Bladder, ureter & renal pelvis


Chronic cystitis

Last author update: 1 June 2016
Last staff update: 25 August 2021

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PubMed Search: Bladder chronic cystitis [title]

Mirna Toukatly, M.D.
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Cite this page: Toukatly M. Chronic cystitis. website. Accessed January 29th, 2023.
Definition / general
  • Clinical term referring to chronic inflammatory condition of bladder that is refractory to treatment or surgical correction
  • Multiple variants include interstitial, follicular, polypoid and nonspecific chronic cystitides
  • 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
  • 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
  • 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

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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
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