This document summarizes different types of lower urinary tract infections including cystitis, urethritis, and ureteritis. It describes the typical causative agents, symptoms, pathological findings, and distinguishing features of various forms of cystitis including acute cystitis, tuberculous cystitis, interstitial cystitis, and metaplastic lesions of the bladder. Special conditions like malacoplakia and polypoid cystitis are also briefly discussed. Urethritis is mentioned as often being accompanied by cystitis in women and prostatitis in men.

1. LOWER URINARY TRACT INFECTION, CYSTITIS, AND URETHRITIS Sarawut Kongkarnka, MD, FRCPath Department of Pathology Faculty of Medicine Chiang Mai University

3. URETERITIS One component of lower urinary tract infections Entirely non-specific morphologic changes Chronic ureteritis - Persistence of infection - Repeated acute exacerbations

4. URETERITIS Specialized reaction patterns: - Ureteritis follicularis - Ureteritis cystica Ureteritis cystica. Note the smooth cysts projecting from the mucosa. http://library.med.utah.edu/WebPath/jpeg1/RENAL148.jpg

5. CYSTITIS Bacterial pyelonephritis frequently preceded by infection of urinary bladder Common agents are coliforms: Escherichia coli Proteus Klebsiella Enterobacter Women > Men: Shorter urethras

6. CYSTITIS Tuberculous cystitis Candidal cystitis, Cryptococcal cystitis Schistosomiasis Virus, Chlamydia, Mycoplasma Hemorrhagic cystitis: Cyclophosphamide Radiation cystitis Predisposing factors: Bladder calculi, bladder obstruction, DM, instrumentation, or immune deficiency

7. http :// www . drrajmd . com / conditions / bladder / cystitis / cystits / 19094 . jpg

8. Schistosoma life cycle. http :// www . newplague . org / Schistomes_LifeCycle . gif

9. CYSTITIS Triad of symptoms - Frequency: every 15-20 minutes - Lower abdominal pain - Dysuria: pain or burning on urination Acute cystitis. Hyperemia of the mucosa, sometimes associated with exudate.

10. CYSTITIS Hemorrhagic cystitis: Bleomycin Suppurative cystitis Ulcerative cystitis Chronic cystitis Follicular cystitis: DDx from lymphoma Eosinophilic cystitis

11. SPECIAL FORMS OF CYSTITIS Interstitial cystitis (Hunner cystitis) Persistent, painful, form of chronic cystitis occurring most frequently in women and associated with inflammation and fibrosis of all layers of the bladder wall Clinical Constellation of symptoms Cystoscopic findings: fissures and punctate hemorrhages in mucosa Hunner ulcers

12. Interstitial cystitis. http://www.health.harvard.edu/newsweek/images/cystitis2.jpg

13. Interstitial cystitis. http://www.smithinstituteforurology.com/images/patient_pelvic_hydrodistention_img_1.jpg

14. Interstitial cystitis. http://www.icaction.com/images/bladder_before.jpg

15. Interstitial cystitis. http://www.smithinstituteforurology.com/images/patient_pelvic_lesions_img_1.jpg

16. INTERSTITIAL CYSTITIS Early stage (nonclassic, nonulcerative) Late stage (classic, ulcerative) Biopsy Roles - Specific diagnosis - Rule out flat carcinoma in situ Autoimmune origin Associate with SLE, Sj Ö gren syndrome Incurable, palliative treatment for relief

17. MALACOPLAKIA Gross: soft yellow, slightly raised mucosal plaques, 3-4 cm in diameter Micro: infiltration with large, foamy histiocytes with occasional multinucleate giant cells and interspersed lymphocytes Von Hansemann macrophages: abundant granular cytoplasm (PAS +) Michaelis-Gutmann bodies

18. Cystitis with malacoplakia.

19. Malacoplakia (H&E stain)

20. Malacoplakia (PAS stain)

21. MALACOPLAKIA Colon, lung, bone, kidney, prostate, and epididymis Chronic bacterial infection: E. coli Immunocompromised host Defect in phagocytic or degradative functions of macrophages DDx: - Langerhans cell histiocytosis - Xanthogranulomatous inflammation

22. POLYPOID CYSTITIS Irritation to the bladder mucosa resulting in a polypoid configuration Urothelium: broad, bulbous, polypoid projection Benign course Both genders equally DDx: Papillary urothelial cell carcinoma

23. Polypoid cystitis.

24. POLYPOID CYSTITIS Polypoid cystitis Broad-based, thick papillae with marked edema Bullous cystitis Papillae with extensive edema such that width is greater than height Papillary cystitis End stage with slender finger-like papillae with more fibrosis

25. METAPLASTIC LESIONS Brunn nest grow downward into lamina propria Cystitis cystica: lined by urothelium Cystitis glandularis: lined by cuboidal or columnar epithelium Cystitis cystica et glandularis Not associate with adenocarcinoma

26. Cystitis cystica and Cystitis glandularis

27. Cystitis cystica

28. Cystitis glandularis

29. URETHRITIS Gonococcal and non-gonococcal urethritis Often accompanied by cystitis (women) and prostatitis (men) Chlamydia (e.g. C. trachomatis) Ureaplasma urealyticum Reiter syndrome: Triad of arthritis, conjunctivitis, and urethritis Local pain, itching, and frequency

30. THANKS FOR YOUR ATTENTION