. This is a rare condition most frequently
cystitis. In addition, radiation, direct exposure to chemical found in the urinary bladder but can occur in the ureters,
irritant, foreign bodies and local trauma may all initiate kidney, testis and prostate, and occasionally in the gut. The
cystitis. etiology of the condition is unknown but probably results from
Cystitis, like UTI, is more common in females than in persistence of chronic inflammation with defective
males because of the shortness of urethra which is liable to phagocytic process by the macrophages. Malakoplakia
faecal contamination and due to mechanical trauma during occurs more frequently in immunosuppressed patients and
sexual intercourse. In males, prostatic obstruction is a recipients of transplants.
frequent cause of cystitis. All forms of cystitis are clinically
characterised by a triad of symptoms—frequency (repeated Grossly, the lesions appear as soft, flat, yellowish, slightly CHAPTER 22
urination), dysuria (painful or burning micturition) and low raised plaques on the bladder mucosa. They may vary
abdominal pain. There may, however, be systemic manifes- from 0.5 to 5 cm in diameter.
tations of bacteraemia such as fever, chills and malaise. Microscopically, the plaques are composed of massive
accumulation of foamy macrophages with occasional
MORPHOLOGIC FEATURES. Cystitis may be acute or multinucleate giant cells and some lymphocytes. These
chronic. macrophages have granular PAS-positive cytoplasm and
some of them contain cytoplasmic laminated concretions
ACUTE CYSTITIS. Grossly, the bladder mucosa is red,
swollen and haemorrhagic. There may be suppurative of calcium phosphate called Michaelis-Gutmann bodies.
exudate or ulcers on the bladder mucosa. These bodies ultrastructurally represent lysosomes filled
Microscopically, this form of cystitis is characterised by with partly digested debris of bacteria phagocytosed by
intense neutrophilic exudate admixed with lymphocytes macrophages which have not been digested fully by them
and macrophages. There is oedema and congestion of due to defective phagocytosis.
mucosa. POLYPOID CYSTITIS. Polypoid cystitis is characterised by The Kidney and Lower Urinary Tract
CHRONIC CYSTITIS. Repeated attacks of acute cystitis papillary projections on the bladder mucosa due to
lead to chronic cystitis. submucosal oedema and can be confused with transitional
Grossly, the mucosal epithelium is thickened, red and cell carcinoma. The condition occurs due to indwelling
granular with formation of polypoid masses. Long- catheters and infection.
standing cases result in thickened bladder wall and
shrunken cavity. Urethritis
Microscopically, there is patchy ulceration of the mucosa
with formation of granulation tissue in the regions of Urethritis may be gonococcal or non-gonococcal.
polypoid masses. Submucosa and muscular coat show Gonococcal (gonorrhoeal) urethritis is an acute
fibrosis and infiltration by chronic inflammatory cells. A suppurative condition caused by gonococci (Neisseria gonorr-
form of chronic cystitis characterised by formation of lym- hoeae). The mucosa and submucosa are eventually converted
phoid follicles in the bladder mucosa is termed cystitis into granulation tissue which becomes fibrosed and scarred
follicularis. resulting in urethral stricture.
Non-gonococcal urethritis is more common and is most
A few other special forms of cystitis having distinct
clinical and morphological appearance are described below. frequently caused by E. coli. The infection of urethra often
accompanies cystitis in females and prostatitis in males.
INTERSTITIAL CYSTITIS (HUNNER’S ULCER). This Urethritis is one of the components in the triad of Reiter’s
variant of cystitis occurs in middle-aged women. The patients syndrome which comprises arthritis, conjunctivitis and