Bladder, ureter & renal pelvis

Cystitis

Chronic cystitis

Author: Mirna Toukatly, M.D.

Topic Completed: 1 June 2016

Minor changes: 25 August 2021

Copyright: 2002-2019, PathologyOutlines.com, Inc.

PubMed Search: Bladder chronic cystitis [title]

Page views in 2020: 5,220

Page views in 2021 to date: 4,091

Table of Contents

Cite this page: Toukatly M. Chronic cystitis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladderchroniccystitis.html. Accessed September 21st, 2021.

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

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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