Bladder, ureter & renal pelvis

Other nonneoplastic

Müllerian lesions



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Last staff update: 2 November 2022

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PubMed Search: Bladder Müllerian lesions

Alcides Chaux, M.D.
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Cite this page: Chaux A. Müllerian lesions. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladderendocervicosis.html. Accessed December 7th, 2022.
Definition / general
Endocervicosis
  • Rare benign tumor-like lesions characterized by prominent endocervical type glands in muscularis propria

Endometriosis
  • Presence of functional endometrial tissue within bladder
  • Ureter:
    • Rare in ureter but can result in renal failure due to silent obstruction
    • Associated with hydroureter / hydronephrosis
    • Tendency to involve distal third of left ureter (Hum Pathol 2008;39:954)
    • Extrinsic: involving serosal or peritoneal surface (adventitia or connective tissue)
    • Intrinsic: involving muscularis propria, lamina propria, lumen
    • Rarely malignant transformation or endometrial hyperplasia can be present

Endosalpingiosis
  • Involvement of lamina propria and muscularis propria by tubules and cysts with tubal type epithelium (ciliated cells, intercalated cells, peg cells)
Terminology
Endosalpingiosis
  • Called Müllerianosis if 2 of 3 related entities (endocervicosis, endometriosis or endosalpingiosis) are present (Mod Pathol 1996;9:731)
Epidemiology
Endocervicosis
  • Women in reproductive years (mean age 39 years, range 34 - 65 years)
  • Also men receiving estrogen for prostate cancer

Endometriosis
  • Women between the second and fifth decades
  • Uncommon, occurs in < 2% of all patients with endometriosis
  • Seen in post menopausal women receiving exogenous estrogen
  • Also can occur, very rarely, in men taking estrogens for prostate cancer

Endosalpingiosis
  • Very uncommon
  • Usually seen in women of childbearing age
Sites
Endocervicosis
  • Posterior wall or posterior dome preferentially affected

Endometriosis
  • Usually posterior wall of bladder above trigone or at dome

Endosalpingiosis
  • Posterior wall or posterior dome
Etiology
Endocervicosis
Endometriosis
  • Probably due to retrograde menstruation, which seeds surface of bladder serosa or postsurgical
  • Not due to metaplasia of Müllerian remnants or extension from anterior uterine adenomyosis (Am J Obstet Gynecol 2002;187:538)

Endosalpingiosis
  • Metaplastic (Müllerian metaplasia) or implantative (similar to endometriosis)
Clinical features
Endocervicosis
Endometriosis
  • Bladder is the most common site (70 - 80%) of endometriosis of the urinary tract
  • May develop into endocervicosis (mucinous metaplasia), endometrioid adenocarcinoma, clear cell carcinoma, adenosarcoma
  • Usually associated with prior surgery or female GU symptoms of urgency, frequency, suprapubic pain, rarely hematuria
  • Mass is frequently apparent either by palpation or cystoscopic examination
  • Bladder implants typically occur at vesicouterine pouch; may grow through muscularis into submucosa, producing a luminal bulge or rarely a polypoid mucosal mass (Radiographics 2006;26:1847)
  • Mucosa may appear blue at cystoscopy

Endosalpingiosis
  • Suprapubic pain, urinary frequency, dysuria
  • May occur after surgery in some cases
Case reports
Endocervicosis
Endometriosis
Endosalpingiosis
Treatment
Endocervicosis
  • Excision

Endometriosis
Endosalpingiosis
Clinical images

Images hosted on other servers:

Endometriosis

Laparoscopic segmental cystectomy

Gross description
Endocervicosis
  • Mass between bladder and uterus in posterior bladder wall, dome or trigone
  • Up to 2.5 to 3.0 cm in size
  • Spongy cut surface with mucinous / milky fluid

Endometriosis
Endosalpingiosis
  • May form mass on posterior wall of bladder
Microscopic (histologic) description
Endocervicosis
  • Irregular proliferation of prominent endocervical type glands in muscularis propria, less frequently in lamina propria or subserosal connective tissue
  • Glands are irregular in size and shape and may be cystically dilated, containing mucinous secretions with neutrophils
  • Glands are lined by a single layer of tall mucinous columnar cells, less commonly flat or cuboidal cells, rarely ciliated or goblet-like cells
  • Focal glandular rupture leads to mucin accumulation within the stroma with a fibroblastic histiocytic response
  • Absent or mild nuclear atypia, no mitotic figures
  • No desmoplasia, no glandular crowding or back to back architecture

Endometriosis
  • Resembles endometriosis elsewhere: endometrium-like glandular epithelium associated with endometrial stroma cells and recent or old hemorrhage
  • Rarely, only glands or stroma are found
  • Ureter:
    • Similar to endometriosis seen elsewhere, diagnosis based on the presence of endometrial glands (usually inactive or proliferative pattern) with endometrial stroma (usually normal appearing), sometimes restricted to a thin zone around the glandular component
    • Foamy or hemosiderin laden macrophages
    • Sometimes a fibrotic reaction

Endosalpingiosis
  • Involvement of lamina propria and muscularis propria by tubules and cysts of Müllerian type epithelium
  • May replace urothelium and form polypoid projections into bladder lumen
  • Tubules and cysts are round / oval, may have prominent branching
  • Glands are lined by tubal type epithelium (ciliated cells, intercalated cells, peg cells)
  • No atypia, no mitotic figures, no necrosis
Microscopic (histologic) images

AFIP images

Endosalpingiosis

Ovary: glands lined by ciliated epithelium lie in fibrous stroma

Ovary: ciliated,
secretory and
intercalated cells
line the cystic space



Images hosted on other servers:

Endocervicosis

Prominent
endocervical
glands in
muscularis propria

Complex cystic lesion

Columnar cells with granular mucinous apical cytoplasm


Endometriosis

Endometrial glands and
stroma involving the
peri-ureteral soft tissue

Positive stains
Endocervicosis
Endometriosis
Differential diagnosis
Endocervicosis
  • Adenocarcinoma:
    • Marked atypia, mitotic figures
  • Adenoma malignum from uterine cervix:
    • Infiltration of bladder serosa, deep cervical involvement
    • Glands are variable in shape or size with irregular or claw shaped outlines

Endosalpingiosis
  • Adenocarcinoma:
    • Marked atypia, invasive borders, usually not ciliated and lacks 3 types of tubal cells
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