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
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
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.