Bladder

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BLADDER:TRAUMA, INFLAMMATION, TUMORS : 

BLADDER:TRAUMA, INFLAMMATION, TUMORS Olabamiyo Oluwole

BLADDER : 

BLADDER Gross anatomy Distensible sac-like organ for collecting urine before micturition Becomes intra-abdominal with distention Relations Ant- pubic symphysis Sup- intestine Post- rectum/ vagina+ cervix Lat- levator ani

Slide 3: 

Histology. Transitional cell epithelium Detrusor muscle Blood supply Superior and inferior vesical branches of internal iliac artery Venous plexus to internal iliac vein Lymph drainage Iliac and then para-aortic nodes Nerve supply Parasympathetic from S2-S4 (motor to wall, -ve to sphincter) Sympathetic (-ve to wall, +ve to sphincter) Pudendal nn. (external sphincter)

BLADDER TRAUMA : 

BLADDER TRAUMA Introduction Etiology Pathology Types of injury Clinical features Investigations treatment

BLADDER TRAUMA : 

BLADDER TRAUMA The bladder is a pelvic hollow viscus which many times gets injured in the multiply injured patient.

AETIOLOGY : 

AETIOLOGY Road traffic accidents + pelvic fractures Contact sports (blunt trauma) Obstetric trauma. Difficult hysterectomy Spontaneous/idiopatic.

PATHOLOGY : 

PATHOLOGY External injury to the empty bladder usually results in extraperitoneal rupture. When distended, injury usually results in intraperitoneal injury In children below 6yrs, it is usually an intraperitoneal injury

TYPES OF INJURY : 

TYPES OF INJURY Blunt injuries Bladder contusion Extraperitoneal rupture (80%; ant & lat parts) Intraperitoneal rupture (20%; dome of bladder) Open bladder injuries (stab, missiles) Vesical fistulae Vesico-vaginal Vesico-cutaneous

CLINICAL FEATURES : 

CLINICAL FEATURES History of trauma Lower abdominal pain Hematuria Suprapubic pain and swelling Failure to pass any urine Features of peritonitis(intraperitoneal)

INVESTIGATIONS : 

INVESTIGATIONS Retrograde urethrocystogram: extravasation of contrast into retropubic space or peritoneal cavity Cystoscopy IVU

TREATMENT : 

TREATMENT Resuscitation of the injured patient Contused bladder Urinary catheterisation for 7-10 days Antibiotics Extraperitoneal rupture Conservative: as above OR Laparotomy (to exclude intraperitoneal injury) Suture tear in bladder Urinary catheterisation for 7-10 days Antibiotics

TREATMENT : 

TREATMENT Intraperitoneal rupture Laparotomy Suture tear in bladder Urinary catheterisation for 7-10 days Antibiotics The duration between injury and repair determines mortality. Very high if >48hrs

Bladder inflammation : 

Bladder inflammation

CYSTITIS : 

CYSTITIS A.k.a. inflammation of the urinary bladder Affects all ages Prevalence Childhood Females Pregnancy menopause

CYSTITIS : 

CYSTITIS

ACUTE BACTERIAL : 

ACUTE BACTERIAL Etiology: E. coli, Proteus vulgaris, P. aeruginosa, Strep faecalis, S. aureus, C. albicans, Klebsiella spp Routes Ascending (p-papilla & p-papilla receptors) Descending Instrumentation Blood lymphatic

PATHOLOGY : 

PATHOLOGY Trigone and base are most commonly affected Congested blood Submucosal hemorrhages Fibrinous or purulent discharge Histology: leukocyte infiltration mucosal and submucosal oedema

CLINICAL FEATURES : 

CLINICAL FEATURES Frequency, urgency, dysuria, strangury +/- hematuria Chills, rigors, sweating. Nausea, giddiness, tiredness Urine: foul odor and debris Examination: nothing significant Suprapubic tenderness

INVESTIGATIONS : 

INVESTIGATIONS Urinalysis – mid stream urine (pus cells, proteinuria) IVU- (bladder calculus, effects of BOO) Cystoscopy – reduced bladder capacity, hyperemia

TREATMENT : 

TREATMENT Antibiotics. Empirically nitrofurantoin, nalidixic acid, septrin, cephalosporin. Then according to culture and sensitivity tests Increase fluid intake Alkalinise urine Treat predisposing factors, sources of ascending and descending infections

ACUTE NON-BACTERIAL : 

ACUTE NON-BACTERIAL chemical (formaldehyde, silver nitrate, CYCLOPHOSPHAMIDE) Radiation Mechanical (foreign bodies, bladder calculi) Allergic ( drugs) ABACTERIAL PYURIA

TREATMENT : 

TREATMENT STOP / REMOVE IRRITATING AGENT TREAT SUPERINFECTION

CHRONIC BACTERIAL CYSTITIS : 

CHRONIC BACTERIAL CYSTITIS Chronic inflammation with episodes of acute exacerbation PATHOLOGY {macro} Hyperplastic mucosa + bullous oedema {micro} Granulation tissue + macrophages + giant cells (sometimes in the muscle layer)

CLINICAL FEATURES : 

CLINICAL FEATURES Similar to acute but milder and of gradual onset Recurrent episodes of acute exacerbation INVESTIGATIONS Urine m/c/s Cystoscopy IVU and USS r/o tuberculosis

TREATMENT : 

TREATMENT Antibiotics. Empirically nitrofurantoin, nalidixic acid, septrin, cephalosporin. Then according to culture and sensitivity tests Increase fluid intake Alkalinise urine Treat predisposing factors, sources of ascending and descending infections Antispasmodic agents, sedation and analgesics

CHRONIC NON-BACTERIAL CYSTITIS : 

CHRONIC NON-BACTERIAL CYSTITIS Tuberculous cystitis Interstitial cystitis Parasitic cystitis Schistosomiasis Trichomonal Amoebic

NEUROGENIC BLADDER : 

NEUROGENIC BLADDER Malfunctioning urinary bladder due to neurologic dysfunction or insult emanating from internal or external trauma, disease or injury.

PRESENTATION : 

PRESENTATION

BLADDER TUMORS : 

BLADDER TUMORS Introduction Epidemiology Aetiology Classification and staging Clinical features Investigations Complications treatment

INTRODUCTION : 

INTRODUCTION Benign tumors are rare Bladder cancer is the 2nd most common genitourinary neoplasm after ca prostate

EPIDEMIOLOGY : 

EPIDEMIOLOGY Industrialized / caucasians > blacks 16-20/100000 in men ; 5/100000 in women M:F 3:1 Incidence increases with age usually >50yrs Peak prevalence 60-70 years (median 68yrs)* Incidence is rising: from 1985 to 2000 by 33%* Recurrence is high up to 80%* M & M in U.S. : [in 2004] 60,200 new patients, 12,700 of them died* *Gary David Steinberg, prof of urology, university of chicago cancer research center

AETIOLOGY : 

AETIOLOGY Tobacco (carcinogenic arylamines e.g nitrosamine, 2-naphthylamine, 4-aminobiphenyl) Exposure to aniline and aromatic dyes, solvents, paints, leather dust, inks, rubber Phenacetin abuse Chemotherapy with cyclophosphamide (acrolein)

AETIOLOGY : 

AETIOLOGY Schisosomiasis Prior irradiation of the pelvis Long term indwelling catheters (scc) familial;- (no convincing evidence)* TSG for p53 (xsome 17)- high grade& CIS TSG for p16 (xsome 9)- low grade

Classification and staging : 

Classification and staging Urothelial primary tumors Transitional cell carcinoma Squamous cell carcinoma Adenocarcinoma Anaplastic ca Non-urothelial primary tumors (rare) Sarcoma, neurofibroma, small cell ca, Secondary tumors (direct spread from prostate and cervix)

Transitional cell carcinoma >90% : 

Transitional cell carcinoma >90% Commonest bladder tumor Could be papillary(pedunculated) OR nodular(sessile) Papillary: well-differentiated, low invasion Nodular: poorly-diff, high invasion TCCs are often multiple Spread: direct> lymphatic (V,H,C.I) >blood stream (L,L,B)

Squamous cell carcinoma <5% : 

Squamous cell carcinoma <5% Associated with persistent inflammation from Long term Indwelling catheter Schistosomiasis Bladder stones Metaplasia of the transitional epithelium Common in underdeveloped countries

Adenocarcinoma (<2%) : 

Adenocarcinoma (<2%) Arises from Extrophic bladder( commonest) Urachal remnants Misplaced prostatic glands Area of cystitis cystica and glandularis spontaneously

Slide 41: 

Anaplastic ca Rare Poorly differentiated, infiltraion Carcinoma –in-situ : A flat non-invasive , HIGH GRADE urothelial carcinoma

Non urothelial primary tumors : 

Non urothelial primary tumors sarcomas Rare (<3%) Rhabdomyosarcoma Leiomyosarcoma Fibrosarcoma Myxosarcoma Primary malignant lymphoma Neurofibroma Small cell carcinoma ( from neuroendocrine stem cells) Phaechromocytomas carcinocarcinoma

Histological staging [UICC 1987] : 

Histological staging [UICC 1987] Tis: Ca-in-situ Ta: Papillary non-invasive Ca T1: invasion of sub-mucosa to lamina propria T2: invasion of superficial muscle to muscularis propria T3a: invasion of deep muscle T3b: invasion of perivesical fat; mobile T4a: invasion of contiguous organs(prostate,uterus,cervix,vagina) T4b: invasion of pelvic/ abdominal wall; fixed

Histological staging : 

Histological staging N1 single node <2cm N2 single node >2cm <5cm / multiple<5cm N3 >5cm M1 distant metastases Clincal staging is done with cystoscopy, biopsy, palpation UGA, IVU/USS,

CLINICAL FEATURES : 

CLINICAL FEATURES Gross hematuria- total/ terminal; intermittent Symptoms of cystitis (when infection suprvenes) Loin pain (hydroureters/hydronephrosis) Weak stream, retentiion (involvement of bladder neck) Sloughs in urine (tumor necrosis) Uni/ bi- lateral pedal edema (venous/ lymphatic occlusion) Wt loss, malaise, severe anaemia, bone pain

CLINICAL FEATURES : 

CLINICAL FEATURES Suprapubic mass (tumor/ urinary retention) Palpable and tender kidneys (hydronephrosis VE / DRE: mass at base of bladder Bimanual exam under GA of tumor (findings correlate with clinical stage of tumor)

INVESTIGATIONS : 

INVESTIGATIONS Pcv (anaemia) Urine C/S (infection) Urine cytology: barbotage better than voided (tumour cells) flow cytometry (diploid better aneuploid) Renal fxn test IVU (hydronephrosis) X ray: chest, bones, calcification in bladder(schistosomiasis)

INVESTIGATIONS : 

INVESTIGATIONS USS – spread of tumor CT scan, MRI (staging) Cystoscopy Number - size Surface - condition of adjacent mucosa position Biopsy

TREATMENT : 

TREATMENT Depends on Degree of invasion Cell type Grade of differentiation Accessibility Size and number of tumor Age and clinical condition of patient

TREATMENT : 

TREATMENT TisNoMo : Intravesical chemotherapy Immunotherapy Total cystectomy Ta-T1 NoMo Transurethral endoscopic diathermy resection + follow up Intravesical chemotherapy Immunotherapy Total cystectomy

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T2 No/N1Mo Partial cystectomy Radical Radiotherapy + salvage cystectomy Radical cystectomy + urinary diversions T3 No/N1Mo Radical Radiotherapy + salvage cystectomy Radical cystectomy + urinary diversions T4 N1Mo/M1 Radical Radiotherapy Systemic chemotherapy Neoadjuvant chemotherapy

Treatment of non-TCC : 

Treatment of non-TCC Squamous cell ca: radical cystectomy + pre-op radiotherapy sarcoma : radical cystectomy + chemotherapy Adenocarcinoma: radical cystectomy + urinary diversion

FOLLOW-UP : 

FOLLOW-UP Cystoscopy + bimanual exam every 3mths for 1yr, then half-yearly for 1yr then yearly Annual IVU Urinary cytology every 3mths +/- USS, CT, MRI

COMPLICATIONS : 

COMPLICATIONS Hemorrhage/ anaemia Cystitis / radiation cystitis /hemorrhagic Hydronephrosis, hyrdroureter, renal failure Urinary retention Fistulae Limb oedema

PROGNOSIS : 

PROGNOSIS Tis Ta T1 5yr survival rate 80-90% T2-T3b 30-50% T4 0% Blacks worse prognosis Women worse prognosis

CONCLUSION : 

CONCLUSION The urinary bladder is an important organ of the body, one of its kind. A good knowledge of its anatomy, physiology and pathologies will go a long way in preparing the practitioner for management of the various bladder problems.

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