BLADDER

TRAUMA,
INFLAMMATION,
TUMORS

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

BLADDER TRAUMA
The bladder is a pelvic hollow viscus which
may be damaged as a result of a penetrating
injury to the lower abd, or through the
course of pelvic surgery.

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

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

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

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
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

Congenital anomalies:
Diverticula.

- Vesical diverticulum consists of a pouch-like evagination of the

bladder wall.
- commonly arise as congenital defects but more commonly as acquired lesions
caused by persistent urethral obstruction.

Exstrophy
- is a developmental failure in the anterior wall of the abdomen and the bladder,
so that the bladder either communicates directly through a large defect with
the surface of the body or lies as an opened sac.

 Miscellaneous Anomalies
Vesicoureteral reflux is the most common and serious anomaly. As a major
contributor to renal infection and scarring (pyelonephritis).
Rarely, the urachus (the canal that connects the fetal bladder with the allantois)
may remain patent in part or in whole. When totally patent, a fistulous urinary
tract is created that connects the bladder with the umbilicus.

Bladder Inflammation: CYSTITIS

A.k.a. inflammation of the urinary bladder
Affects all ages
Prevalence

Childhood
Females
Pregnancy
menopause

CYSTITIS

acute
cystitis
chronic

Acute
bacterial
Acute nonbacterial

Chronic
bacterial
Nonbacterial

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

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

Suprapubic tenderness

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

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 CYSTITIS

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

TREATMENT
STOP / REMOVE IRRITATING AGENT
TREAT SUPERINFECTION

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
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
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

Tuberculous cystitis
Interstitial cystitis
Parasitic cystitis
Schistosomiasis
Trichomonal
Amoebic

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

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

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)
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

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%

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 >blood stream

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%)
Arises from

Extrophic bladder( commonest)

Urachal remnants
Misplaced prostatic glands
Area of cystitis cystica and glandularis
spontaneously

 Anaplastic ca
Rare
Poorly differentiated, infiltraion

Carcinoma in-situ :
A flat non-invasive , HIGH GRADE urothelial carcinoma

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

T (Primary tumour)
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Ta Non-invasive papillary carcinoma
Tis Carcinoma in situ (flat tumour)
T1 Tumour invades subepithelial connective tissue
T2a Tumour invades superficial muscle (inner half)
T2b Tumour invades deep muscle (outer half)
T3 Tumour invades perivesical tissue:
T3a Microscopically
T3b Macroscopically (extravesical mass)
T4a Tumour invades prostate, uterus or vagina
T4b Tumour invades pelvic wall or abdominal wall

N (Lymph nodes)
NX Regional lymph nodes cannot be
assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node
2 cm or less in greatest dimension
N2 Metastasis in a single lymph node
more than 2 cm but not more than 5 cm
in greatest dimension, or multiple lymph
nodes, none more than 5 cm in greatest
dimension
N3 Metastasis in a lymph node more than
5 cm in greatest dimension
M (Distant metastasis)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis.

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

Biopsy

TREATMENT
Depends on

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

TREATMENT
TisNoMo :
Intravesical chemotherapy
Immunotherapy
Total cystectomy

Ta-T1 NoMo

Transurethral endoscopic diathermy resection + follow up

Intravesical chemotherapy
Immunotherapy
Total cystectomy

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

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

PROGNOSIS
Tis Ta T1
T2-T3b
T4

5yr survival rate 80-90%

30-50%

Blacks worse prognosis

Women worse prognosis

0%

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.