Leonard: Urinary bladder
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| Obstructive uropathy can occur from ____ to ____ | Renal calyces
Distal urethral meatus
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| Obstructive Uropathy Common Causes | Pregnancy
BPH
Calculi
Congential anomalies
Inflammation
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| Obstructive Uropathy Common Sequelae | Stagnation of urine with
-↑ risk of infxn
-↑ risk of calculi
Loss of renal fxn from hydronephrosis
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| Obstructive lesions of the urinary tract can be ____ Vs ____ | Sudden Vs. Insidious
Partial Vs. Complete
Intrinsic Vs. Extrinsic
Mechanical Vs. Functional
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| Hydronephrosis | Dilation of the renal pelvis and calyces associated with atrophy of the kidney
Caused by obstruction of outflow of urine
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| Obstructive Uropathy Clinical considerations | Pain: renal colic
Altered U/O: stream, amount, etc
Unilateral obstruction may be asymptomatic
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| Obstructive Uropathy Clinical considerations Bilateral Partial | From chronic tubulointerstial nephritis
Presents with polyuria, nocturia from inability to concentrate urine
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| Obstructive Uropathy Clinical considerations Bilateral complete | Presents with oliguria or anuria
Urine output must be restored for survival
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| Urolithiasis General | Calculi can form at any level
Most arise in the kidney
~80% are unilateral
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| Urolithiasis Clinical | 5-10% US population, M>F
Familial/hereditary tendencies
Smaller stones→ureters→renal colic pain obstruction and hematuria
Larger stones→hematuria, hydronephrosis
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| Urolithiasis Etiology | 4 main types
1.Calcium (oxalate/phosphate) ~70%
2.Struvite (triple stone): Mg, NH4, phosphate
3.Uric Acid 4.Cystine
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| Urolithiasis Etiology/Pathology | Urinary supersatutation
-Low urine volume
-Metabolic abnormalities, altered pH
Loss of natural inhibitors
Infection
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| Calculi Calcium | Radiopaque
~70% of all stones
Hypercalcemic states
-Hyperparathyroidism, diffuse bone disease, sarcoidosis
Hypercalciuria w/o hypercalcemia
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| Calculi Magnesium ammonium phosphate | ~20% of all stones
Bacterial infections
-Urea→ammonia (↑ urine pH)
+↑precipitation of Mg, NH4, phos
Large stones (Staghorn caculi)
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| Caculi Uric acid | Radiolucent
~10% of stones
Hyperuricemia (gout)
Tendency to excrete urine with pH < 5.5
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| Caculi Cystine | <1%
Genetic efects in renal reabsorption of amino acids
Stoned form at low urine pH
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| Urinary bladder Anatomy | Superior surface: dome
Anteriosuperior: apex
Posterior surface: base
Trigone: triangular region located at base of bladder
Bladder neck: most distal
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| Urinary bladder Layers of visceral organ | Mucosa: urothelium
Lamina propria: slips of smooth muscle
Muscularis propria: thick bundles of smooth muscle
Adventitia (conn tiss)
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| Urinary bladder disorders/diseases Non-neoplastic (congenital or developmental) | Diverticula
Exstrophy
Urachal cysts
VRR (most common)
Inflammation
Metaplastic changes
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| Urinary bladder disorders/diseases Neoplastic | Urothelial (TCC)
Squamous cell carcinoma
Adenocarcinoma
Mixed carcinoma
Small cell carcinoma
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| Diverticula | True:out-pouching of visceral organ consisting of all wall layers
Acquired:increased intraluminal pressure
Congenital:defect in wall muscle
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| Exstrophy | ~33/1,000,000 live births
Anterior bladder wall and abdominal wall are absent
Exposes bladder mucosa to external environment
↑ risk of cystitis and carcinoma
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| Urachus | Vestigial remnant of the connection of bladder apex to the allantois
Prone to neoplastic transformation→adenocarcinoma
<0.5% bladder cancers
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| Patent urachus | Communicating duct between umbilicus and urinary bladder→infection
May close spontaneously
Typically requires surgical closure
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| Urachal cysts | **Most common urachal anomaly**
Suprapubic palpable mass
Columnar lining secrets watery secretions
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| Cystitis | Can be acute or chronic
Systemic signs are uncommon in uncomplicated cystitis
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| Infectious Cystitis | Bacterial: E.coli
Fungal: Candida
Parasitic: Schistosomiasis
-Middle East, northern Africa
Viruses: Chlamydia
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| Chemical or Physical Agent Cystitis | Drugs and other chemicals:
-Cytotoxic chemotherapy (cyclophosphamide) hemorrhagic cystitis
Radiation
Cacluli (mechanical)
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| Interstitial Cystitis | Chronic pelvic pain syndrome
Etiology uncertain
F>>M
Recurrent, severe, intermittent suprapubic pain
Hematuria, Urinary urgency
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| Interstitial Cystitis (cont) | May result in transmural fibrosis with dysfunctional bladder
*May mimic in situ urothelial carcinoma*
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| Malacoplakia | Macroscopic: soft, tan/yellow slightly elevated mucosal plaques
**Micro: large foamy macrophages mixed with multinucleated giant cells
-Michaelis-Gutmann bodies**
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| Malcoplakia (cont) | Chronic bacterial infections
-E.coli
-immunosuppressed transplant pts
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| Metaplasia | Alteration of the epthelium from its typical mature form to a different type of epithelium
Mostly transitional to columnar
Metaplastic epi offers beneficial protective features
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| Neoplasms of the Urinary Bladder | ~95% are epithelial
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| Urothelial (Transitional cell) | Benign: urothelial papilloma
Premalignant:
Papillary- PUNLMP
Flat- urothelial carcinoma in situ (CIS)
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| **Urothelial Carcinoma In Situ (CIS)** | Multifocal
Greater tendency to progress to more aggressive malignant neoplasm
Multifocal- pagetoid spread of tumor cells
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| Cancers of Transitional Epithelium | Papillary urothelial carcinoma (TCC):
Tend to recur, maybe multifocal
Not all are invasive
"Flat" (ass. with CIS):
Multifocal, invasive, high-grade
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| Staging of Urinary Bladder Cancers | Ta: noninvasive papillary
Tis: carcinoma in situ
T#: invasive
Higher #, more invasion
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| Squamous cell carcinoma | ~3-7% of bladder cancers
More common in areas with schistosomiasis
Most common ass. with Sch. (70%)
Ass. Chronic irritation/infxn
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| Bladder Cancer Epidemiology | M>F
More common in developed countries
Urban>rural
Generally no familial association
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| Bladder Cancer Pathogenesis | Modifiable risk factors
*Tobacco
*Artlamine chemicals (aromatic hydrocarbons)
Long-term analgesic use
Radiation exposure
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| Urinary Bladder Cancer Clinical Features | Classic: painless hematuria
Risk of recurrence: tumor size, stage, grade, multifocality, presence of CIS
Prognosis: grade and stage at Dx most important (early detection)
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| Urinary Bladder Cancer Treatment Small, localized papillary tumors | Transurethral resection of bladder tumor (TURBT)
Close follow-up surveillance
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| Urinary Bladder Cancer Treatment CIS, high grade TCC, etc | Topical immunotherapy/chemo
Intravesical installation of bacillus Calmette-Guerin (BCG)
Local inflammation reaction destroys tumor
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| Urinary Bladder Cancer Treatment Invasion of muscularis propria | Cystectomy
Possibly systemic chemotherapt
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