Lower Urinary Tract

Ureter
Congenital anomalies
Double ureters
Ureteropelvic junction obstruction
Diverticula
Hydroureter dilation & tortuosity of the ureter
Inflammation
ureteritis may develop as one component of urinary
tract infection
Obstructive lesions of the ureter
 Tumors of the ureter
Primary neoplasia of ureter is rare
Benign tumors include leimyoma & fibroepithelial polyp
Primary malignant tumors are usually transitional cell
carcinomas
Urinary bladder
 Congenital anomalies of U.bladder
Diverticula
Out pouching of the bladder mucosa
could be congenital or acquired from persistent urethral
obstruction
urinary stasis = predispose to infection, formation of bladder
calculi
impingement on the ureter = vesicouretral reflux
 Bladder Exstrophy
Presence of a developmental failure in the anterior abdominal
wall & bladder so that the bladder either communicates
directly through a large defect with the surface of the body or
lies as an opened sac
Infection & pyelonephritis with predisposition to
adenocarcinoma are important sequel
 Persistent urachus
Urachus may remain patent in part or in whole
When totally patent, fistulous tract is created that connects the
bladder with umbilicus
Partial retention results in a diverticulum arising from the dome of
the bladder.
central area may persist & present as a cyst
Adenocarcinoma develop in these urachal reminant
Inflammation
Acute & chronic cystitis
Cystitis is common in young women of reproductive age & in
older age groups of both sexes
Common etiologic agents include E.coli, Proteus, Kleibsiela,
enterobacter
Women are more likely to develop cystitis as a result of their
shorter urethras
Other causes tuberculous cystitis, candida albicans , schistosoma
hematobium
Radiation, drugs & trauma due to instrumentation cause cystitis,
which is often sterile
 Predisposing factors include:
bladder calculi
urinary obstruction
diabetes mellitus
instrumentation &
immune deficiency
 Morphology of cystitis
hypermia of the mucosa associated with
exudate
 Clinical features
All cystitis are characterized by a triad of
symptoms
Frequency
Lower abdominal pain localized on suprapubic
region
Dysuria
Cystitis is important as antecedents to
pyelonephritis
Malacoplakia
peculiar pattern of vesical inflammatory reaction
characterized
Macroscopically- by soft, yellow, slightly raised mucosal
plaques 3 to 4 cm in diameter
Histologically- by infiltration with large, foamy macrophages
with occasional multinucleate giant cells and interspersed
lymphocytes
Michaelis-Gutmann bodies
Related to chronic bacterial infection, mostly by E. coli
or occasionally Proteus species
occurs with increased frequency in immunosuppressed
transplant recipients
Neoplasms
95% of bladder tumors are epithelial origin
Urothelial (transitional cell) tumors
account for 90% of all bladder tumors
range from small benign tumor to aggressive cancers
many of the tumors are multifocal at presentation
Morphology
gross pattern of urothelial tumors vary from papillary to nodular
or flat
 The histologic changes encompass a spectrum from
benign papilloma to invasive carcinoma
Squamous cell carcinoma
Account about 3-7% of bladder cancer
Arise from metaplastic squamous epithelium
occurs most often in association with calculi &
schistosomaisis
Adenocarcinoma
Rare
Some arise from urachal reminant or intestinal
metaplasia
Pathogenesis
80% of patients are b/n age of 50-80 yrs, more common in men
Many factors are implicated in causation of transitional cancer
Cigarette smoking- the most important
Industrial exposure to arylamines
Schistosoma hematobium
Analgesics
Long term use of cyclophosphamide
Radiation
 Clinical features
Bladder tumors classically produce painless hematuria
But frequency, dysuria & urgency occasionally
accompany the hematuria
Characteristically urothelial tumors tend to recur after
excision
Prognosis depend on stage & grade at diagnosis
Mesenchymal tumors
Benign leiomyoma
Malignant embryonal rhabdomyosarcoma,
leimyosarcoma
Obstruction
A great variety of intrinsic & extrinsic diseases of bladder can
cause partial or complete vesical obstruction
Enlargment of prostate either due to hyperplasia or carcinoma
Cystocele of the bladder
Urethral strictures
Bladder tumor
Mechanical obstruction by foreign bodies & calculi
Neurogenic bladder
Urethra
Inflammations
Urethritis is classically divided into gonococcal & non
gonococcal urethritis
Gonococcal urethritis is one of the earliest manifestation
of this venereal infection
Non gonococcal urethritis is common & can be caused
by a variety of bacteria , among which E.coli & other
enteric organisms predominate
Tumors
Benign transitional cell papilloma,
condyloma
Malignant urothelial carcinoma
 Hypospadias
Incidence: up to 1:250 births
Associations: undescended testicles (DSD),
inguinal hernias
Management: recognition, avoidance of
circumcision
Surgery: usually by 2 years of life
Hypo/Epispadias
Hypospadias
 Epispadias
Incidence: 1:10,000 to 1:20,000
Associations: Bladder exstrophy, VUR (40%)
Management: recognition, avoidance of
circumcision
Surgery: multistaged reconstruction