Special forms of lower urinary tract infection

Acute abacterial cystitis (acute haemorrhagic cystitis)

The patient presents with symptoms of severe UTI. Pus is present in the urine, but no organism can be cultured. It is sometimes associated with abacterial urethritis and is commonly sexually acquired. Tuberculous infection and carcinoma in situ must be ruled out. The underlying causative organism may be mycoplasma or herpes.

Frequency—dysuria syndrome (urethral syndrome)

This is common in women. It consists of symptoms suggestive of urinary infection, but with negative urine cultures and absent pus cells. Carcinoma in situ, tuberculosis and interstitial cystitis should be excluded. No significant abnormalities in these patients have been found and most urologists advise patients to adopt general measures such as wearing cotton underwear, using simple soaps, general perineal hygiene and voiding after intercourse. Other treatments include cystoscopy and urethral dilatation, although the benefits remain doubtful.

Tuberculous urinary infection

Tuberculous urinary infection is secondary to renal tuberculosis. Cystoscopy shows that early tuberculosis of the bladder commences around the ureteric orifice or trigone, the earliest evidence being pallor of the mucosa due to submucous oedema. Subsequently tubercles may be seen, and in long-standing cases there is much fibrosis and the capacity of the bladder is greatly reduced (Fig. 65.41).

Treatment

Tuberculous infection usually responds rapidly to antituberculous drugs (see Chapter 7), but occasionally, in cases with advanced renal changes, may not subside until the involved kidney and ureter have been removed.

If the bladder remains of low capacity, patients will have severe symptoms and the upper tracts are at risk of dilatation because of high filling pressures plus vesicoureteric reflux. Such patients after appropriate chemotherapy respond very well to bladder augmentation. The ureters may need reimplantation into the neo-bladder.

Bladder augmentation by ileocystoplasty or caecocystoplasty. The fibrosed supratrigonal bladder is removed and the bladder augmented with a segment of bowel. This may con­sist of an intact segment of caecum, a detubularised segment of ileum or a detubularised ileocaecal segment. After pre­operative preparation bowel preparation (see Chapter 56) a segment of bowel with an ample blood supply as demonstrated by transillumination is disconnected, leaving its mesentery intact, and the continuity of the intestine is restored by anastomosis. The segment of bowel is opened longitudinally and sutured together as a ‘U’ shape. This can then be anastomosed to the trigone of the bladder. Alternatively, an intact segment of caecum may be used (Figs 65.20,65.21,65.22 and—65.23).  

Interstitial cystitis (Hunner’s ulcer)

For practical purposes, this is confined to women. The symptoms commence when the patient is in her 40s and cause significant distress.

A etiology

This is as obscure as it was when Guy Hunner's first described the condition in 1914. It does not appear to start as an ordinary UTI, but consists of a chronic pancystitis, often with marked infiltration with lymphocytes and macrophages.

Pathology

As a result of the pancystitis, fibrosis of the vesical muscula­ture ensues, leading to contracture of the bladder and areas of avascular atrophy of the epithelium. Ulceration of the mucosa occurs in the fundus of the bladder. In severe cases, the bladder capacity is reduced to 3 0—60 ml. The characteristic linear bleeding ulcer is due to splitting of the mucosa when the bladder is distended under anaesthesia for cystoscopy.

Microscopically, inflammation of all coats of the bladder is present with granulation tissue in the submucosa underlying the ulcer. The muscularis is hypertrophied and the peritoneum in proximity to the area of maximum disease is thickened. The inflammation may involve the trigone, the urethra and, in severe cases, the peritoneum. Pronounced mast cell infiltration is seen, but is not specific to the condition.

Clinical features

The first symptom is increased frequency. Pain, relieved by micturation and aggravated by jarring and over-distension of the bladder, is a characteristic symptom. In most patients pyuria and urinary infection are absent. Haematuria also occurs.

Cystoscopy

The characteristic ulcer is found in the fundus, but it may be absent. This area bleeds readily as the bladder is decompressed.

Treatment

Treatment is difficult and unsatisfactory. Hydrostatic dilatation under anaesthesia may give relief for some months. Light diathermy fulguration of the ulcer may help. Instillation of dimethylsulphoxide (Rimso 50®) improves some patients. Other drugs that have been tried include ranitidine. Patients with severe symptoms may well come to bladder substitution. In patients with severe inflammation involving the tnigone and urethra, this operation may not result in complete relief and some type of urinary diversion may be needed.

Alkaline encrusting cystitis

Alkaline encrusting cystitis is rare and is due to urea-splitting organisms causing phosphatic encrustations on the bladder mucosa of elderly women. There are symptoms of chronic UTI and a plain X-ray shows the bladder outline. The encrustations may be removed by bladder irrigation and the infection treated with appropriate antibiotics.

Cystitis cystica

Glands are not found in the normal bladder mucosa. Under the influence of chronic inflammation, the surface epithelium sends down buds, resulting in minute cysts filled with clear fluid, most abundant on the tnigone. This is frequently found in patients with recurrent frequency and dysuria. Whilst very rarely cases of adenocarcinoma of the bladder may arise in these areas of glandular metaplasia, there is no doubt that cystitis cystica is usually completely innocuous.