Bladder, ureter & renal pelvis
Cystitis
Chronic cystitis
Author: Mirna Toukatly, M.D.
Topic Completed: 1 June 2016
Minor changes: 20 June 2019
Copyright: 2002-2019, PathologyOutlines.com, Inc.
PubMed Search: Bladder chronic cystitis [title]
Table of Contents
Definition / general | Terminology | Epidemiology | Etiology | Clinical features | Treatment | Clinical images | Gross description | Microscopic (histologic) description | Cytology description | Differential diagnosisCite this page: Toukatly M. Chronic cystitis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladderchroniccystitis.html. Accessed August 7th, 2020.
Definition / general
- Clinical term referring to chronic inflammatory condition of bladder that is refractory to treatment or surgical correction
Terminology
- Multiple variants include interstitial, follicular, polypoid and nonspecific chronic cystitides
Epidemiology
- More common in women (90%) between 30s and 50s, most likely because urethra is shorter
- 50% of all women experience symptoms of urinary tract infection (UTI) and 20 - 30% will have recurrence
Etiology
- Acute bacterial UTI is thought to be an inciting event, with many factors contributing to its development, recurrence and chronicity including antibiotic resistance
- Anatomic or physiologic factors, which may induce and prolong UTI
- Physiologic factors: prolonged / repeated bouts of UTI by bacterial pathogens (commonly gram negative), radiation for neoplasm
- Anatomic factors: bladder outlet obstruction, neurogenic or muscular dysfunction of the bladder or the urethra; congenital anomalies or vesicoureteral reflux in childhood
- Immune mediated tissue damage during acute infection; in an experimental mouse model of chronic bladder infection with uropatogenic E. coli infection (causative agent of 80% of UTI), injury to the bladder mucosal lining due to severe inflammation preceded chronic cystitis
- Immunodeficient mice, lacking this immune response, did not develop chronic infection (PLoS Pathog 2010;6:e1001042)
- Carcinoma has been implicated in the development of cystitis, particularly follicular cystitis (J Urol 1970;104:709)
- Uncertain etiology for chronic interstitial cystitis (aka "painful bladder syndrome") and for nonspecific chronic cystitis
Clinical features
- Variable symptoms, including discomfort with bladder filling and relief with voiding, bladder pain (especially with interstitial cystitis) or pressure, urgency and frequency
- Gradual onset of symptoms worsening over a period of months
Treatment
- Corrective surgical treatment of anatomic pathology
- Addition of immunomodulatory therapy (such as Dexamethasone) to antibiotics, to temper the neutrophil response early during UTI and to prevent chronic infection
- Intravesical botulinum toxin A injection, known for its antinociceptive, antiinflammatory and muscle relaxant activity, has been used recently to treat refractory chronic bladder pain (especially with interstitial cystitis) (Toxins 2015;7:2232)
- Ovestin intravaginal cream (estriol) may reduce recurrence (Urologiia 2009;4:14)
Clinical images
Images hosted on other servers:
Cystoscopy findings in interstitial cystitis case: small vessels radiating towards a heaped, red inflamed central scar which easily bleeds
Gross description
- Red, friable, heaped and ulcerated mucosa on cystoscopy
- Small vessels radiating towards a central scar (Hunner ulcer), with a fibrin deposit or coagulum attached to this area (most commonly seen in interstitial cystitis)
- In nonulcerative form, exhibits petechiae and submucosal hemorrhages (glomerulations) or linear cracks after bladder distention
Microscopic (histologic) description
- Chronic inflammatory cell infiltrate composed mainly of mononuclear cells (lymphocytes and macrophages) in the lamina propria
- With repeated bouts of infection and chronicity, may have formation of lymphoid follicles, particularly in the lamina propria of the trigonal region (recognized as follicular cystitis)
- Urothelial denudation, erosion, ulceration and reactive atypia (especially in the classic type of interstitial cystitis)
- Edema, hyperemia, hemorrhages
- Fibrous thickening of muscularis propria in longstanding disease
- Florid chronic cystitis may mask urothelial carcinoma
Cytology description
- Nuclei are enlarged with prominent nucleoli
- Variable cytoplasmic vacuoles
- Presence of lymphoid follicular tissue with germinal centers may indicate follicular cystitis
Differential diagnosis
- Bladder stones or foreign body: especially in cases of chronic bladder catheterization, ureteral stents or suture material from prior surgical procedures
- MALT lymphoma and low grade lymphomas (particularly follicular lymphoma): forms solitary or multiple masses
- Urothelial carcinoma: may be masked by lymphoid follicles
