Urinary bladder 2

Lower urinary infection & cystitis • Infection of the bladder gives to symptoms of frequency, ,suprapubic discomfort, dysuria and cloudy offensive urine. These symptoms are often known as (cystitis). predisposing causes of urinary tract infection :- I. Incomplete emptying of the bladder, which may be secondary to bladder outflow obstruction caused by prostatic obstruction, urethral stricture or meatal stenosis, bladder diverticulum, neurogenic bladder dysfunction or decompensation of the detrusor muscle.

II. The presence of a stone, foreign body or neoplasm. III. Incomplete emptying of the upper tract caused by dilatation of the ureters associated with pregnancy or vesicoureteric reflux. IV. Estrogen deficiency, which may give rise to lowered local resistance. V. Colonization of the perineal skin by strains of E. coli. VI. Diabetes. VII. Immunosuppression

Clinical features Frequency: the urge to micturate occurs during the day and night ; it may occur every few minutes and may cause incontinence. Pain : pain varies from mild to sever. It may be referred to the suprapubic region, the tip of the penis, the labia majora or the perineum . Haematuria : the passage of a few drops of blood-stained urine or blood- stained debris at the end of micturition. Pyuria: this is usually present. On examination there is tenderness over the bladder. Routes of infection 1) ascending infection from the urethra is the most common route. 2) descending from the kidney (tuberculosis). 3) haematogenous spread. 4) lymphogenous spread. 5) spread from adjoining structures (fallopian tube, vagina or gut). Treatment Appropriate first-line antibiotics include trimethoprim, amoxicillin Failure to respond indicates the need for further investigation to exclude predisposing factors. Ask the patient to drink water

Neoplasms of the bladder - 95% of primary bladder tumours originate in the transitional epithelium; the remainder arise from connective tissue (angioma, fibroma, myoma & sarcoma) Secondary tumours of the bladder are not rare and most commonly arise from a neighbouring organ particularly the sigmoid & rectum, the prostate, the uterus or ovary, although bronchial neoplasms also may spread to bladder. Carcinoma of the bladder Histological types of bladder cancer include, transitional, squamous and Adencarcinoma ( or mixed). Over 90% are transitional cells in origin. pure squamous carcinoma is uncommon ( 5%). Primary adenocarcinoma, accounts for l-2% of cases. Transitional cell carcinoma etiology Cigarette smoking is the main etiological factor and accounts for more than 40% of cancers. Occupational exposure to urothelial carcinogens The following compounds may be carcinogenic: 2 - naphthylamine; benzidine 4 - amino biphenyl 2- chloraniline methylene dianiline;

Occupations which have been reported to be associated with a significantly increased risk of bladder cancer are: leather workers * textile workers * dye workers petrol workers * painters * tyre rubber & cable workers metastatic spread: bladder carcinoma spreads by:-direct spread--into the adjacent organs such as the colon, prostate, and uterusLymphatics — the primary lymphatic drainage pattern from the bladder is to the external iliac, hypogastric, and presacral lymph nodesHaematogenous dissemination — to the lungs, bones, and liver.Implantation- bladder cancer may be seeded into the urethra & possibly onto other parts of the bladder by direct contact. Also to the wounds therefore open surgical excision & biopsy of bladder tumor is contraindicated

Tumor Staging & Grading The Stage is an indication as to where the tumor was physically located Stage has two “superficial” and “invasive.” *Superficial tumors involve only the lining of the bladder. * an invasive tumor is growing into the layers of the wall of the bladder. The grade is simply an estimate of the speed of growth of the tumor based on what the cells look like under the microscope.

AJCC stage Description Jewett stagePrimary tumorTa noninvasive papillary carcinoma 0Tis carcinoma in situ 0Ti tumor invades subepithelial connective tissue AT2a = = superficial muscle B1 T2b = = deep muscle B2T3a = = perivesical tissue-microscopic only CT3b = = perivesical tissue-macroscopic CT4a = = prostate, uterus, vagina CT4b = = pelvic wall, abdominal wall CLymph nodesN1 single regional lymph node, <2cm in diameter D1N2 one or more lymph nodes, none>5 cm in diameter D1N3 = = = = = , >5 cm in diameter D1MetastasesM1 distant metastasis D2 ——————————————————\\\\———————————————————AJCC , American Joint Committee on Cancer

Grade Grade I: mild anaplasia (well differentiated) Grade II: moderate anaplasia (moderately differentiated) Grade III : sever anaplasia (poorly differentiated) Diagnosis :- 1- signs & symptoms. Approximately 80% of patients present with gross, painless haematuria. Dysuria & irritative symptoms are present in 20% of patients-especially those with carcinoma in situ. Secondary urinary infection may be present in about 30% of patients. Upper urinary tract obstruction signs 2- Cystoscopy. It is the most important investigation, it is important to confirm the presence of the tumor & to show the shape of the tumor whether it is small villous, papillary, sessile or pedunculated tumour. N.B :- the sessile tumor is the worst because it is very fast growing type. 3- Urinary cytology. Cells for microscopic examination are collected from voided urine or bladder washings. Urinary cytologic study is not sensitive(30%) in diagnosing low-grade bladder cancer but is excellent for detecting carcinoma in situ & high-grade lesions(90%). 4 - Flow cytometry. Is the computerized analysis of DNA content in exfoliated cells. The main advantage over routine cytologic study is the ability of flow cytometry to detect low-grade-tumors accurately. 5- Imaging studies ultrasound, IVU, CT scan (important to show any L.N involvement), MRI (to show the extent of the tumor)

Treatment :- 1 - carcinoma in situ & superfidal bladder cancer (Ta, T1):- TURBT & fulguration followed by a course of intravesical instillations of thiotepa, mitomycin or adriamycin . Or course of intravesical immunotherapy with intravesical bacille Calmette-Guerrin (BCG).the risk of overlooking neoplastic lesions of the bladder using white-light endoscopy is significant, so we can do photodynamic examination of the bladder ( 5-ALA is installed into the bladder through small Foley’ s catheter & by using U.V light, the carcinoma cells appear as red-colored cells, while the rest normal cells appear as blue-colored cells). - 2 invasive bladder cancer(T2b,T3a,T3b,T4a,T4b):- Radiotherapy or Surgery or combination of both A- partial cystectomy:- removal of a 2 cm margin of normal tissue around the tumor. Here the tumor should be single & away from the ureteric orifice at least by 1 inch & must be in the dome of the bladder. B- Radical cystectomy with urinary diversion is usually the treatment of choice for invasive bladder carcinomaIn male we do removal of the U.B, prostate & surrounding L.N. then do urinary diversion. Types of urinary diversion are :-*ureterosigmoidostomy *cutaneous ureterostomy* Ileal conduit *recently orthotopic ileal neobladder