What Is Interstitial Cystitis? Symptoms, Causes, Diagnosis, Treatment, and Prevention

There isn’t any single treatment that works for everyone with interstitial cystitis. Your doctor will recommend treatments on the basis of your symptoms and whether previous treatments have failed to control them. (1)

The American Urological Association recommends starting with more conservative therapies, before gradually moving to more invasive treatments when “symptom control is inadequate for acceptable quality of life.” (4)

Treatment strategies for IC typically follow this series of phases.

Phase 1: Lifestyle measures and physical therapy The first step in treating IC is to identify things that trigger your symptoms, such as stress or certain foods and beverages. Your doctor may also recommend that you see a pelvic floor physical therapist, who can manipulate muscles in the area or prescribe exercises to help with symptoms.

Phase 2: Medications Your doctor may prescribe a number of drugs to treat IC symptoms. Some of these medications are taken my mouth, while others are applied directly to the bladder through a catheter (narrow tube).

Phase 3: Neuromodulation, ulcer cauterization, and Botox Neuromodulation involves delivering electrical impulses to nerves to change how they work. Cauterizing bladder ulcers (known as Hunner’s ulcers) can offer long-term pain relief, and Botox (botulinum toxin) injections into the bladder muscle may help reduce IC pain when other treatments don’t.

Phase 4: Cyclosporine This immunosuppressant drug carries many risks, but it may help when other treatments for IC are ineffective.

Phase 5: Surgery As a last resort, surgery to divert the flow of urine or remove the bladder may be considered. (1,2)

Medication Options

At first, your doctor may recommend that you take over-the-counter pain relief medications for interstitial cystitis. If additional drug treatments are needed, your doctor may recommend the following oral drugs (taken by mouth):

Your doctor may also consider administering the following drugs by injection to your bladder:

• Dimethyl sulfoxide (DMSO)
• Heparin
• Lidocaine

As an alternative to cauterization, your doctor may decide to inject the steroid drug triamcinolone at the site of a bladder ulcer.

Botox (botulinum toxin) is a drug that paralyzes muscles when injected into them, and may be considered as a bladder treatment for IC when prior treatments are no longer adequate.

Cyclosporine, the last drug that is typically considered for IC, is an oral drug that suppresses the immune system. While it may provide symptom relief, it carries significant risks, including a generally higher risk of infection. (1,4)

Prevention of Interstitial Cystitis

Since the causes of interstitial cystitis are unclear, and the condition may have multiple causes, there aren’t any specific steps you can take to avoid IC in the first place.

But once you have IC, there are a number of lifestyle measures that may help reduce your symptoms.

Avoiding foods that cause bladder irritation may help relieve symptoms of interstitial cystitis.

Common bladder-irritating foods include:

• Tomatoes
• Citrus fruits
• Spicy foods
• Chocolate
• Coffee and caffeinated beverages
• Alcoholic beverages
• Carbonated beverages

Since so many foods can contribute to symptoms of interstitial cystitis, you may benefit from an elimination diet, in which you stop eating all potential irritant foods for one to two weeks. If your symptoms improve, you can then gradually reintroduce eliminated foods to see if they trigger any symptoms.

Emotional or mental stress can contribute to IC symptoms, so it’s important to identify potential sources of stress in your life and avoid or cope with them to the best of your ability. (1)

Stages, Symptoms, Treatment & Tests

Overview

Blue Light Technology in Bladder Cancer Therapy

What is bladder cancer?

The bladder, a hollow organ in the lower part of the abdomen, serves as a reservoir for urine until it is discharged out of the body through the urethra.

There are different types of bladder cancer. The cancer cell type can be transitional cell carcinoma, squamous cell carcinoma or adenocarcinoma—each named for the types of cells that line the wall of the bladder where the cancer originates.

• Most bladder cancers (more than 90 percent) start from the transitional cells, which occupy the innermost lining of the bladder wall. The cancers, which originate in these cells lining the bladder can, in some instances, invade into the deeper layers of the bladder (called the lamina propria), the thick muscle layer of the bladder, or through the bladder wall into the fatty tissues that surround the bladder.
• Squamous cells are thin flat cells that line the urethra and can form in the bladder after long bouts of bladder inflammation or irritation. Squamous cell carcinoma makes up about 5 percent of bladder cancers.
• Adenocarcinoma is a very rare type of bladder cancer that begins in glandular (secretory) cells in the lining of the bladder. Only 1 percent to 2 percent of bladder cancers are adenocarcinoma.

What are the stages of bladder cancer?

Bladder cancer can be either early stage (confined to the lining of the bladder) or invasive (penetrating the bladder wall and possibly spreading to nearby organs or lymph nodes).

The stages range from TA (confined to the internal lining of the bladder) to IV (most invasive). In the earliest stages (TA, T1 or CIS), the cancer is confined to the lining of the bladder or in the connective tissue just below the lining, but has not invaded into the main muscle wall of the bladder.

Stages II to IV denote invasive cancer:

• In Stage II, cancer has spread to the muscle wall of the bladder.
• In Stage III, the cancer has spread to the fatty tissue outside the bladder muscle.
• In Stage IV, the cancer has metastasized from the bladder to the lymph nodes or to other organs or bones.

A more sophisticated and preferred staging system is known as TNM, which stands for tumor, node involvement and metastases. In this system:

• Invasive bladder tumors can range from T2 (spread to the main muscle wall below the lining) all the way to T4 (tumor spreads beyond the bladder to nearby organs or the pelvic side wall).
• Lymph node involvement ranges from N0 (no cancer in lymph nodes) to N3 (cancer in many lymph nodes, or in one or more bulky lymph nodes larger than 5 cm).
• M0 means that there is no metastasis outside of the pelvis. M1 means that it has metastasized outside of the pelvis.

Symptoms and Causes

What are the warning signs of bladder cancer?

Some symptoms of bladder cancer are also symptoms of other conditions, and should prompt a visit to your physician. Blood in the urine is the most important warning sign. Pain during urination, frequent urination or difficulty urinating are other symptoms.

Diagnosis and Tests

What tests will I have if my doctor suspects bladder cancer or another urinary problem?

Your doctor will want to analyze your urine (urinalysis) to determine if an infection could be a cause of your symptoms. A microscopic examination of the urine, called cytology, will look for cancer cells.

A cystoscopy is the main procedure to identify and diagnose bladder cancer. In this procedure, a lighted telescope (cystoscope) is inserted into your bladder from the urethra to view the inside of the bladder and, when done under anesthesia, take tissue samples (biopsy), which are later examined under a microscope for signs of cancer. When this procedure is done in the doctor’s office, local anesthesia gel is placed into the urethra prior to the procedure to minimize the discomfort.

If the diagnosis of bladder cancer is made, then the next step is to remove the tumor for detailed staging and diagnosis.

Transurethral resection (TURBT) is a procedure done under general or spinal anesthesia in the operating room. A telescope is inserted into the bladder and the tumor is removed by scraping it from the bladder wall (a portion of the bladder wall is removed with it), using a special cystoscope (called a resectoscope). This procedure is diagnostic as well as therapeutic.

This often can be done as an outpatient procedure, with patients discharged from hospital the same day. After removal, the tumor is analyzed by a pathologist, who will determine the type of tumor, the tumor grade (aggressiveness) and the depth of invasion. The purpose of the procedure is to remove the tumor and obtain important staging information (such as the tumor grade and depth of invasion).

For some patients with invasive cancer, a CT scan of the abdomen and pelvis might be the next step to determine if there is any spread of the disease outside of the bladder.

Magnetic resonance imaging, which uses a magnet, radio waves, and a computer to take detailed images, can also be done, and is helpful in planning additional treatment.

A chest X-ray may also be performed to detect if any cancer has spread to the lungs. At times, a bone scan may be performed to look for metastasis (spread) of the cancer to the bone. Most of these tests are used selectively, i.e., only in certain patients with related symptoms.

Once bladder cancer is diagnosed, staging of the disease is done using the tests described above. The stage of the disease will determine the treatment course.

Management and Treatment

What are the treatment options for bladder cancer?

There are four types of treatment for patients with bladder cancer. These include:

Sometimes, combinations of these treatments will be used.

Surgical options

Surgery is a common treatment option for bladder cancer. The type of surgery chosen will depend on the stage of the cancer.

• Transurethral resection of the bladder is used most often for early stage disease (TA, T1, or CIS). It is done under general or spinal anesthesia. In this procedure, a special telescope called a resectoscope is inserted through the urethra into the bladder. The tumor is then trimmed away with the resectoscope, using a wire loop, and the raw surface of the bladder is then fulgurated (destroyed with an electric current).
• Partial cystectomy is the removal of a section of the bladder. At times, it is used for a single tumor that invades the bladder wall in only one region of the bladder. This type of surgery retains most of the bladder. Chemotherapy or radiation therapy is often used in combination. Only a minority of patients will qualify for this bladder-sparing procedure.
• Radical cystectomy is complete removal of the bladder. It is used for more extensive cancers and those that have spread beyond the bladder (or several early tumors over a large portion of the bladder).

This surgery is often done using a robot, which removes the bladder and any other surrounding organs. In men, this is the prostate and seminal vesicles. In women, the ovaries, uterus and a portion of the vagina may be removed along with the bladder.

Because the bladder is removed, a procedure called a urinary diversion must be done so that urine can exit the body. A pouch constructed of intestine may be made inside the body, or a leak-proof bag worn outside the body may be used to collect urine. The procedure typically requires a hospital stay of five to six days, give or take a few either way.

Chemotherapy

Chemotherapy refers to the use of any of a group of drugs whose main effect is either to kill or slow the reproduction of rapidly multiplying cells. Cancer cells absorb chemotherapy drugs faster than normal cells do (but all cells are exposed to the chemotherapy drug). Chemotherapy drugs are delivered intravenously (through a vein) or can be delivered intravesically (directly into the bladder through a catheter threaded through the ureter), depending on the stage of the cancer.

Some common chemotherapy drugs that are used for the treatment of bladder cancer include:

• Methotrexate
• Vinblastine
• Doxorubicin
• Cyclophosphamide
• Paclitaxel
• Carboplatin
• Cisplatin
• Ifosfamide
• Gemcitabine

Many of these drugs are used in combinations.

Side effects can occur with chemotherapy, and their severity depends on the particular drug used and the ability of the patient to tolerate the drugs. Common side effects from chemotherapy include:

Chemotherapy can be used alone, but is often used with surgery or radiation therapy.

Intravesical therapy

Bladder cancer may be treated with intravesical (into the bladder through a tube inserted into the urethra) immunotherapy or chemotherapy.

Immunotherapy refers to using the body’s own immune system to attack the cancer cells. A vaccine called Bacillus Calmette-Guérin (BCG) is commonly used for this purpose in the intravesical treatment of stages Ta, T1, or carcinoma in situ (limited to the innermost lining) bladder cancers. In the procedure, a solution containing BCG is retained in the bladder for a few hours before being drained.

Intravesical BCG is usually given once a week for six weeks, but sometimes long-term maintenance therapy is needed. Bladder irritation, pain or burning during urination, and low-grade fever and chills are possible side effects of intravesical BCG.

Intravesical chemotherapy with mitomycin C is another treatment option. Because the chemotherapy is given directly into the bladder, other cells in the body aren’t exposed to the chemotherapy, which reduces the chances for side effects from the chemotherapy. It’s also often given as a single dose after a tumor has been removed via cystoscopy.

Radiation therapy

Radiation therapy damages the DNA of cancer cells by bombarding them with high-energy X-rays or other types of radiation. It may be an alternative to surgery or used in combination with surgery or chemotherapy. Radiation therapy can be delivered externally or internally.

In external radiation therapy, the radiation source is a machine outside the body that directs a focused beam of radiation at the tumor. With better imaging technologies in use today, computer-guided radiation delivered from several angles minimizes radiation exposure to surrounding tissues and organs, limiting damage to these tissues. Fatigue, swelling of soft tissues and skin irritation are common side effects of external radiation.

Internal radiation therapy is not often used for bladder cancer. In this type of treatment, a radioactive pellet is inserted into the bladder through the urethra or an incision in the lower abdomen. Internal radiation requires a hospital stay during the course of treatment, which can be several days, after which the pellet is removed.

Prevention

What are the risk factors for bladder cancer?

Some factors increase the risk of bladder cancer:

• Cigarette smoking is the biggest risk factor; it more than doubles the risk. Pipe and cigar smoking and exposure to second-hand smoking may also increase one’s risk.
• Prior radiation exposure is the next most common risk factor (e.g., as treatment for cervical cancer, prostate cancer or rectal cancer).
• Certain chemotherapy drugs (e.g., cyclophosphamide) also increase the risk of bladder cancer.
• Environmental exposures increase the risk of bladder cancer. People who work with chemicals, such as aromatic amines (chemicals used in dyes) are at risk. Extensive exposure to rubber, leather, some textiles, paint, and hairdressing supplies, typically related to occupational exposure, also appears to increase the risk.
• Infection with a parasite known as Schistosoma haematobium, which is more common in developing countries and the Middle East. (This organism is not found in the United States.)
• People who have frequent infections of the bladder, bladder stones, or other diseases of the urinary tract, or who have chronic need for a catheter in the bladder, may be at higher risk of squamous cell carcinoma.
• Patients with a previous bladder cancer are at increased risk to form new or recurrent bladder tumors.

Other risk factors include diets high in fried meats and animal fats, and older age. In addition, men have a three-fold higher risk than women.

Resources

Download Our Free Treatment Guide

Stages, Symptoms, Treatment & Tests

Overview

Blue Light Technology in Bladder Cancer Therapy

What is bladder cancer?

The bladder, a hollow organ in the lower part of the abdomen, serves as a reservoir for urine until it is discharged out of the body through the urethra.

There are different types of bladder cancer. The cancer cell type can be transitional cell carcinoma, squamous cell carcinoma or adenocarcinoma—each named for the types of cells that line the wall of the bladder where the cancer originates.

• Most bladder cancers (more than 90 percent) start from the transitional cells, which occupy the innermost lining of the bladder wall. The cancers, which originate in these cells lining the bladder can, in some instances, invade into the deeper layers of the bladder (called the lamina propria), the thick muscle layer of the bladder, or through the bladder wall into the fatty tissues that surround the bladder.
• Squamous cells are thin flat cells that line the urethra and can form in the bladder after long bouts of bladder inflammation or irritation. Squamous cell carcinoma makes up about 5 percent of bladder cancers.
• Adenocarcinoma is a very rare type of bladder cancer that begins in glandular (secretory) cells in the lining of the bladder. Only 1 percent to 2 percent of bladder cancers are adenocarcinoma.

What are the stages of bladder cancer?

Bladder cancer can be either early stage (confined to the lining of the bladder) or invasive (penetrating the bladder wall and possibly spreading to nearby organs or lymph nodes).

The stages range from TA (confined to the internal lining of the bladder) to IV (most invasive). In the earliest stages (TA, T1 or CIS), the cancer is confined to the lining of the bladder or in the connective tissue just below the lining, but has not invaded into the main muscle wall of the bladder.

Stages II to IV denote invasive cancer:

• In Stage II, cancer has spread to the muscle wall of the bladder.
• In Stage III, the cancer has spread to the fatty tissue outside the bladder muscle.
• In Stage IV, the cancer has metastasized from the bladder to the lymph nodes or to other organs or bones.

A more sophisticated and preferred staging system is known as TNM, which stands for tumor, node involvement and metastases. In this system:

• Invasive bladder tumors can range from T2 (spread to the main muscle wall below the lining) all the way to T4 (tumor spreads beyond the bladder to nearby organs or the pelvic side wall).
• Lymph node involvement ranges from N0 (no cancer in lymph nodes) to N3 (cancer in many lymph nodes, or in one or more bulky lymph nodes larger than 5 cm).
• M0 means that there is no metastasis outside of the pelvis. M1 means that it has metastasized outside of the pelvis.

Symptoms and Causes

What are the warning signs of bladder cancer?

Some symptoms of bladder cancer are also symptoms of other conditions, and should prompt a visit to your physician. Blood in the urine is the most important warning sign. Pain during urination, frequent urination or difficulty urinating are other symptoms.

Diagnosis and Tests

What tests will I have if my doctor suspects bladder cancer or another urinary problem?

Your doctor will want to analyze your urine (urinalysis) to determine if an infection could be a cause of your symptoms. A microscopic examination of the urine, called cytology, will look for cancer cells.

A cystoscopy is the main procedure to identify and diagnose bladder cancer. In this procedure, a lighted telescope (cystoscope) is inserted into your bladder from the urethra to view the inside of the bladder and, when done under anesthesia, take tissue samples (biopsy), which are later examined under a microscope for signs of cancer. When this procedure is done in the doctor’s office, local anesthesia gel is placed into the urethra prior to the procedure to minimize the discomfort.

If the diagnosis of bladder cancer is made, then the next step is to remove the tumor for detailed staging and diagnosis.

Transurethral resection (TURBT) is a procedure done under general or spinal anesthesia in the operating room. A telescope is inserted into the bladder and the tumor is removed by scraping it from the bladder wall (a portion of the bladder wall is removed with it), using a special cystoscope (called a resectoscope). This procedure is diagnostic as well as therapeutic.

This often can be done as an outpatient procedure, with patients discharged from hospital the same day. After removal, the tumor is analyzed by a pathologist, who will determine the type of tumor, the tumor grade (aggressiveness) and the depth of invasion. The purpose of the procedure is to remove the tumor and obtain important staging information (such as the tumor grade and depth of invasion).

For some patients with invasive cancer, a CT scan of the abdomen and pelvis might be the next step to determine if there is any spread of the disease outside of the bladder.

Magnetic resonance imaging, which uses a magnet, radio waves, and a computer to take detailed images, can also be done, and is helpful in planning additional treatment.

A chest X-ray may also be performed to detect if any cancer has spread to the lungs. At times, a bone scan may be performed to look for metastasis (spread) of the cancer to the bone. Most of these tests are used selectively, i.e., only in certain patients with related symptoms.

Once bladder cancer is diagnosed, staging of the disease is done using the tests described above. The stage of the disease will determine the treatment course.

Management and Treatment

What are the treatment options for bladder cancer?

There are four types of treatment for patients with bladder cancer. These include:

Sometimes, combinations of these treatments will be used.

Surgical options

Surgery is a common treatment option for bladder cancer. The type of surgery chosen will depend on the stage of the cancer.

• Transurethral resection of the bladder is used most often for early stage disease (TA, T1, or CIS). It is done under general or spinal anesthesia. In this procedure, a special telescope called a resectoscope is inserted through the urethra into the bladder. The tumor is then trimmed away with the resectoscope, using a wire loop, and the raw surface of the bladder is then fulgurated (destroyed with an electric current).
• Partial cystectomy is the removal of a section of the bladder. At times, it is used for a single tumor that invades the bladder wall in only one region of the bladder. This type of surgery retains most of the bladder. Chemotherapy or radiation therapy is often used in combination. Only a minority of patients will qualify for this bladder-sparing procedure.
• Radical cystectomy is complete removal of the bladder. It is used for more extensive cancers and those that have spread beyond the bladder (or several early tumors over a large portion of the bladder).

This surgery is often done using a robot, which removes the bladder and any other surrounding organs. In men, this is the prostate and seminal vesicles. In women, the ovaries, uterus and a portion of the vagina may be removed along with the bladder.

Because the bladder is removed, a procedure called a urinary diversion must be done so that urine can exit the body. A pouch constructed of intestine may be made inside the body, or a leak-proof bag worn outside the body may be used to collect urine. The procedure typically requires a hospital stay of five to six days, give or take a few either way.

Chemotherapy

Chemotherapy refers to the use of any of a group of drugs whose main effect is either to kill or slow the reproduction of rapidly multiplying cells. Cancer cells absorb chemotherapy drugs faster than normal cells do (but all cells are exposed to the chemotherapy drug). Chemotherapy drugs are delivered intravenously (through a vein) or can be delivered intravesically (directly into the bladder through a catheter threaded through the ureter), depending on the stage of the cancer.

Some common chemotherapy drugs that are used for the treatment of bladder cancer include:

• Methotrexate
• Vinblastine
• Doxorubicin
• Cyclophosphamide
• Paclitaxel
• Carboplatin
• Cisplatin
• Ifosfamide
• Gemcitabine

Many of these drugs are used in combinations.

Side effects can occur with chemotherapy, and their severity depends on the particular drug used and the ability of the patient to tolerate the drugs. Common side effects from chemotherapy include:

Chemotherapy can be used alone, but is often used with surgery or radiation therapy.

Intravesical therapy

Bladder cancer may be treated with intravesical (into the bladder through a tube inserted into the urethra) immunotherapy or chemotherapy.

Immunotherapy refers to using the body’s own immune system to attack the cancer cells. A vaccine called Bacillus Calmette-Guérin (BCG) is commonly used for this purpose in the intravesical treatment of stages Ta, T1, or carcinoma in situ (limited to the innermost lining) bladder cancers. In the procedure, a solution containing BCG is retained in the bladder for a few hours before being drained.

Intravesical BCG is usually given once a week for six weeks, but sometimes long-term maintenance therapy is needed. Bladder irritation, pain or burning during urination, and low-grade fever and chills are possible side effects of intravesical BCG.

Intravesical chemotherapy with mitomycin C is another treatment option. Because the chemotherapy is given directly into the bladder, other cells in the body aren’t exposed to the chemotherapy, which reduces the chances for side effects from the chemotherapy. It’s also often given as a single dose after a tumor has been removed via cystoscopy.

Radiation therapy

Radiation therapy damages the DNA of cancer cells by bombarding them with high-energy X-rays or other types of radiation. It may be an alternative to surgery or used in combination with surgery or chemotherapy. Radiation therapy can be delivered externally or internally.

In external radiation therapy, the radiation source is a machine outside the body that directs a focused beam of radiation at the tumor. With better imaging technologies in use today, computer-guided radiation delivered from several angles minimizes radiation exposure to surrounding tissues and organs, limiting damage to these tissues. Fatigue, swelling of soft tissues and skin irritation are common side effects of external radiation.

Internal radiation therapy is not often used for bladder cancer. In this type of treatment, a radioactive pellet is inserted into the bladder through the urethra or an incision in the lower abdomen. Internal radiation requires a hospital stay during the course of treatment, which can be several days, after which the pellet is removed.

Prevention

What are the risk factors for bladder cancer?

Some factors increase the risk of bladder cancer:

• Cigarette smoking is the biggest risk factor; it more than doubles the risk. Pipe and cigar smoking and exposure to second-hand smoking may also increase one’s risk.
• Prior radiation exposure is the next most common risk factor (e.g., as treatment for cervical cancer, prostate cancer or rectal cancer).
• Certain chemotherapy drugs (e.g., cyclophosphamide) also increase the risk of bladder cancer.
• Environmental exposures increase the risk of bladder cancer. People who work with chemicals, such as aromatic amines (chemicals used in dyes) are at risk. Extensive exposure to rubber, leather, some textiles, paint, and hairdressing supplies, typically related to occupational exposure, also appears to increase the risk.
• Infection with a parasite known as Schistosoma haematobium, which is more common in developing countries and the Middle East. (This organism is not found in the United States.)
• People who have frequent infections of the bladder, bladder stones, or other diseases of the urinary tract, or who have chronic need for a catheter in the bladder, may be at higher risk of squamous cell carcinoma.
• Patients with a previous bladder cancer are at increased risk to form new or recurrent bladder tumors.

Other risk factors include diets high in fried meats and animal fats, and older age. In addition, men have a three-fold higher risk than women.

Resources

Download Our Free Treatment Guide

Stages, Symptoms, Treatment & Tests

Overview

Blue Light Technology in Bladder Cancer Therapy

What is bladder cancer?

The bladder, a hollow organ in the lower part of the abdomen, serves as a reservoir for urine until it is discharged out of the body through the urethra.

There are different types of bladder cancer. The cancer cell type can be transitional cell carcinoma, squamous cell carcinoma or adenocarcinoma—each named for the types of cells that line the wall of the bladder where the cancer originates.

• Most bladder cancers (more than 90 percent) start from the transitional cells, which occupy the innermost lining of the bladder wall. The cancers, which originate in these cells lining the bladder can, in some instances, invade into the deeper layers of the bladder (called the lamina propria), the thick muscle layer of the bladder, or through the bladder wall into the fatty tissues that surround the bladder.
• Squamous cells are thin flat cells that line the urethra and can form in the bladder after long bouts of bladder inflammation or irritation. Squamous cell carcinoma makes up about 5 percent of bladder cancers.
• Adenocarcinoma is a very rare type of bladder cancer that begins in glandular (secretory) cells in the lining of the bladder. Only 1 percent to 2 percent of bladder cancers are adenocarcinoma.

What are the stages of bladder cancer?

Bladder cancer can be either early stage (confined to the lining of the bladder) or invasive (penetrating the bladder wall and possibly spreading to nearby organs or lymph nodes).

The stages range from TA (confined to the internal lining of the bladder) to IV (most invasive). In the earliest stages (TA, T1 or CIS), the cancer is confined to the lining of the bladder or in the connective tissue just below the lining, but has not invaded into the main muscle wall of the bladder.

Stages II to IV denote invasive cancer:

• In Stage II, cancer has spread to the muscle wall of the bladder.
• In Stage III, the cancer has spread to the fatty tissue outside the bladder muscle.
• In Stage IV, the cancer has metastasized from the bladder to the lymph nodes or to other organs or bones.

A more sophisticated and preferred staging system is known as TNM, which stands for tumor, node involvement and metastases. In this system:

• Invasive bladder tumors can range from T2 (spread to the main muscle wall below the lining) all the way to T4 (tumor spreads beyond the bladder to nearby organs or the pelvic side wall).
• Lymph node involvement ranges from N0 (no cancer in lymph nodes) to N3 (cancer in many lymph nodes, or in one or more bulky lymph nodes larger than 5 cm).
• M0 means that there is no metastasis outside of the pelvis. M1 means that it has metastasized outside of the pelvis.

Symptoms and Causes

What are the warning signs of bladder cancer?

Some symptoms of bladder cancer are also symptoms of other conditions, and should prompt a visit to your physician. Blood in the urine is the most important warning sign. Pain during urination, frequent urination or difficulty urinating are other symptoms.

Diagnosis and Tests

What tests will I have if my doctor suspects bladder cancer or another urinary problem?

Your doctor will want to analyze your urine (urinalysis) to determine if an infection could be a cause of your symptoms. A microscopic examination of the urine, called cytology, will look for cancer cells.

A cystoscopy is the main procedure to identify and diagnose bladder cancer. In this procedure, a lighted telescope (cystoscope) is inserted into your bladder from the urethra to view the inside of the bladder and, when done under anesthesia, take tissue samples (biopsy), which are later examined under a microscope for signs of cancer. When this procedure is done in the doctor’s office, local anesthesia gel is placed into the urethra prior to the procedure to minimize the discomfort.

If the diagnosis of bladder cancer is made, then the next step is to remove the tumor for detailed staging and diagnosis.

Transurethral resection (TURBT) is a procedure done under general or spinal anesthesia in the operating room. A telescope is inserted into the bladder and the tumor is removed by scraping it from the bladder wall (a portion of the bladder wall is removed with it), using a special cystoscope (called a resectoscope). This procedure is diagnostic as well as therapeutic.

This often can be done as an outpatient procedure, with patients discharged from hospital the same day. After removal, the tumor is analyzed by a pathologist, who will determine the type of tumor, the tumor grade (aggressiveness) and the depth of invasion. The purpose of the procedure is to remove the tumor and obtain important staging information (such as the tumor grade and depth of invasion).

For some patients with invasive cancer, a CT scan of the abdomen and pelvis might be the next step to determine if there is any spread of the disease outside of the bladder.

Magnetic resonance imaging, which uses a magnet, radio waves, and a computer to take detailed images, can also be done, and is helpful in planning additional treatment.

A chest X-ray may also be performed to detect if any cancer has spread to the lungs. At times, a bone scan may be performed to look for metastasis (spread) of the cancer to the bone. Most of these tests are used selectively, i.e., only in certain patients with related symptoms.

Once bladder cancer is diagnosed, staging of the disease is done using the tests described above. The stage of the disease will determine the treatment course.

Management and Treatment

What are the treatment options for bladder cancer?

There are four types of treatment for patients with bladder cancer. These include:

Sometimes, combinations of these treatments will be used.

Surgical options

Surgery is a common treatment option for bladder cancer. The type of surgery chosen will depend on the stage of the cancer.

• Transurethral resection of the bladder is used most often for early stage disease (TA, T1, or CIS). It is done under general or spinal anesthesia. In this procedure, a special telescope called a resectoscope is inserted through the urethra into the bladder. The tumor is then trimmed away with the resectoscope, using a wire loop, and the raw surface of the bladder is then fulgurated (destroyed with an electric current).
• Partial cystectomy is the removal of a section of the bladder. At times, it is used for a single tumor that invades the bladder wall in only one region of the bladder. This type of surgery retains most of the bladder. Chemotherapy or radiation therapy is often used in combination. Only a minority of patients will qualify for this bladder-sparing procedure.
• Radical cystectomy is complete removal of the bladder. It is used for more extensive cancers and those that have spread beyond the bladder (or several early tumors over a large portion of the bladder).

This surgery is often done using a robot, which removes the bladder and any other surrounding organs. In men, this is the prostate and seminal vesicles. In women, the ovaries, uterus and a portion of the vagina may be removed along with the bladder.

Because the bladder is removed, a procedure called a urinary diversion must be done so that urine can exit the body. A pouch constructed of intestine may be made inside the body, or a leak-proof bag worn outside the body may be used to collect urine. The procedure typically requires a hospital stay of five to six days, give or take a few either way.

Chemotherapy

Chemotherapy refers to the use of any of a group of drugs whose main effect is either to kill or slow the reproduction of rapidly multiplying cells. Cancer cells absorb chemotherapy drugs faster than normal cells do (but all cells are exposed to the chemotherapy drug). Chemotherapy drugs are delivered intravenously (through a vein) or can be delivered intravesically (directly into the bladder through a catheter threaded through the ureter), depending on the stage of the cancer.

Some common chemotherapy drugs that are used for the treatment of bladder cancer include:

• Methotrexate
• Vinblastine
• Doxorubicin
• Cyclophosphamide
• Paclitaxel
• Carboplatin
• Cisplatin
• Ifosfamide
• Gemcitabine

Many of these drugs are used in combinations.

Side effects can occur with chemotherapy, and their severity depends on the particular drug used and the ability of the patient to tolerate the drugs. Common side effects from chemotherapy include:

Chemotherapy can be used alone, but is often used with surgery or radiation therapy.

Intravesical therapy

Bladder cancer may be treated with intravesical (into the bladder through a tube inserted into the urethra) immunotherapy or chemotherapy.

Immunotherapy refers to using the body’s own immune system to attack the cancer cells. A vaccine called Bacillus Calmette-Guérin (BCG) is commonly used for this purpose in the intravesical treatment of stages Ta, T1, or carcinoma in situ (limited to the innermost lining) bladder cancers. In the procedure, a solution containing BCG is retained in the bladder for a few hours before being drained.

Intravesical BCG is usually given once a week for six weeks, but sometimes long-term maintenance therapy is needed. Bladder irritation, pain or burning during urination, and low-grade fever and chills are possible side effects of intravesical BCG.

Intravesical chemotherapy with mitomycin C is another treatment option. Because the chemotherapy is given directly into the bladder, other cells in the body aren’t exposed to the chemotherapy, which reduces the chances for side effects from the chemotherapy. It’s also often given as a single dose after a tumor has been removed via cystoscopy.

Radiation therapy

Radiation therapy damages the DNA of cancer cells by bombarding them with high-energy X-rays or other types of radiation. It may be an alternative to surgery or used in combination with surgery or chemotherapy. Radiation therapy can be delivered externally or internally.

In external radiation therapy, the radiation source is a machine outside the body that directs a focused beam of radiation at the tumor. With better imaging technologies in use today, computer-guided radiation delivered from several angles minimizes radiation exposure to surrounding tissues and organs, limiting damage to these tissues. Fatigue, swelling of soft tissues and skin irritation are common side effects of external radiation.

Internal radiation therapy is not often used for bladder cancer. In this type of treatment, a radioactive pellet is inserted into the bladder through the urethra or an incision in the lower abdomen. Internal radiation requires a hospital stay during the course of treatment, which can be several days, after which the pellet is removed.

Prevention

What are the risk factors for bladder cancer?

Some factors increase the risk of bladder cancer:

• Cigarette smoking is the biggest risk factor; it more than doubles the risk. Pipe and cigar smoking and exposure to second-hand smoking may also increase one’s risk.
• Prior radiation exposure is the next most common risk factor (e.g., as treatment for cervical cancer, prostate cancer or rectal cancer).
• Certain chemotherapy drugs (e.g., cyclophosphamide) also increase the risk of bladder cancer.
• Environmental exposures increase the risk of bladder cancer. People who work with chemicals, such as aromatic amines (chemicals used in dyes) are at risk. Extensive exposure to rubber, leather, some textiles, paint, and hairdressing supplies, typically related to occupational exposure, also appears to increase the risk.
• Infection with a parasite known as Schistosoma haematobium, which is more common in developing countries and the Middle East. (This organism is not found in the United States.)
• People who have frequent infections of the bladder, bladder stones, or other diseases of the urinary tract, or who have chronic need for a catheter in the bladder, may be at higher risk of squamous cell carcinoma.
• Patients with a previous bladder cancer are at increased risk to form new or recurrent bladder tumors.

Other risk factors include diets high in fried meats and animal fats, and older age. In addition, men have a three-fold higher risk than women.

Resources

Download Our Free Treatment Guide

Stages, Symptoms, Treatment & Tests

Overview

Blue Light Technology in Bladder Cancer Therapy

What is bladder cancer?

The bladder, a hollow organ in the lower part of the abdomen, serves as a reservoir for urine until it is discharged out of the body through the urethra.

There are different types of bladder cancer. The cancer cell type can be transitional cell carcinoma, squamous cell carcinoma or adenocarcinoma—each named for the types of cells that line the wall of the bladder where the cancer originates.

• Most bladder cancers (more than 90 percent) start from the transitional cells, which occupy the innermost lining of the bladder wall. The cancers, which originate in these cells lining the bladder can, in some instances, invade into the deeper layers of the bladder (called the lamina propria), the thick muscle layer of the bladder, or through the bladder wall into the fatty tissues that surround the bladder.
• Squamous cells are thin flat cells that line the urethra and can form in the bladder after long bouts of bladder inflammation or irritation. Squamous cell carcinoma makes up about 5 percent of bladder cancers.
• Adenocarcinoma is a very rare type of bladder cancer that begins in glandular (secretory) cells in the lining of the bladder. Only 1 percent to 2 percent of bladder cancers are adenocarcinoma.

What are the stages of bladder cancer?

Bladder cancer can be either early stage (confined to the lining of the bladder) or invasive (penetrating the bladder wall and possibly spreading to nearby organs or lymph nodes).

The stages range from TA (confined to the internal lining of the bladder) to IV (most invasive). In the earliest stages (TA, T1 or CIS), the cancer is confined to the lining of the bladder or in the connective tissue just below the lining, but has not invaded into the main muscle wall of the bladder.

Stages II to IV denote invasive cancer:

• In Stage II, cancer has spread to the muscle wall of the bladder.
• In Stage III, the cancer has spread to the fatty tissue outside the bladder muscle.
• In Stage IV, the cancer has metastasized from the bladder to the lymph nodes or to other organs or bones.

A more sophisticated and preferred staging system is known as TNM, which stands for tumor, node involvement and metastases. In this system:

• Invasive bladder tumors can range from T2 (spread to the main muscle wall below the lining) all the way to T4 (tumor spreads beyond the bladder to nearby organs or the pelvic side wall).
• Lymph node involvement ranges from N0 (no cancer in lymph nodes) to N3 (cancer in many lymph nodes, or in one or more bulky lymph nodes larger than 5 cm).
• M0 means that there is no metastasis outside of the pelvis. M1 means that it has metastasized outside of the pelvis.

Symptoms and Causes

What are the warning signs of bladder cancer?

Some symptoms of bladder cancer are also symptoms of other conditions, and should prompt a visit to your physician. Blood in the urine is the most important warning sign. Pain during urination, frequent urination or difficulty urinating are other symptoms.

Diagnosis and Tests

What tests will I have if my doctor suspects bladder cancer or another urinary problem?

Your doctor will want to analyze your urine (urinalysis) to determine if an infection could be a cause of your symptoms. A microscopic examination of the urine, called cytology, will look for cancer cells.

A cystoscopy is the main procedure to identify and diagnose bladder cancer. In this procedure, a lighted telescope (cystoscope) is inserted into your bladder from the urethra to view the inside of the bladder and, when done under anesthesia, take tissue samples (biopsy), which are later examined under a microscope for signs of cancer. When this procedure is done in the doctor’s office, local anesthesia gel is placed into the urethra prior to the procedure to minimize the discomfort.

If the diagnosis of bladder cancer is made, then the next step is to remove the tumor for detailed staging and diagnosis.

Transurethral resection (TURBT) is a procedure done under general or spinal anesthesia in the operating room. A telescope is inserted into the bladder and the tumor is removed by scraping it from the bladder wall (a portion of the bladder wall is removed with it), using a special cystoscope (called a resectoscope). This procedure is diagnostic as well as therapeutic.

This often can be done as an outpatient procedure, with patients discharged from hospital the same day. After removal, the tumor is analyzed by a pathologist, who will determine the type of tumor, the tumor grade (aggressiveness) and the depth of invasion. The purpose of the procedure is to remove the tumor and obtain important staging information (such as the tumor grade and depth of invasion).

For some patients with invasive cancer, a CT scan of the abdomen and pelvis might be the next step to determine if there is any spread of the disease outside of the bladder.

Magnetic resonance imaging, which uses a magnet, radio waves, and a computer to take detailed images, can also be done, and is helpful in planning additional treatment.

A chest X-ray may also be performed to detect if any cancer has spread to the lungs. At times, a bone scan may be performed to look for metastasis (spread) of the cancer to the bone. Most of these tests are used selectively, i.e., only in certain patients with related symptoms.

Once bladder cancer is diagnosed, staging of the disease is done using the tests described above. The stage of the disease will determine the treatment course.

Management and Treatment

What are the treatment options for bladder cancer?

There are four types of treatment for patients with bladder cancer. These include:

Sometimes, combinations of these treatments will be used.

Surgical options

Surgery is a common treatment option for bladder cancer. The type of surgery chosen will depend on the stage of the cancer.

• Transurethral resection of the bladder is used most often for early stage disease (TA, T1, or CIS). It is done under general or spinal anesthesia. In this procedure, a special telescope called a resectoscope is inserted through the urethra into the bladder. The tumor is then trimmed away with the resectoscope, using a wire loop, and the raw surface of the bladder is then fulgurated (destroyed with an electric current).
• Partial cystectomy is the removal of a section of the bladder. At times, it is used for a single tumor that invades the bladder wall in only one region of the bladder. This type of surgery retains most of the bladder. Chemotherapy or radiation therapy is often used in combination. Only a minority of patients will qualify for this bladder-sparing procedure.
• Radical cystectomy is complete removal of the bladder. It is used for more extensive cancers and those that have spread beyond the bladder (or several early tumors over a large portion of the bladder).

This surgery is often done using a robot, which removes the bladder and any other surrounding organs. In men, this is the prostate and seminal vesicles. In women, the ovaries, uterus and a portion of the vagina may be removed along with the bladder.

Because the bladder is removed, a procedure called a urinary diversion must be done so that urine can exit the body. A pouch constructed of intestine may be made inside the body, or a leak-proof bag worn outside the body may be used to collect urine. The procedure typically requires a hospital stay of five to six days, give or take a few either way.

Chemotherapy

Chemotherapy refers to the use of any of a group of drugs whose main effect is either to kill or slow the reproduction of rapidly multiplying cells. Cancer cells absorb chemotherapy drugs faster than normal cells do (but all cells are exposed to the chemotherapy drug). Chemotherapy drugs are delivered intravenously (through a vein) or can be delivered intravesically (directly into the bladder through a catheter threaded through the ureter), depending on the stage of the cancer.

Some common chemotherapy drugs that are used for the treatment of bladder cancer include:

• Methotrexate
• Vinblastine
• Doxorubicin
• Cyclophosphamide
• Paclitaxel
• Carboplatin
• Cisplatin
• Ifosfamide
• Gemcitabine

Many of these drugs are used in combinations.

Side effects can occur with chemotherapy, and their severity depends on the particular drug used and the ability of the patient to tolerate the drugs. Common side effects from chemotherapy include:

Chemotherapy can be used alone, but is often used with surgery or radiation therapy.

Intravesical therapy

Bladder cancer may be treated with intravesical (into the bladder through a tube inserted into the urethra) immunotherapy or chemotherapy.

Immunotherapy refers to using the body’s own immune system to attack the cancer cells. A vaccine called Bacillus Calmette-Guérin (BCG) is commonly used for this purpose in the intravesical treatment of stages Ta, T1, or carcinoma in situ (limited to the innermost lining) bladder cancers. In the procedure, a solution containing BCG is retained in the bladder for a few hours before being drained.

Intravesical BCG is usually given once a week for six weeks, but sometimes long-term maintenance therapy is needed. Bladder irritation, pain or burning during urination, and low-grade fever and chills are possible side effects of intravesical BCG.

Intravesical chemotherapy with mitomycin C is another treatment option. Because the chemotherapy is given directly into the bladder, other cells in the body aren’t exposed to the chemotherapy, which reduces the chances for side effects from the chemotherapy. It’s also often given as a single dose after a tumor has been removed via cystoscopy.

Radiation therapy

Radiation therapy damages the DNA of cancer cells by bombarding them with high-energy X-rays or other types of radiation. It may be an alternative to surgery or used in combination with surgery or chemotherapy. Radiation therapy can be delivered externally or internally.

In external radiation therapy, the radiation source is a machine outside the body that directs a focused beam of radiation at the tumor. With better imaging technologies in use today, computer-guided radiation delivered from several angles minimizes radiation exposure to surrounding tissues and organs, limiting damage to these tissues. Fatigue, swelling of soft tissues and skin irritation are common side effects of external radiation.

Internal radiation therapy is not often used for bladder cancer. In this type of treatment, a radioactive pellet is inserted into the bladder through the urethra or an incision in the lower abdomen. Internal radiation requires a hospital stay during the course of treatment, which can be several days, after which the pellet is removed.

Prevention

What are the risk factors for bladder cancer?

Some factors increase the risk of bladder cancer:

• Cigarette smoking is the biggest risk factor; it more than doubles the risk. Pipe and cigar smoking and exposure to second-hand smoking may also increase one’s risk.
• Prior radiation exposure is the next most common risk factor (e.g., as treatment for cervical cancer, prostate cancer or rectal cancer).
• Certain chemotherapy drugs (e.g., cyclophosphamide) also increase the risk of bladder cancer.
• Environmental exposures increase the risk of bladder cancer. People who work with chemicals, such as aromatic amines (chemicals used in dyes) are at risk. Extensive exposure to rubber, leather, some textiles, paint, and hairdressing supplies, typically related to occupational exposure, also appears to increase the risk.
• Infection with a parasite known as Schistosoma haematobium, which is more common in developing countries and the Middle East. (This organism is not found in the United States.)
• People who have frequent infections of the bladder, bladder stones, or other diseases of the urinary tract, or who have chronic need for a catheter in the bladder, may be at higher risk of squamous cell carcinoma.
• Patients with a previous bladder cancer are at increased risk to form new or recurrent bladder tumors.

Other risk factors include diets high in fried meats and animal fats, and older age. In addition, men have a three-fold higher risk than women.

Resources

Download Our Free Treatment Guide

Interstitial Cystitis: A Bladder Problem

Please note: This information was current at the time of publication. But medical information is always changing, and some information given here may be out of date. For regularly updated information on a variety of health topics, please visit familydoctor.org, the AAFP patient education website.

Information from Your Family Doctor

Am Fam Physician. 2001 Oct 1;64(7):1212-1214.

What is interstitial cystitis?

Interstitial cystitis is a chronic bladder problem. About 750,000 Americans have interstitial cystitis. Most of them are women. People with interstitial cystitis have a bladder wall that is inflamed and irritated (red and sore). This inflammation can scar the bladder or make it stiff. A stiff bladder can’t expand as urine fills it. There may be pinpoint bleeding from the walls of the bladder. A few people get sores in the bladder lining.

People with interstitial cystitis may have many of the following symptoms:

• An urgent need to urinate, both in the daytime and during the night

• Pressure, pain and tenderness around the bladder, pelvis and perineum (the area between the anus and vagina or the anus and scrotum). This pain and pressure may increase as the bladder fills and decrease as it empties in urination.

• A bladder that won’t hold as much urine as it did before

• Pain during sexual intercourse

• In men, discomfort or pain in the penis or scrotum

In many women, the symptoms get worse before their menstrual period. Stress may also make the symptoms worse, but it doesn’t cause them.

What causes interstitial cystitis?

We don’t yet know what causes interstitial cystitis. We do know that infections with bacteria or viruses don’t cause it. It might be caused by a defect in the lining of the bladder. Normally, the lining protects the bladder wall from the toxic effects of urine. In about 70 percent of people with interstitial cystitis, the protective layer of the bladder is “leaky.” This may let urine irritate the bladder wall, causing interstitial cystitis.

Other possible causes may be an increase of histamine-producing cells in the bladder wall or an autoimmune response (when antibodies are made that act against a part of the body).

How does my doctor know I have interstitial cystitis?

You may have interstitial cystitis if any of the following occur:

• You have to urinate often or urgently

• You have pelvic or bladder pain

• A urologist (a doctor whose specialty is problems of the urinary tract) finds bladder wall inflammation, pinpoint bleeding or ulcers during an exam with a special scope (called a cystoscope) that looks inside your bladder

• Your doctor has ruled out other diseases such as urinary tract infections, vaginal infections, bladder cancer, sexually transmitted diseases and, in men, chronic prostatitis

How is interstitial cystitis treated?

There is no cure yet for interstitial cystitis. Many treatments can help with your symptoms. Most people feel better after trying one or more of the following treatments:

• Diet. Your doctor may tell you to change what you eat. You may need to avoid alcohol, acidic foods and tobacco.

• Bladder distention. Sometimes people feel better after having a bladder distention. Under anesthesia, a doctor overfills your bladder with fluid. This stretches the walls of the bladder. Doctors don’t know why distention helps. It may make your bladder be able to hold more urine. It may also interfere with pain signals sent by nerves in the bladder.

• Medicine. Your doctor may have you take an oral medicine called pentosan polysulfate (brand name: Elmiron). This medicine helps to protect the lining of the bladder wall from the toxic parts of urine.

  Another oral medicine used to treat interstitial cystitis is an antihistamine called hydroxyzine (brand names: Vistaril and Atarax). This medicine reduces the amount of histamine that is made in the bladder wall.

  Another medicine that may help is amitriptyline (brand name: Elavil). It blocks pain and reduces bladder spasms. This medicine can make you sleepy, so it’s usually taken at bedtime.

• Bladder instillation. During a bladder instillation, a catheter (a thin tube) is used to fill your bladder with a liquid medicine. You hold the medicine inside your bladder for a few seconds to 15 minutes. Then the liquid drains out through the catheter. Treatments are given every one to two weeks for six to eight weeks. The treatment can be repeated as needed.

What else can I do to help my symptoms?

• Diet. Alcohol, tomatoes, spices, chocolate, caffeine, citrus drinks, artificial sweeteners and acidic foods may irritate your bladder. That makes your symptoms worse. Try removing these foods from your diet for a couple of weeks. Then try eating one food at a time to see if it makes your symptoms worse.

• Smoking. Many people with interstitial cystitis find that smoking makes their symptoms worse. Because smoking is also a main cause of bladder cancer, people with interstitial cystitis have another good reason to quit smoking.

• Bladder training. Many people can train their bladder to urinate less often. You can train your bladder by going to the bathroom at scheduled times and using relaxation techniques. After a while, you try to make the time you can wait longer. Your doctor can help you with bladder training and relaxation techniques.

• Physical therapy and biofeedback. People with interstitial cystitis may have painful spasms of the pelvic floor muscles. If you have muscle spasms, you can learn exercises to help strengthen and relax your pelvic floor muscles.

• TENS (this stands for “transcutaneous electrical nerve stimulation”). You can use a TENS machine to put mild electrical pulses into your body through special wires. You would do this at least two times a day. You might do it for a few minutes, or you might do it for a longer time. Some doctors think that electric pulses increase blood flow to the bladder. The increased blood flow strengthens the muscles that help control the bladder. It also releases hormones that block pain. TENS is not expensive.

Where can I get more information about interstitial cystitis?

The support of family, friends and other people with interstitial cystitis is very important to help you cope with this problem. People who learn about interstitial cystitis and participate in their own care do better than people who don’t.

People with interstitial cystitis can get more information on this disease from these groups:

Interstitial Cystitis Association

51 Monroe St., Suite 1402

Rockville, MD 20850

Telephone: 1-800-435-7422 or 1-301-610-5300

Web site: http://www.ichelp.org

National Kidney Foundation

30 E. 33rd St., Suite 1100

New York, NY 10016

Telephone: 1-800-622-9010 or 1-212-889-2210

Web site: http://www.kidney.org

Bladder Health for Older Adults

Everyone uses their bladder many times each day, but they may not know what to do to keep their bladder healthy.

Located in the lower abdomen, the bladder is a hollow organ, much like a balloon, that stores urine. It is part of the urinary system, which also includes the kidneys, ureters, and urethra. Urine contains wastes and extra fluid left over after the body takes what it needs from what we eat and drink.

As you get older, the bladder changes. The elastic bladder tissue may toughen and become less stretchy. A less stretchy bladder cannot hold as much urine as before and might make you go to the bathroom more often. The bladder wall and pelvic floor muscles may weaken, making it harder to empty the bladder fully and causing urine to leak.

Common Bladder Problems

Bladder problems are common and can disrupt day-to-day life. When people have bladder problems, they may avoid social settings and have a harder time getting tasks done at home or at work.

Common bladder problems include:

• Urinary tract infections (UTIs)—UTIs are the second most common type of infection in the body and can happen anywhere in the urinary system. More than half of women will have at least one UTI in their lifetime. Older women are more likely to get UTIs because the bladder muscles weaken and make it hard to fully empty the bladder. This causes urine to stay in the bladder. When urine stays in the bladder too long, it makes an infection more likely. Types of UTIs include:
  • Bladder infection—This is the most common type of UTI, in which bacteria enter the bladder and cause symptoms such as strong and sudden urges to urinate.
  • Kidney infection—Infections in the bladder can spread to the kidneys, which can lead to severe problems. When kidney infections occur frequently or last a long time, they may cause permanent damage to the kidneys.
  • Urethra infection —A UTI can also develop in the urethra, but this is less common.
• Lower urinary tract symptoms (LUTS)—a group of symptoms such as trouble urinating, loss of bladder control, leaking urine, and frequent need to urinate. LUTS are caused by problems with the bladder, urethra, or pelvic floor muscles.
• Bladder cancer—Bladder cancer occurs in the lining of the bladder.

What Can Affect Bladder Health?

Many things can affect bladder health. You can’t control everything that affects bladder health, but there are many bladder health behaviors that you can control. Here are some things that may affect your bladder health.

• Constipation. Constipation can cause too much stool to build up in the colon, which can put pressure on the bladder and keep it from expanding the way it should.
• Diabetes. Diabetes can damage nerves around the bladder that help with control.
• Being overweight. People who are overweight may be at higher risk for leaking urine.
• Low physical activity. Physical activity can help prevent bladder problems, as well as constipation. It can also help you keep a healthy weight.
• Smoking. Bladder problems are more common among people who smoke. Smoking can also increase the risk for bladder cancer.
• Some medicines. Some medicines may make it more likely for your bladder to leak urine. For example, medicines that calm your nerves so you can sleep or relax may dull the nerves in the bladder, and you may not feel the urge to go to the bathroom.
• Alcohol. For many people, drinking alcohol can make bladder problems worse.
• Caffeine. Caffeine can bother the bladder and change how your bladder tells you when you need to urinate.
• Diet. Some people with bladder problems find that some foods and drinks, such as sodas, artificial sweeteners, spicy foods, citrus fruits and juices, and tomato-based foods, make the problem worse. People who have bladder problems may feel better when they don’t eat these foods and drinks.
• Pelvic Injury. Trauma—such as prostate surgery, childbirth, or sexual assault—can damage the muscles and nerves that help control the bladder.

Some activities can increase the risk of urinary tract infections, including:

• Having sex. Sexual activity can move bacteria from the bowel or vaginal cavity to the urethral opening. Urinating after sex lowers the risk of infection.
• Using a catheter to urinate. A catheter is a tube placed in the urethra and bladder to help empty the bladder. The catheter can make a direct path for bacteria to reach the bladder.
• Using certain types of birth control. Diaphragms can bring bacteria with them when they are placed. Spermicides (a birth control that kills sperm) may also make UTIs more likely.

Signs of a Bladder Problem

Everyone’s bladder behaves a little bit differently. But certain signs may mean a bladder problem. If you have signs of a bladder problem, talk with your healthcare provider.

Signs of a bladder problem can include:

• Inability to hold urine or leaking urine (called urinary incontinence)
• Needing to urinate eight or more times in one day
• Waking up many times at night to urinate
• Sudden and urgent need to urinate
• Pain or burning before, during, or after urinating
• Cloudy or bloody urine
• Passing only small amounts of urine after strong urges to urinate
• Trouble starting or having a weak stream while urinating
• Trouble emptying the bladder

Signs of Urinary Tract Infection

In some elderly people, mental changes and confusion may be the only signs of a UTI. Older adults with a UTI are more likely to be tired, shaky, and weak and have muscle aches and abdominal pain.

Symptoms of a UTI in the bladder may include:

• Cloudy, bloody, or foul-smelling urine
• Pain or burning during urination
• Strong and frequent need to urinate, even right after emptying the bladder
• A mild fever below 101°F in some people

If a UTI spreads to the kidneys, symptoms may include:

• Chills and shaking
• Night sweats
• Feeling tired or generally ill
• Fever above 101°F
• Pain in the side, back, or groin
• Flushed, warm, or reddened skin
• Mental changes or confusion
• Nausea and vomiting
• Very bad abdominal pain in some people

Some people may have bacteria in the bladder or urinary tract, but not feel any symptoms. If a urine test shows that you have bacteria in your urine, but you do not feel any symptoms, you may not need any treatment. Talk to your healthcare provider about whether antibiotics—the medications that treat UTIs—are needed.

When to See a Health Care Provider—and What to Expect

If you have any of the signs of a bladder problem or urinary tract infection, talk to your healthcare provider. Read advice on talking to your doctor about sensitive subjects, like bladder problems.

When you see your healthcare provider, he or she may perform the following tests to try to figure out what might be causing your bladder problem:

• Give you a physical exam to look for any health issues that may cause a bladder problem. For women, the physical exam may include a pelvic exam. For men, the physical exam may include a prostate exam, which is usually done with a rectal exam.
• Take a urine sample to check for a bladder (or urinary tract) infection.
• Examine the inside of your bladder using a cystoscope, a long, thin tube that slides up into the bladder through the urethra. This is usually done by a urinary specialist.
• Fill the bladder with warm fluid to check how much fluid your bladder can hold before leaking.
• Check a bladder scan using ultrasound to see if you are fully emptying your bladder with each void.

Treating Bladder Problems

Treatment for bladder problems may include behavioral and lifestyle changes, exercises, medicines, surgery, or a combination of these treatments and others. For more information on treatment and management of urinary incontinence, visit Urinary Incontinence in Older Adults.

Because most urinary tract infections are caused by bacteria, bacteria-fighting medications called antibiotics are the usual treatment for UTIs. The type of antibiotic and length of treatment depend on the patient’s history and the type of bacteria causing the infection. Drinking lots of fluids and urinating often may also speed healing. If needed, painkillers can relieve the pain of a UTI. A heating pad on the back or abdomen may also help.

For more information on bladder health, visit 13 Tips to Keep Your Bladder Healthy.

For More Information on Bladder Health

This content is provided by the NIH National Institute on Aging (NIA). NIA scientists and other experts review this content to ensure it is accurate and up to date.

Content reviewed:
May 16, 2017

Bladder diverticulum | Description of the disease

Bladder diverticulum – a specific condition of the organ, in which there is a characteristic protrusion of its wall. The main danger of pathology lies not in symptomatic manifestations, but in complications that can occur in the absence of proper treatment.

What causes a bladder diverticulum

There are 2 types of diverticula – true and false.

A true diverticulum is a congenital pathology in which a diverticulum forms simultaneously with other layers of the bladder and consists of all of them. A pseudo-diverticulum can occur only in the postpartum period. The reasons for the appearance of a bladder diverticulum of this type are thinning of the layers of the bladder, an increase in pressure inside it, hypertrophy and loosening of the urinary muscle. It is the weakness of the fibers that causes the protrusions.

Risk factors

A number of factors contribute to the appearance of true and false diverticula.The development of a true diverticulum is largely influenced by the state of health of the mother during pregnancy, during the laying of the genitourinary system of the child.

Radioactive exposure, prolonged exposure to chemical mutagents and severe infectious diseases can significantly complicate the course of pregnancy and negatively affect the formation of the fetus.

In male patients, the appearance of a diverticulum can be triggered by prostate adenoma; urethral strictures, tumors of the urinary system and stenosis of the urinary neck are also dangerous in this regard.

Symptoms and clinical picture of bladder diverticulum

At the initial stage, the manifestations of the bladder diverticulum are lubricated, and the patient may not notice the presence of pathological protrusion for a long time.

When the diverticulum reaches a significant size, signs of urine stagnation appear, and, consequently, the development of specific disorders.

Specific signs of urinary bladder diverticulum:

• two-stage urination;
• increased frequency of urination;
• painful sensations;
• slight admixture of blood;
• the appearance of concomitant diseases: pyelonephritis, urolithiasis, cystitis.

Which doctor treats a bladder diverticulum

A urological diverticulum is treated by a urologist, if necessary, a surgeon joins.

Diagnosis of bladder diverticulum

Diagnosis of bladder diverticulum is based on the study of anamnestic data.

It is recommended to carry out a number of additional examinations, first of all – ultrasound of the bladder. With its help, you can determine the state of the organ, localization and size of calculi.

Diagnostic methods

If there is any doubt about the diagnosis, transurethral cystoscopy is prescribed. There are no specific tests for a bladder diverticulum, since no changes are observed in the urine in this condition.

Treatment regimen for urinary bladder diverticulum

Currently, there are no conservative treatments for bladder diverticulum. With a small size and no complaints from the patient, manipulation is not necessary.

Main methods of treatment and contraindications

In the presence of complications, it is recommended to start immediate treatment. The answer to the question of how to treat a bladder diverticulum is unequivocal. Treatment consists in surgical intervention and occurs according to the following algorithm:

• removal of the diverticulum;
• stitching of the resulting defect;
• Treatment of the etiological disease.

Thanks to the latest methods, with timely intervention, it is quite possible to eliminate the protrusion, regardless of the severity and neglect of the process.

Possible complications

False protrusion is formed at the site of thinning of the walls of the organ, which means that even a small injury is enough to rupture it. In this case, the most dangerous complication of a bladder diverticulum may develop – inflammation of the peritoneum (peritonitis), which is a life-threatening condition.

Chronic bladder diverticulum. Causes, symptoms, treatment

Since this disease does not give acute symptoms, the concept of “chronic bladder diverticulum” is not relevant.

Measures for the prevention of bladder diverticulum

The main method for the prevention of bladder diverticulum is regular health monitoring, participation in routine medical examinations. Thanks to them, the disease can be detected at an early stage and treatment can be started in a timely manner.

Bladder diverticula. Causes, symptoms, diagnosis and treatment of urinary bladder diverticula

1.General information

A diverticulum in medicine is called a protrusion (in the form of a sac) of the wall of a hollow organ. Accordingly, a dicerticulum of the bladder is a local bulging of its wall, congenital or acquired under the influence of any unfavorable factors.

It is difficult to judge how widespread this phenomenon is, since the statistical data are contradictory and insufficient (this is probably due to the fact that the epidemiological data on diverticula as such are absorbed by the statistics of concomitant or background urogenital diseases).However, urologists agree that this pathology, firstly, is not uncommon and, secondly, about fifteen times more often observed in men than in women.

Bladder diverticula can vary significantly in origin, size, localization, developmental dynamics, and clinical presentation. In some cases, a diverticulum is discovered by chance (during examination for another reason) and does not manifest itself in anything, in others it is accompanied by severe complications and can cause a life-threatening condition that requires urgent surgical intervention.

A must for your reference!
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2.Reasons

In most sources, congenital (true) and acquired (false) diverticula of the bladder are considered as two fundamentally different types.

Congenital diverticula are an anomaly of intrauterine growth; such protrusions are almost always single, located on the posterior wall of the bladder, consist of the same tissue and are separated by a relatively narrow neck.

The main conditions for the development of false diverticula are the thinning of the walls of the bladder and / or constantly increased pressure inside it. This condition, in turn, can lead to various diseases and anomalies of the genitourinary system: infectious and inflammatory processes, prostate adenoma (which in women is impossible in principle due to the absence of the prostate gland, – which is one of the main determinants of the aforementioned statistical difference between the sexes ), oncopathology, etc.n. Acquired diverticula are usually multiple in nature, consist of a mucous layer and do not contain muscle fibers (unlike the main wall of the bladder), vary widely in size, shape and localization.

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3.Symptoms, diagnostics

The early stages of the formation of protrusions, like congenital diverticula, are usually asymptomatic. However, sooner or later, a characteristic clinical picture may develop, determined, first of all, by stagnant phenomena in the diverticulum: the outflow and evacuation of urine from a relatively isolated “sac” space can be significantly hampered, which causes the development of infectious and inflammatory processes (cystitis, in the case of ascending spread infections – pyelonephritis, in the case of descending – urethritis).In addition, it is often in the diverticular space that a benign or malignant tumor develops, calculi (stones) are deposited, which over time increases the risk of wall perforation with further development of peritonitis.

One of the most specific symptoms of a diverticulum is a feeling of insufficient emptying of the bladder and the need for repeated urination, which is caused by unnatural hydrodynamics of urine circulation: urine evacuates through a narrow lumen in the neck much longer (the second “portion” of urine emitted is usually much more turbid than the first and may contain blood).Urination is painful in many cases. With the addition of inflammatory diseases and / or other complications, their symptoms usually come to the fore.

In addition to the analysis of complaints, the diagnosis of bladder diverticula usually includes certain variants of contrast x-ray examination of the urinary system, as well as ultrasound of the abdominal cavity and pelvis, transurethral cystoscopy, and laboratory clinical tests.

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4. Treatment

There are no methods of medical elimination of deformation of the bladder walls, and they are unlikely to appear ever in the future. Since the decision on abdominal surgery is always very responsible, it should be reasoned enough by the clinical picture and the data of the diagnostic examination.

At present, minimally invasive transurethral endoscopic techniques for the operative elimination of bladder diverticula are being intensively developed and increasingly introduced into urosurgical practice.

The prognosis, regardless of the method of intervention, is favorable in most cases. It should be understood, however, that a necessary condition for the prevention of recurrent formation of acquired diverticula is the maximum possible elimination of the causes that led to the protrusion of the walls of the bladder (treatment of chronic infections, removal of a prostate tumor, etc.).).

90,000 What is diverticulosis and should it be treated

In half of the elderly, doctors diagnose diverticulosis – multiple protrusions of the intestinal walls. What kind of disease is it, how dangerous it is and whether it can be prevented, Gazeta.Ru was investigating.

Diverticulosis is a multiple formation of diverticula, saccular protrusions of the wall of a hollow or internal organ. Most often, diverticula form in the digestive tract.The disease can be either congenital or acquired. In the first case, the diverticulum consists of all the membranes of the organ – serous, muscular, mucous and submucosa. These include, in particular, Meckel’s diverticulum – a protrusion of the ileal wall caused by incomplete infection of the yolk duct, which is involved in the nutrition of the embryo in the womb.

It occurs in 2% of the population and is the most common congenital abnormality of the gastrointestinal tract.

Acquired diverticula are protrusions of the submucosa and mucous membranes between the individual bundles of the muscular membrane.

The most common place for diverticula formation is the intestine.

Colon diverticula are detected only in 5% of patients under 50, in 30% of patients over 50 and 50% over 70.

In intestinal diverticulosis, in 70% of cases, diverticula are located in the sigmoid colon. This is due to its anatomical and functional features: smaller diameter, more bends, denser consistency of the contents. In addition, it has a reservoir function, which increases the pressure on its walls.

In more rare cases, diverticula of the small intestine develop. The most common place of their appearance is the duodenum.

Doctors find it difficult to identify the specific causes of the formation of diverticula. The most common is the hernial theory, according to which diverticula arise from the weakness of the connective tissue framework of the intestinal wall. And the violation of intestinal motility, characteristic of an aging body, leads to an increase in intraintestinal pressure, which causes protrusion of the mucous membrane in places of least resistance.The most common risk factor is old age.

In addition, studies of recent years show that the development of diverticulosis may be associated with a lack of vitamin D.

Diverticulosis is probably not associated with decreased fiber intake, as previously thought. So, when studying the lifestyle of 539 patients with diverticulosis and a control group of 1659 healthy subjects, researchers did not reveal a relationship between a lack of fiber and the appearance of diverticula.

In 70% of cases, diverticulosis is asymptomatic.

However, diverticula can cause abdominal pain, diarrhea, constipation, flatulence. To establish a diagnosis and exclude other causes of complaints, a colonoscopy (endoscopic examination of the intestine) or irrigoscopy (an X-ray examination of the intestine with the introduction of a radiopaque contrast agent into it) is performed, as well as computed tomography.

Some patients with diverticulosis experience diverticulitis – inflammation of diverticula.Previously, the number of such cases was estimated at 25% of the total number of patients. However, according to study from 2013, the risk of developing diverticulitis with diverticulosis may be much lower. Observation of 2222 patients for 15 years showed that within seven years after the detection of diverticulosis, diverticulitis develops in only 1% of patients. It is more common in patients diagnosed with diverticulosis at an earlier age.

“These bulges are often found during colonoscopy and patients wonder how dangerous they are and what to do with them,” the researchers explain.

In short, diverticulosis is not a cause for concern. The chances of complications are low. ”

The characteristic symptoms of diverticulitis are pain and tension in the muscles of the anterior abdominal wall at the bottom left, fever, chills, nausea and vomiting, constipation or diarrhea.

When a diverticulum is perforated into the abdominal cavity, a clinical picture of diffuse peritonitis develops. With perforation into the retroperitoneal tissue or between the mesenteric sheets, abscesses and infiltrates occur.The latter, in particular, can cause intestinal obstruction.

A serious complication in diverticulosis is the formation of intestinal fistulas, both external, opening on the skin of the abdomen, and internal, through which feces can enter the bladder. In women, fistulas may develop that open into the vagina.

Asymptomatic and accidentally diagnosed diverticulosis, according to doctors, does not require treatment. For the prevention of both the disease itself and the development of its complications, proper nutrition, the minimum use of laxatives and cleansing enemas, and moderate physical activity are recommended.

In case of diverticulum perforation, bleeding and other complications, hospitalization and surgical treatment are necessary. In addition, the first appearance of complications increases the risk of complications in the future, so regular check-ups are necessary.

90,000 Structural transformations of the bladder and its vascular system in elderly and senile men

Kulikov S.V., Shormanov I.S., Soloviev A.S.

Information about the authors:

• Shormanov I.P. – Head of the Department of Urology with Nephrology of the Federal State Budgetary Educational Institution of Higher Education “Yaroslavl State Medical University” of the Ministry of Health of the Russian Federation, Doctor of Medical Sciences, Professor, AuthorID 584874
• Kulikov S.V. – Head of the Department of Pathological Anatomy of the Federal State Budgetary Educational Institution of Higher Education “Yaroslavl State Medical University” of the Ministry of Health of the Russian Federation, Doctor of Medical Sciences, Associate Professor, AuthorID 715490
• Soloviev A.P. – Assistant of the Department of Urology with Nephrology of the Federal State Budgetary Educational Institution of Higher Education “Yaroslavl State Medical University” of the Ministry of Health of the Russian Federation, Candidate of Medical Sciences, AuthorID 975843

INTRODUCTION

The aging process of the world’s population is becoming one of the most significant social transformations of the twenty-first century [1-5]. According to statistical data, the number of persons with disorders of the function of the lower urinary tract increases with age [6-8].Clinically and urodynamically age-related changes in the lower urinary tract are manifested by a decrease in the flow rate of urine and bladder capacity, the appearance of its hyperactivity, as well as an increase in the volume of residual urine [9,10]. The reasons for such pathological conditions are not entirely clear to this day. Also, the differences between the consequences of the so-called “biological aging” and disorders associated with exogenous factors such as lifestyle, bad habits, concomitant diseases, etc. are not clear.etc. [11,12]. According to the majority of authors, the most important “external” factors of dysuric phenomena are vascular disorders and disturbances of nervous trophism, progressing in the process of human aging. At the same time, researchers most often name pelvic atherosclerosis, endothelial dysfunction, hormonal disorders and bladder outlet obstruction as the causes of regional hemodynamic disorders [13-15].

Meanwhile, in the literature, the morphology of the vascular bed of the urinary bladder in terms of natural aging, as well as the relationship between systemic impairment of hemocirculation and circulatory disorders in the organ wall, reflecting the morphogenesis of the “senile detrusor”, is described in a rather fragmentary and contradictory manner [16-18].The current situation requires large-scale comparative studies involving large populations of people of different age groups and using modern morphological methods. All this predetermined the course and nature of our work.

The purpose of this study was to study the structural changes in the bladder and its vascular bed in elderly and senile men, as well as to determine the role of these changes in the development of functional disorders.

MATERIALS AND METHODS

Pieces of the bladder were taken from 15 men aged 60-80 who died from diseases not related to urological and cardiovascular pathology.The material obtained from 10 persons aged 20-30 years who died as a result of injuries was used as a control. Fragments of the entire thickness of the wall, including the outer membrane and paravesical tissue, were cut from various zones of the bladder. The material was fixed in 10% neutral formalin and embedded in paraffin. Histological sections were stained with hematoxylin-eosin, Masson’s – for connective tissue, and Hart’s – for elastic fibers.

RESULTS OF STUDY

Microscopic examination revealed that the urothelium (transitional epithelium) lining the mucous membrane of the bladder had an uneven thickness as a result of alternating areas of atrophy and hyperplasia.The epithelial cells of the urothelium had a light and vacuolated cytoplasm, i.e. underwent hydropic degeneration. In addition, desquamation of epithelial cells was also detected, sometimes reaching an almost complete loss of the lining, which indicates not only dystrophy, but also a violation of the regenerative process (Fig. 1). In the lamina propria of the mucous membrane, the proliferation of coarse-fibrous connective tissue and the appearance of an inflammatory infiltrate in it, represented by lymphocytes and plasma cells with single neutrophils, was revealed, which indicates the presence of chronic inflammation (Fig.1). The submucosa of the bladder, like its own lamina, was also exposed to the growth of coarse fibrous connective tissue. In the muscular membrane (detrusor), a slight thinning of the bundles of smooth muscle fibers was revealed, between which, in comparison with the control series, large layers of coarse-fibrous connective tissue, or a well-visible fine-looped network consisting of collagen fibers, were often identified (Fig. 2). At the same time, the amount of elastic fibers that braided bundles of smooth muscles of the detrusor decreased, and the remaining fibers were defragmented.

Fig. 1. Desquamation of the urothelium and chronic inflammation of the mucous membrane. Hematoxylin-eosin staining. Magnification 200
Fig. 1. Urothelial desquamation and chronic mucosal inflammation. Stained with hematoxylin-eosin. Increase 200

Fig. 2. Growth of coarse-fibrous connective tissue in the form of a narrow-looped network between atrophied muscle bundles. Masson’s staining. Magnification 160
Fig. 2. Growth of coarse-fiber connective tissue in the form of a narrow-leaf network between atrophied muscle bundles.Color by Masson. Increase 160

Gross structural changes were also observed in the vascular system of the urinary bladder, including arteries and veins of various sizes. So, in large extraorganic arteries and arteries of the outer membrane with paravesical tissue, atherosclerotic plaques were determined, which were in the stage of liposclerosis and atheromatosis, which, in some cases, led to a narrowing of the vascular lumen above 25%. In addition, they noted the splitting of the internal elastic membrane into several separate plates (hyperelastosis).

In the intraorgan arteries of the urinary bladder, belonging to the vessels of the muscular type, noticeable changes also took place. Thus, in the large and middle arteries, in comparison with the control, there was a thickening of the wall due to hypertrophy and hyperplasia of smooth myocytes of the middle membrane (media). The inner elastic membrane of these vessels became more folded, “crimped”, thickened and split into separate plates (Fig. 3). The endothelial cells of the inner membrane (intima) were stretched and oriented perpendicular to the lumen of the vessel, assuming a “palisade” appearance.In addition, in the large arteries of the urinary bladder, along with thickening of the media, the appearance of an expanded intimal layer with a uniform and uneven arrangement of longitudinally arranged bundles of smooth myocytes in it was observed. This layer in some of the arteries was replaced by coarse fibrous connective tissue, their lumen was noticeably narrowed, and the media underwent atrophy and sclerosis (Fig. 4). The described pathological changes in the walls of the arteries indicate an increase in vascular tone as a result of the presence of arterial hypertension with a pronounced increase in diastolic pressure.

Fig. 3. Large artery of muscular type with thickened walls and splitting of the internal elastic membrane into separate plates. Hart stained. Magnification 200
Fig. 3. Large muscle-type artery with thickened walls and splitting of the internal elastic membrane into separate plates. Color by Hart. Increase 200

Fig. 4. Large artery of the muscular type with atrophy and sclerosis of the circular smooth muscles of the media, pronounced thickening of the intima due to the proliferation of connective tissue, as well as significant narrowing of the lumen.Masson’s staining. Magnification 160
Fig. 4.large muscle-type artery with atrophy and sclerosis of the circulatory system smooth muscles of the media, a pronounced thickening of the intima due to the growth of connective tissue, as well as a significant narrowing of the lumen. Color by Masson. Increase 160

Intraorgan small arteries and arterioles related to resistance vessels also underwent morphological changes. They had a thickened wall and uneven folding of the inner elastic membrane, as compared to the vessels of the control series.Most of the arteries underwent hyalinosis. This process is characterized by the appearance of a thickened, homogeneous, homogeneous artery wall with a sharp decrease in the lumen and loss of characteristic layers and, especially, smooth myocytes in the middle membrane (Fig. 5). The disappearance of smooth muscles with contractile function led to the inability of such vessels to change their tone, maintaining a state of chronic hypoxia.

Most veins of the lamina propria, submucosa, muscularis membrane, adventitia and paravesical tissue of the bladder, in comparison with the control series, had a thicker wall due to sclerosis.The number of smooth myocytes in it in the inner and middle layers sharply decreased in comparison with the vessels of the control series, where they had rather powerful muscle bundles, the contraction of which ensured the movement of blood to the heart against the action of gravity.

Fig. 5. Hyalinosis of a small artery with a thickening of the wall and a sharp narrowing of the lumen. Hematoxylin-eosin staining. Magnification 200.
Fig. 5. Hyalinosis of a small artery with a thickening of the wall and a sharp narrowing of the lumen.Stained with hematoxylin-eosin. Increase 200

DISCUSSION

Thus, our studies made it possible to determine that in men, in the process of aging, changes are observed in various tissue components and layers of the bladder wall, which, we believe, are the morphological basis of age-related involution. The most pronounced structural transformations are revealed in the vascular bed of this organ. In particular, atherosclerotic plaques are formed in large extraorganic arteries of the muscular-elastic type, causing a narrowing of the lumen, which entails the development of chronic ischemia and hypoxia of the bladder wall.Along with changes in extraorganic arteries, intraorganic arteries of muscular type of various caliber also undergo pronounced remodeling. In the large and middle arteries of this organ, morphological restructuring is expressed in the development of hypertrophy of the smooth muscles of the media and hyperelastosis, which reflects an increase in the tone of these vessels [19, 20]. In the smaller arteries of the bladder (resistance arteries), a morphological picture of hyalinosis is observed. This process is caused by periodically occurring plasmorrhage and plasma impregnation of the intima, and then the media, with the formation of a dense homogeneous protein mass that replaces all layers of the wall, significantly narrowing the lumen, which, along with atherosclerotic plaques, further enhances chronic hypoxia.Thus, the structural recalibration of intraorgan arteries of various levels is an expression of the patient’s hypertension, and, often, with a crisis course and high blood pressure figures. Consequently, the combination of atherosclerotic and angiotonic, characteristic of hypertension, changes in old and senile age in men leads to the involvement of the entire arterial bed of the urinary bladder, from damage to the main arteries to small resistance vessels with a reduction in blood flow in the organ.

Along with this, in order to adapt to the changed conditions of blood circulation, manifested by ischemia of the bladder wall, in the arteries of large and medium caliber, along their entire circumference, an intimate layer appears, consisting of longitudinally located smooth myocytes, the contraction of which leads to a significant decrease in lumen and increased resistance to blood flow, which allows you to “switch” arterial blood flows to different parts of the detrusor, depending on its functional needs.In the literature, such arteries are called “closing”, and this layer is called “functional” [21]. It should be noted that over time, the intimate layer of the closing arteries undergoes sclerosis, and their lumen decreases, which also leads to the progression of chronic hypoxia. Extraorgan and intraorgan venous collectors undergo sclerotic and atrophic changes, thereby contributing to the disruption of venous outflow. The factor of chronic hypoxia, activating collagenogenesis, promotes the development of sclerosis of the lamina propria, submucosa and intermuscular connective tissue, which is accompanied by atrophic changes in the detrusor and inhibition of its contractile function.The resulting functional disturbances from the structurally altered muscle layer underlie such a condition as the “senile bladder”. In addition, the violation of vascular trophism is accompanied by damage to the urothelium, reducing its ability to normal regeneration, which leads to a decrease in protective properties, partial or complete desquamation and inevitably initiates the development of chronic inflammation, sclerosis and closing the “vicious circle”.

CONCLUSIONS

1. During human aging, the entire vascular bed of the urinary bladder undergoes remodeling, including extraorganic arteries, intraorganic arteries and venous collectors of various sizes;
2. Stenosing atherosclerosis and hyperelastosis are noted in the extraorgan arteries of the urinary bladder, which have a vascular structure of the elasto-muscular type;
3. Intraorganic arteries of the urinary bladder of the muscular type of large and medium caliber are characterized by hyperelastosis and thickening of the middle membrane due to the proliferation of smooth myocytes;
4. Small-caliber intraorgan muscle-type arteries undergo hyalinosis, which is expressed as a significant narrowing of the lumen and replacement of all wall layers with a homogeneous structureless mass;
5. Changes in intraorgan arteries of various calibers are a reflection of long-term hypertension with recurrent crises;
6. In conditions of impaired hemodynamics in the wall of the bladder, in order of adaptation, closing arteries are formed with a clearly visible functional layer in the intima;
7. The role of the guard arteries is reduced to the “switching” of arterial blood flows depending on functional needs;
8. Over time, the walls of the intraorgan arteries become sclerosed, including the functional layer of the closing vessels, and their lumen decreases;
9. Veins of the bladder lose a powerful smooth muscle layer in the wall and undergo sclerosis;
10. Remodeling of the arterial basin of the bladder, accompanied by ischemia of its wall, leads to the development of sclerosis of the mucous membrane, submucosa, atrophy of the smooth muscles of the detrusor, a decrease in elastic fibers in it with their defragmentation;
11. Reduction of blood flow in the bladder leads to dystrophy of the urothelium, desquamation and the development of chronic active inflammation of the mucous membrane.

REFERENCES

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15. Vishnevsky E.L., Laurent O.B., Vishnevsky A.E. Clinical Evaluation of Urinary Disorders. M.: TERRA, 2001: 96 p. Vishnevskiy E.L., Loran O.B., Vishnevskiy A.E. Klinicheskaya otsenka rasstroystv mocheispuskaniya. [Clinical evaluation of urination disor-ders.]. Moscow.:TERRA,2001:96 p. (In Russian).
16. Vishnevsky A.E., Stepanova N.A., Mikhailova E.V. Vascular effects of alpha-blockers and their clinical significance in patients with benign prostatic hyperplasia.Clinical Pharmacology and Therapy 2004; (4): – P.90-93. Vishnevskiy A.E., Stepanova N.A., Mihaylova E.V. Sosudistyie effektyi alfa-adrenoblokatorov i ih klinicheskoe znachenie u bolnyih dobrokachestvennoy giperplaziey prostatyi [Vascular effects of alpha-blockers and their clinical significance in patients with benign prostatic hyperplasia]. Klinicheskaya farmakologiya i terapiya 2004; (4): 90-93. (In Russian).
17. Lushnikova E.L., Nepomnyashchikh L.M., Neimark A.I., Isaenko V.I., Molodykh O.P., Koldysheva E.V. and others. The role of structural and functional changes in smooth muscle cells of the detrusor and prostate gland in the development of an overactive bladder. Basic Research 2012: (5): 68-73. Lushnikova E.L., Nepomnyaschih L.M., Neymark A.I., Isaenko V.I., Molodyih O.P., Koldyisheva E.V. i dr. Rol strukturno-funktsionalnyih izmeneniy gladko-myishechnyih kletok detruzora i predstatelnoy zhelezyi v razvitii giperaktivnogo mochevogo puzyirya. [The role of structural and functional changes in detrusor and prostate smooth muscle cells in the development of an overactive bladder.]. Fundamentalnyie issledovaniya 2012: (5): 68-73. (In Russian).
18. Neimark A.I., Likhachev A.G., Salmanov V.I., Gromov O.V., Selivanov A.A. Evaluation of the effectiveness of treatment of overactive bladder and analysis of the morphological features of the detrusor in patients with benign prostatic hyperplasia. Siberian Medical Journal 2010; 5 (1): 10-14. Neymark A.I., Lihachev A.G., Salmanov V.I., Gromov O.V., Selivanov A.A. Otsenka effektivnosti lecheniya giperaktivnosti mochevogo puzyirya i analiz morfologicheskih osobennostey detruzora u bolnyih dobrokachestvennoy giperplaziey predstatelnoy zhelezyi.[Evaluation of the effectiveness of treatment of bladder hyperactivity and analysis of morphological features of detrusor in patients with benign prostatic hyperplasia.]. Sibirskiy meditsinskiy zhurnal 2010; 5 (1): 10-14. (In Russian).
19. Shormanov I.S. Structural remodeling of the renal vascular basin in experimental stenosis of the pulmonary trunk. Morphology 2004; 125 (1): 40-44. Shormanov I.S. Strukturnoe remodelirovanie sosudistogo basseyna pochek pri eksperimentalnom stenoze legochnogo stvola.[Structural remodeling of the renal vascular pool in experimental pulmonary trunk stenosis]. Morfologiya 2004; 125 (1): 40-44. (In Russian).
20. Shormanov I.S. Possible reversibility of structural changes in the vascular bed of the kidneys after the elimination of experimental coarctation of the aorta. Bulletin of Experimental Biology and Medicine 2006; 142 (9): 346-349. Shormanov I.S. O vozmozhnoy obratimosti strukturnyih izmeneniy sosudistogo rusla pochek posle ustraneniya eksperimentalnoy koarktatsii aortyi.[On the possible reversibility of structural changes in the renal vascular bed after elimination of experimental aortic coarctation]. Byulleten eksperimentalnoy biologii i meditsinyi 2006; 142 (9): 346-349.
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Bladder diverticulum: symptoms, signs, diagnosis and treatment

Description

Bladder diverticulum is a disease in which
as a result of the development of which there is a characteristic protrusion of the walls of the urinary
bubble. This pathology is not the most positive meaning, like any
another deviation from the norm, while it will not manifest itself very actively.However, this disease provides the most important pitfall in the fact that
there is a likelihood of developing characteristic complications that it can
provoke.

In the area where it directly occurs
characteristic protrusion of the walls of the bladder, all conditions are created for
so that the process of stagnation of urine begins, as a result of which characteristic
damage to the walls of the organ itself, and the development of quite
a large number of various diseases that are inflammatory
character.

If the patient is suffering from some kind of infection,
as a result of which the bladder was affected, then simply ideal
conditions for the accumulation of dangerous bacteria, therefore,
the treatment of the disease itself is also significantly complicated.

The diverticulum appears precisely in the area where
there is a strong thinning of the organ (in this case, the bladder). V
as a result, the risk of what could happen increases significantly
rupture of the damaged organ, in some cases even
insignificant mechanical impact on the organ.As a result of the break
bladder, it is possible to develop peritonitis, that is, the formation of a dangerous
surgical pathology.

Today, there are several types
diverticula of the bladder, among which there are two main ones:

• true diverticula act as
  abnormalities that have occurred in the development of the bladder itself, therefore,
  a person has this disease from birth. With congenital diverticulum, it will
  to be laid with other walls of the bladder, as a result of which there are
  its composition is all the layers that are in the walls of the bladder.Often
  localization of the congenital form of the disease occurs precisely on the back
  the surface of the damaged organ, while, in almost all cases,
  are single. They look like a baggy cavity that communicates with
  the cavity of the bladder using a narrow neck;
• False diverticula are exclusively worn
  acquired character. So that the beginning of education was provoked
  diverticula, there should be a strong thinning of the walls of the bladder itself, but also
  high intravesical pressure can also cause this phenomenon.Most of
  such an organ as the bladder is represented precisely by muscle tissue, consists
  from several layers and is called the muscle that is responsible for urine output.

In the event that characteristic
difficulties in the process of urine outflow, then muscle hypertrophy begins
layer that will provide natural emptying. But at the same time
this stage of compensation will not take too long.

Over time, to compensate for the difficulty
outflow of the bladder begins to gradually increase its own volume.V
as a result, this leads to the fact that the muscle layer is significantly thinned,
loosening of muscle fibers also occurs.

This is what provokes the appearance of characteristic
prerequisites that can cause the development of diverticula, while such
The diverticulum will not appear as muscle tissue from the side of the walls.

False diverticula can acquire the most
various shapes and sizes, while their localization can fall on
different areas of the body.Such diverticula can be not only solitary,
but also plural.

Bladder diverticulum formation may
occur as a result of a wide variety of pathologies. Development of true
diverticulum will be a definite violation in the process of formation, namely
genitourinary organs.

Also, such a disease can develop as a result
negative effects of high doses of radiation, long-term exposure
chemical mutagens, the presence of a serious infection during intrauterine
fetal development.

Also can cause a congenital disease
non-observance of the doctor’s recommendations during pregnancy, the presence of the mother
a variety of bad habits, and of course, very poor environmental conditions in
place of residence.

The formation of a false diverticulum occurs in
as a result of the presence of adenoma of the prostate gland, in which the inside of the prostate
the urethra is compressed, in case of urethral stricture, which may result
serious diseases of an inflammatory nature, as well as a tumor
genitourinary system and bladder neck stenosis.

Symptoms

If the disease is in its early stages
development, it may not manifest itself at all. Quite common
cases that patients simply do not know about their illness.

In the event that the diverticulum does not occur
stagnation of urine, and the wall appears in all layers, then the patient will not
absolutely no complaints and determine the presence of a bladder diverticulum
will be pretty hard.

However, if the diverticulum itself reaches
quite impressive in size, and urine stagnation also occurs, that’s all
leads to the formation of certain disorders in the bladder itself. Exactly
under such conditions of the development of the disease, the patient will manifest
characteristic signs of a bladder diverticulum, thanks to which it and
diagnosed.

Symptoms of this disease include
that the emission of urine occurs in two stages.The development of this phenomenon
due to the fact that urine will leave the diverticulum significantly
slower.

Therefore, in order to completely empty
bladder, additional emptying and diverticulum are needed. This
phenomenon and causes a feeling of repeated urination. In the event that
the patient has several localizations, then several times there will be
more frequent urination.

Also the main signs of urinary diverticulum
bladder are also unpleasant painful sensations that appear in the patient during
time of urination, and sometimes a small impurity can be observed in the urine
blood.

The patient may show not only the main
symptoms of bladder diverticulum development, but also certain diseases,
which develop as a result of the presence of a diverticulum.

These diseases include cystitis, since
as a result of stagnation of urine, the risk of its formation increases several times, and
also pyelonephritis. It is possible that stones will form in the bladder,
there is a risk of rupture of the diverticulum itself, which as a result will lead to the formation
peritonitis.

Diagnostics

For the diagnosis of bladder diverticulum, in
first of all, without fail, anamnesis is collected, and
the patient undergoes a complete physical examination. To confirm exactly
the correctness of the diagnosis, there is a need for
additional clinical trials.

The patient is assigned an ultrasound examination. This
the technique makes it possible to obtain the maximum amount of necessary
information by which the diagnosis is confirmed.In addition, with the help
such a study can also detect the presence of stones in the bladder,
at the same time, it is possible to assess their shape and size.

If the doctor still has doubts about
the correctness of the diagnosis, then the patient is prescribed a transurethral
cystoscopy. This technique is based on the ability of fiber to conduct
image.

During the procedure, a
a special sensor, which makes it possible to conduct an image.Farther
the doctor will have to assess the condition of all the inner walls of the bladder.
Thanks to such a study, it is possible to determine the anastomosis of the bladder and
diverticulum.

Prevention

The prevention of this disease is not based on
only maintaining a healthy lifestyle, you also need to pay special attention to
their food and regularly undergo routine preventive examinations,
thanks to which there is a chance to diagnose the disease at an early stage and
start his immediate treatment.

Treatment

With the help of conservative methods of treatment it is impossible
cure this disease. In the event that the diverticulum itself has a relatively
small size, while there will be no stagnation of urine, walls
the bladder has the correct structure, the patient has no complaints,
treatment is not necessary. But if the patient himself wishes, it can be started
observation, however, treatment is prescribed if the
development of characteristic complications.

Surgical treatment is based on
excision of the diverticulum itself and further suturing of the resulting defect. Important,
so that in this case, the surgical intervention would be low-traumatic, on the urinary
the bladder should have a minimum amount of traces after the operation.

In the event that treatment of a false
diverticulum, then, without fail, must be completely cured and then
a disease that actually provoked its development.

Otherwise, the risk of developing
relapse, since during treatment the cause of the development was not eliminated
diverticulum. Thanks to modern technology and the right approach to treatment
today almost all types of this pathology can be cured, regardless of
the severity of the disease.

Operating unit | TsPSiR

The operating unit of the Family Planning and Reproduction Center is a modern, high-tech complex providing round-the-clock surgical care for obstetric and gynecological patients.

Arkhipova Lyudmila Aleksandrovna was the first head of the operational department of the Central Pediatric Service of the Russian Federation, who continues her activities to this day, working as an obstetrician-gynecologist in the postpartum department.

Arkhipova Lyudmila Alexandrovna

First head of department

Now the head of the department is Konstantin Olegovich Veklich, an obstetrician-gynecologist of the highest category, who in 20 years at the Central Pedagogical Service of the Russian Federation has gone from a resident to the head of the department.Senior operating nurse of the highest category Irina Borisovna Chmeleva. The operating unit employs 13 highly qualified experienced operating nurses.

The operating unit includes 8 operating rooms: 4 – for obstetric operations (incl.equipped with angiographic equipment), as well as 4 for gynecological operating rooms, allowing for laparoscopic, laparotomy, vaginal, reconstructive plastic surgery.

For the first time in Russia, under the leadership of Corresponding Member of the Russian Academy of Sciences, Professor M.A. On the basis of the department, unique organ-preserving surgeries have been developed and implemented in case of ingrowth of the placenta, multiple myoma of the uterus.

Professor Kurtser M.A. and head. Department of Pathology Lukashina M.B. In 2009, the patent No. 2394509 was received: “A method for the treatment of postpartum hemorrhage by means of plugging staple sutures on the uterus.”

In addition, endovascular techniques for preventing / stopping obstetric bleeding (embolization of the uterine arteries, temporary balloon occlusion of the common iliac arteries), angiographic operations for uterine myoma (UAE) are performed in the operating unit of the TsPSiR. This is a modern, minimally invasive, organ-preserving method of treating uterine fibroids. UAE is performed for fibroids of almost any size and location, leading to the cessation of blood flow in the myomatous nodes with their subsequent “resorption”.

Of particular importance is the use of UAE in women planning pregnancy. In the presence of multiple uterine fibroids, large fibroids, as well as fibroids with an interstitial component, embolization avoids the formation of scars on the uterus, which are the main cause of such a formidable complication as uterine rupture during pregnancy and childbirth, as well as the development of adhesive disease. Often, embolization of the uterine arteries is the only chance to preserve the uterus and fertility.

In the operating department, up to 10 planned and 15 emergency operations are performed daily. In 2013, more than 2,500 surgeries were performed.

Placental growth

Placental ingrowth remains one of the leading causes of massive bleeding in obstetrics, which is associated with an increase in the number of caesarean sections. According to M.A. Kurtser and co-authors to designate placenta accreta, it is advisable to use the term placenta accreta, combining placenta accreta, placenta increta, placenta percreta used earlier in our country, based on the depth of myometrial injury.Currently, the diagnosis of placenta accreta occurs with a frequency of 1 in 533 – 2500 births.

According to M.A. Kurtser. et al (2016), placenta accreta is formed as a result of the complete “spreading” of an incompetent scar, the area of ​​which does not contain muscle fibers and is represented by fibrous tissue covered with the peritoneum with chorionic villi attached to it. Chorionic villi do not grow into the bladder, and the impossibility of separating the placenta from its posterior wall is explained by a pronounced adhesive process between the bladder and the pathologically altered uterine wall.

If there is a suspicion of placental ingrowth, pregnant women at risk (presence of a scar on the uterus after cesarean section and placenta previa located on the anterior wall of the uterus in the area of ​​the scar) should be performed by 2D ultrasound (ultrasound) with color Doppler mapping or magnetic resonance imaging (MRI ).

The echographic criteria for diagnosing placenta accreta are the presence of placental lacunae, obliteration of the hypoechoic zone between the placenta and the myometrium, thinning of the myometrium less than 1 mm, and the absence of a clear border between the uterine wall and the bladder.

MR – signs of ingrowth of the placenta include aneurysm of the lower uterine segment, thinning of the myometrium adjacent to the placenta, variegated vascular placental lacunae, the presence of pathological vessels extending beyond the organ.

According to our chief physician, O.A. Latyshkevich (2015) – the methods have comparable diagnostic value – in the presence of highly qualified specialists, preference should be given to an economically more acceptable ultrasound scan.

In recent years, in pregnant women diagnosed with ingrown placenta during delivery, it has become possible to avoid the previously inevitable hysterectomy due to metroplasty.

The modern surgical approach consists in performing operative delivery with simultaneous plastic surgery of the uterus and bladder. At the first stage of the operation, a bottom cesarean section is performed, which minimizes blood loss and ensures atraumatic fetal extraction.At the second stage, metroplasty is performed. Metroplasty consists in resection of the altered part of the myometrium in a single block with the underlying placenta, followed by reconstruction of the uterine wall.

Such surgeries began to be developed at the Center for Specialized Surgery in 2006: in the period from 2006 to 2017, 154 patients with a diagnosis of placenta accreta were operated on.

When diagnosing placental ingrowth, a pregnant woman must be routed to a level III hospital, where a multidisciplinary approach to delivery must be observed, which provides for the availability of a highly qualified obstetric and anesthetic service, blood products and the possibility of using devices for autologous blood reinfusion, urological and surgical care in round-the-clock availability using modern endovascular techniques.The hospital should have a modern X-ray or mobile angiographic unit (RCOG, 2011).

CPSiR provides medical care to patients with placenta accreta within the framework of the compulsory medical insurance program, we use both modern diagnostic and high-tech methods in the field of endovascular surgery – uterine artery embolization (UAE), temporary balloon occlusion of the common iliac arteries.

Temporary balloon occlusion of the common iliac arteries is highly effective and creates conditions for performing metroplasty with minimal intraoperative blood loss (Kurtser M.A. et al., 2016). After reaching complete occlusion of the arteries, the stage of obstetric surgery begins – with a 20-minute interval, the balloons are alternately deflated for 30-40 seconds – restoration of blood flow through the common iliac arteries in the pelvic organs and lower extremities is achieved.

In 2013, a team of obstetricians-gynecologists and vascular surgeons led by Mark Arkadievich Kurtser (GBUZ TsPSiR DZM, Perinatal Medical Center in St.Moscow, Clinical Hospital Lapino) was awarded the Vocation prize in the nomination “For the creation of a new method of treatment” – for the creation of a new technology for simultaneous delivery by caesarean section with simultaneous plastic surgery of the uterus and bladder.

Ultrasonography in the diagnosis of urinary tract infection in children

Authors: Richard D. Bellah, Monica S. Epelman, Kassa Darge

KEYWORDS

Urinary, infection, evaluation, tract, sonography

Urinary tract infection (UTI) is a common pathology in children and one of the most common causes of childhood morbidity.The gold standard for diagnosing UTI is the detection of a culture of pathogenic bacteria (usually Escherichia coli, Klebsiella, Proteus, and Pseudomonas) in the urine. However, on an outpatient basis, screening methods are often used (for example, determination of the level of leukocyte esterase or nitrite in the urine).

Various components play a role in the pathogenesis of UTI in children. When bacterial virulence factors such as adhesion and motility factors outweigh the body’s resistance factors, the likelihood of developing a UTI is increased.Anatomical, humoral and genetic factors also play an important role. The highest incidence of UTI, both for boys and girls, occurs before the age of one year of life, and then gradually decreases. During the first few months of life, the incidence of UTI in boys is higher than in girls, probably due to colonization by uropathogenic bacteria of the foreskin, in children without circumferential excision of the foreskin. However, primary and recurrent UTIs are more common in girls.Assessment of infection rates in the first 24 months of life gives the following morbidity data: 3% of boys less than 1 year old, 2% of boys older than 1 year (<0.5% for boys with excised foreskin), 7% of girls less than 1 year old and 8% of girls between the ages of 1 and 2 years. Some studies have also shown a downward trend in UTIs in Caucasian versus Black girls.

The symptoms of UTI in children can be very varied, depending on whether the infection is limited to the urethra, bladder, or the proximal urinary tract (ureter, calyx, or renal parenchyma).However, the true incidence is not reliably known due to the nonspecificity and frequent absence of symptoms. In the absence of imaging data, an infant with fever, or a child with clinically significant bacteremia without any other obvious foci of infection, from a purely clinical point of view, a proximal UTI (pyelonephritis) is first diagnosed. When a child develops UTI symptoms and urinary problems, with little or no fever and no systemic manifestations, a distal UTI (cystitis) is first diagnosed.However, the difference is not always obvious, especially in young children. As a result, diseases associated with UTI can be very diverse: from systemic damage associated with acute pyelonephritis to symptoms of urinary disorders – cystitis. Although long-term follow-up data in the literature is limited, several studies of the pediatric population have noted an association between renal fibrosis, which is caused by acute pyelonephritis with hypertension, and advanced renal failure.Although current research raises the question of such a relationship, the high prevalence and frequent morbidity associated with UTI in children has necessitated further research on the role of imaging in diagnostic and treatment algorithms.

PURPOSE AND OBJECTIVES OF THE VISUAL RESEARCH

The goal of urinary tract testing in pediatric patients with infection is to: (1) detect a possible cause of infection in order to prevent recurrence and reduce the risk of disease spread; (2) to determine whether the kidneys have a normal structure, whether they are involved in a pathological process or are at risk of developing a fibrotic process; (3) determine if there is vesicoureteral reflux (VUR), which contributes to the development of an ascending infection from the bladder; (4) identify urinary tract calculi that may persist for a long time and cause recurrent UTI; (5) to identify areas of obstruction of the outflow of urine.Although VUR is considered a major risk factor for UTI and kidney damage, it has been shown that UTI and renal fibrosis can occur without VUR, and some children with UTI and VUR may never show signs of renal fibrosis. The imaging algorithm, which usually includes ultrasound (ultrasound), radionuclide (with dimercaptosuccinic acid DMSA) and vocal cystourethrography (MCUG), is gradually changing.Despite this, many organizations, such as the American Society of Radiology and the European Society of Pediatric Radiology, have standardized diagnostic imaging studies, and have prepared guidelines and guidelines for evaluating a child with UTI. However, it is common knowledge that no single visual diagnostic technique can answer all basic questions. Even more controversial, some researchers have recently questioned the use of ultrasound, despite its attractiveness as a non-invasive method.This is mainly due to the inability of ultrasound to detect inflammatory changes, small lesions in the kidney, or intermittent dilation that is associated with VUR. In one study, which questioned the need for routine ultrasound, the following indicators were obtained for detecting VUR: sensitivity – 17%, specificity – 88%, positive predictive value – 24% and negative predictive value – 83%. In another study, the sensitivity was 10%, while none of the patients with abnormal ultrasound picture of the kidneys did not need to change treatment tactics.However, given the fact that new ultrasound techniques are emerging and developing, and the quality of grayscale ultrasound and color Doppler techniques continues to improve, radiological organizations and pediatric urological radiological societies always include ultrasound as an important step in the imaging algorithm. Pediatric practitioners are still reluctant to abandon the traditional standard ultrasound scan because it poses no risk or discomfort to younger patients.The following describes the basic basic features of ultrasound for the diagnosis of UTI in children, and describes the benefits of potential complementary ultrasound techniques and applications such as high-resolution ultrasound, harmonic imaging, and contrast-enhanced voiding urosonography (IUS).

URINARY TRACT INFECTION: ULTRASONOGRAPHY TECHNIQUE AND INTERPRETATION OF RESULTS

Assessment of the state of the urinary tract in children with UTI should include a study of the kidneys; ureters (if visible) and bladder.A high-frequency transducer should be used that reaches the depth of the area of ​​interest. For babies, a convex probe from 8 to 13 MHz is used, for young children, a convex probe from 4 to 9 MHz, and for adolescents, a convex probe from 2 to 5 MHz can be used.

For infants and young children, the bladder should be examined first, because the child can empty his bladder without permission, which makes it difficult to obtain further useful information about the bladder itself, about the bladder wall and the distal part of the ureters (their diameter and place of confluence).The bladder should be sufficiently distended and examined in the transverse and sagittal planes. In the transverse plane, images should be obtained from the apex of the bladder to the bottom in the area of ​​the internal opening of the urethra. In the sagittal plane, images should include the internal opening of the urethra, the distal ureters on both sides, and the confluence of the ureters. Color Doppler ultrasonography can be effective in identifying the place where the ureters flow as a trickle of urine.

In a patient with a UTI, the purpose of bladder sonography is to obtain information about the possible cause of the child’s susceptibility to infection. Bladder wall thickness is usually considered normal up to 0.3 cm when the bladder is full and 0.5 cm when empty. Conditions that can cause bladder wall thickening and trigger infection include obstruction of the bladder outlet (internal opening of the urethra) and urinary dysfunction (with or without neurogenic bladder dysfunction) (Fig.1).

Fig. 1. Eliminator dysfunction syndrome. Ultrasound of the bladder (transverse view) before urination (A) and after urination (B) in a 6-year-old girl with frequent micturition in a thin trickle and recurrent UTI. There is a thickening of the bladder wall, and a moderate amount of residual urine.

In a child with so-called Eliminator Dysfunction Syndrome, in addition to urinary dysfunction, constipation may also play a role in the development of UTIs.Large diverticula of the bladder can also lead to dysfunction of urination due to the inability to empty the bladder completely or effectively (Fig. 2).

Fig. 2. Large bladder diverticulum that results in incomplete emptying of the bladder. (A) Ultrasound (transverse view) of the bladder (bl) showing a large right-sided bladder diverticulum (d). (B, C) MCUG shows a large right-sided bladder diverticulum (d) that enlarges during urination, resulting in incomplete emptying of the bladder.

In acute onset of the disease, the thickening of the bladder wall can be caused by cystitis, which can be of bacterial or viral origin. Grayscale images show uneven thickening of the bladder wall, and color Doppler shows hypervascularization of the bladder wall (Figure 3).

Fig. 3. Bacterial cystitis. Color Doppler ultrasonography of the bladder (transverse view) shows significant irregular thickening of the bladder wall with hypervascularization of the base of the bladder (arrows).

Thickening of the bladder wall in cystitis caused by adenovirus can be so pronounced in some cases that it visually mimics the picture of a bladder tumor (Fig. 4).

Fig. 4. Viral cystitis mimicking the neoplasm of the bladder. Grayscale ultrasound of the bladder (A) and color Doppler (B) show an irregular, hypervascular tumor-like thickening that encloses the left bladder wall (arrows).(C) Ultrasound of the bladder after 4 weeks shows the disappearance of focal thickening of the bladder wall.

In addition to determining functional disorders of the bladder, ultrasound of the bladder is required to detect potential associated urinary tract abnormalities, such as: ectopia of the ureter, ureterocele, or megaureter. In this case, the diameter and place of confluence of the distal ureters are assessed. Low-level echoes or internal cellular debris within the dilated lumen may indicate superinfection or pyoureteronephrosis (Fig.5).

Fig. 5. Pyoureteronephrosis (upper pole) in a duplicated kidney with ureterocele. Ultrasound of the left kidney (sagittal view) (A) and bladder (transverse view) (B) show a dilated echogenic superior pole (arrows), a dilated ureter (s), and a ureterocele (uc), which generates internal echoes.

Routine gray scale ultrasonography of the distal ureters and pelvicellular system is generally considered a poor screening method for VUR.Hoberman and colleagues studied 309 children aged 1 to 24 months using ultrasound, DMSA, and MCUG. In doing so, they found that the sensitivity of ultrasound for detecting PMR during the MCUG was 10%, and the positive predictive value was 40%. VUR diagnosis can be improved with accurate and sophisticated ultrasound techniques. Contrast-enhanced ICS, which uses intravesical ultrasound contrast agent, is gaining widespread use, especially in Europe, as a safe alternative to the traditional X-ray methods of VUR diagnostics – MCUG and radionuclide cystography.If we consider the ICUG technique as a reference standard, the ICC technique for the diagnosis of VUR has the following indicators: sensitivity from 57% to 100%, specificity from 85% to 100%, positive and negative predictive values ​​from 58% to 100% and 87% to 100 %, as well as diagnostic accuracy from 78% to 96%. Attempts are under way to introduce the ICC in Canada, where appropriate contrast agents are already available. However, in the United States, the lack of suitable contrast agents for children that are approved by the Food and Drug Administration is delaying the introduction of this method.ICC includes the following four main stages: (1) preliminary examination, standard ultrasound of the urinary tract in the supine position, (2) catheterization or suprapubic puncture of the bladder under sterile conditions with the introduction of saline and contrast ultrasound, (3) postcontrast examination, repetition of standard sonography of the urinary tract, (4) postcontrast examination after urination, sonography of the kidneys and terminal sections of the ureters (urethra) during and after urination.Reflux is diagnosed when echogenic microbubbles are found in the ureters or in the calyx-pelvic system. During postcontrast examinations, the right and left renal pelvis are scanned in turn. A voiding test can be performed while the patient is lying or sitting on a bedpan, or standing up and urinating in a bottle. Reflux severity is assessed similarly to the International Reflux Scoring System for ICUG (Grades 1-5).

Depending on the equipment available, the IUS uses a variety of ultrasound imaging techniques to display reflux microbubbles.Imaging options not only affect the visibility of microbubbles, but also the overall diagnostic accuracy of the exam. Standard (fundamental) ultrasound is widely used for ICC. It can be combined with color Doppler to improve the quality of reflux detection. With harmonic imaging, the microbubbles are significantly more visible than the standard mode, which increases the sensitivity of reflux detection. The most modern ICC techniques, which significantly improve the technique for detecting microbubbles in reflux, use a contrast-specific imaging modality that is tuned to a specific contrast medium using a low or high mechanical index.

These contrast agents not only enhance the image and are colored in a certain color on the sonogram, they also allow visualization of only microbubbles during reflux, while blocking the background image in grayscale (Fig. 6).

Fig. 6. Vesicoureteral reflux (micturition urosonography). Vibration urosonography (IUS) before (A) and after (B, C) intravesical administration of a galactose-based contrast agent. For the study, a contrast-specific imaging modality with a high mechanical index is used.(A) In the kidney, there is a pronounced pyelocaliceal dilatation and thinning of the cortex. Reflux microbubbles are depicted as a color overlay, without (B) and partially with the elimination of the background in the sonogram in gray scale (C).

Potential disadvantages of ICC versus ICUG are: (1) urethral sonography is performed in only a few centers and is still not widely used, (2) longer study duration, and (3) limited assessment of bladder function.

Renal sonography serves several purposes in the initial evaluation of a child with UTI. Its main task is to identify structural disorders (congenital or acquired). In an acute process, when a UTI is diagnosed in an infant or young child, the purpose of a kidney ultrasound is to look for signs of infection and to identify congenital kidney abnormalities that may contribute to infection. Among them, obstructive uropathies, uroliths, abnormalities in the size of the kidneys, abnormalities of position or shape, doubling of the calyceal system with ectopia of the ureter with or without ureterocele are distinguished.Kidney length (and volume) should be measured routinely and compared to normal values ​​according to age, weight and possibly body surface area. The sagittal plane of the kidneys is the most easily reproducible projection for measuring their length, since the length of the kidneys can vary depending on the position of the patient. Kidney enlargement in acute pyelonephritis can be very variable. Initially, the volume of the kidneys may be normal, but over time it may increase as the inflammatory process progresses.The enlargement of the kidneys can be local or global (the whole organ), in the latter case, it varies from 120 to 175% of the normal size (Fig. 7).

Fig. 7. Acute pyelonephritis, diffuse process. Renal sonogram on both sides shows a normal right kidney. The left kidney is uniformly enlarged, while its general echogenicity is also increased. Loss of normal cortico-medullary differentiation is determined. Note the thickening of the renal pelvis epithelium (arrows).

The enlargement of the kidneys may no longer be detected on the sonogram after 1 – 2 weeks from the start of treatment, after elimination of the focus of infection. In addition to unilateral or bilateral enlargement of the kidneys, other pathological signs are also determined, which are especially pronounced in severe infections: loss of cortico-medullary differentiation, local hypoechoic or hyperogenic foci in the renal parenchyma (Fig. 8).

Fig. 8. Acute pyelonephritis, local process.(A) Gray-scale sonogram of the left kidney demonstrates a large local area (arrows) of hyperechogenicity and loss of cortico-medullary differentiation at the upper pole of the left kidney. (B) Color Doppler shows a significant decrease in flux within the affected echogenic superior pole (arrows). (C) Contrast CT (coronary reconstruction) confirms localized acute pyelonephritis in the upper left pole and a smaller area in the middle (arrows) of the left kidney.

Thickening of the epithelium of the renal pelvis system of the kidneys or ureters can be observed with infection (pyelitis), as well as with VUR (see.rice. 7). In the harmonic image, posterior shading, acoustic enhancement, or comet tail artifact is significantly better distinguished, which improves the quality and resolution of the image of small focal kidney lesions (Fig. 9).

Fig. 9. Acute pyelonephritis, high-resolution ultrasonography. (A) Ultrasonography (sagittal view) of the left kidney using a convex array transducer shows normal cortical echogenicity, cortico-medullary differentiation, and no local anomalies.(B) High-resolution line image shows the multifocal areas (arrows) of the cortical layer as hypoechoic bands that characterize acute pyelonephritis.

With harmonic imaging, contrast and lateral resolution can also be improved, and in pediatric urological practice, harmonic imaging is significantly superior to conventional sonography on the dorsal side of the kidney. In some cases, when the patient can be at rest and practically not move, color and power Doppler ultrasonography can complement the research data for the diagnosis of acute pyelonephritis by displaying areas of poor or absent perfusion.These areas of hypoperfusion reflect vasculitis or vasoconstriction of peripheral arterioles in response to bacterial infection (Fig. 10).

Fig. 10. Acute pyelonephritis, power Doppler sonography. (A) Grayscale sonography demonstrates a slight increase in echogenicity of the upper pole of the left kidney (arrows). (B) Power Doppler imaging demonstrates a decrease in perfusion at the upper and lower poles (arrows) of the left kidney, which is indicative of multifocal acute pyelonephritis.

This technique is especially important for infants less than 3 months of age, in whom the use of Tc-99m DMSA scintigraphy, the reference standard for assessing acute pyelonephritis, is generally not recommended. However, in general, in the diagnosis of acute pyelonephritis without complications, ultrasound is inferior to standard imaging techniques such as Tc-99m DMSA scintigraphy (Fig. 11).

Fig. 11. Acute pyelonephritis, ultrasonography / DMSA. (A) Sonography of the right kidney demonstrates normal cortical echogenicity, cortico-medullary differentiation, and no focal anomalies.(B). A simultaneous DMSA (posterior view) shows an area of ​​weak accumulation in the middle of the lower pole of the left kidney (arrows), which characterizes acute pyelonephritis.

In one study, it was shown that pathological changes that were diagnosed with DMSA in 63% of 91 children with acute UTI were identified in only 24% of the same group according to sonography. However, it is well known and supported by research that UTI in children with fever may indicate either a congenital anatomical abnormality or VUR, so many clinicians believe that renal ultrasound remains a necessary study in the algorithm for diagnosing the first episode of a febrile UTI.Ultrasound of the bladder and kidneys is most often the initial test to identify the underlying pathological conditions that are predisposing factors for the development of infection in an infant or young child. It should be noted, however, that some authors question this tactic for those infants who underwent prenatal sonography in a specialized center after 30-32 weeks of gestation. In most cases, the predisposing factor is one of the forms of congenital obstructive uropathy or severe VUR.An interesting fact is that although obstruction of the ureteropelvic junction is the most common congenital form of urinary tract obstruction, in our practice we have rarely noted obstruction of the ureteropelvic junction as the main cause of UTI in children. Pyoureteronephrosis, in which infection or purulent debris manifests itself as a low-level echo signal in the enlarged areas of the collecting system, preferably develops against the background of such abnormalities as megaureter and kidney doubling with urethral ectopy or ureterocele, which, in turn, are associated with ureteral dilatation (see.rice. 5). Under certain conditions, such as premature birth or long-term use of antibiotics, a fungal infection of the kidney can occur, which manifests itself as casts or clumps of echogenic material (fungal balls) in dilated areas of the upper urinary tract (Fig. 12).

Fig. 12. Kidney candidiasis (in a newborn). A sonogram (coronary view) of the right kidney in a premature infant shows casts of echogenic debris in the moderately dilated pelvicellular system within the kidney.

In rare cases, E. coli toxin can cause ureteral atony, resulting in isolated dilatation of the ureter.

Sonography can detect complications associated with acute pyelonephritis. Among them: kidney abscess, perinephric abscess, xanthogranulomatous pyelonephritis and renal calculi (Fig. 13). Abscesses can be single or multiple, and they are the result of acute pyelonephritis or hematogenous infection. Small parenchymal or perinephral abscesses may be poorly visualized on a grayscale sonogram.Large abscesses are defined as well-defined hypoechoic fluid accumulations with internal echo. In most cases, ultrasound examination can be supplemented by additional visualization of renal sections in transverse projections, which can be useful for performing ultrasound-guided interventions (Fig. 14).

Fig. 13. Xanthogranulomatous pyelonephritis. (A) Sonogram of the left kidney (sagittal, transverse) showing enlargement of the left kidney with large hypoechoic regions secondary to moderate pyelocaliectasia.A small calculus (arrow) is defined in the left pelvis. (B) Delayed contrast CT shows normal right kidney, enlarged left kidney with inflammatory changes in Gerot’s fascia, minimal cortical enhancement without excretion, significant pyelocalicoectasia, and small renal calculi. (C) Tc-99m Mag-3 renal scintigraphy (posterior view) demonstrates a nonfunctioning left kidney and normal right kidney function

Fig. 14. Acute pyelonephritis with kidney abscesses.(A) Sonogram (sagittal view) of the right kidney shows enlargement of the kidney, with loss of normal architectonics in the upper pole area with several focal hypoechoic areas (arrows). (B) Color Doppler shows pronounced upper pole perfusion (arrows). (C) Contrast CT (coronary view) shows signs of acute pyelonephritis with multifocal abscesses (arrows) in the upper pole of the right kidney.

Perinephral abscesses usually result from the breakthrough of cortical abscesses into adjacent perinephral soft tissues.

Another task of the primary ultrasound examination of the kidneys, not necessarily during the acute process, is to identify acquired changes, for example, parenchymal fibrosis caused by a previously unknown or undiagnosed infectious process in the kidneys. Significant focal thinning of the cortex can be suspected if the echo of the renal sinus (adipose tissue) reaches the edge of the cortex of the affected kidney. These changes most often manifest themselves in the area of ​​the renal poles (Fig.15).

Fig. 15. Chronic pyelonephritis. Sonograms of both kidneys show a focal area of ​​cortical thinning (arrow) in the upper pole of the right kidney (left kidney without pathology).

Small to medium sized fibrosis is not easily detected by sonography. The degree of cortical thinning can be severe enough to result in significant replacement of healthy kidney tissue. As with acute pyelonephritis, DMSA is the standard method for detecting renal fibrosis.Only about 4% of children have visual signs of parenchymal lesions as a result of UTI, which are visible on DMSA scans. In a study by Luk and colleagues of 55 children with kidney fibrosis according to DMSA, only 29% had pathological changes on sonography (sensitivity – 29%, positive predictive value – 41%, accuracy – 89%). In their study, they found that the negative predictive value of sonography combined with MCUG was high in predicting the absence of fibrosis, suggesting that DMSA need not be performed in children less than 2 years of age if ultrasound and MCUG are normal.Similarly, Christian and colleagues examined the risk of false-negative diagnosis of cortical renal fibrosis (found on DMSA scintigraphy) using ultrasound alone, factoring for clinical signs (upper or lower urinary tract), recurrent UTI, and age group. They found that the risk of no ultrasound evidence of cortical renal fibrosis found with DMSA ranged from 0.4% (in school-aged children with isolated lower UTI) to 11% (in infants with recurrent upper UTI).However, as with ultrasound techniques, DMSA scintigraphy is also evolving. With a focus on renal fibrosis, some authors suggest that children under 2 years of age with documented UTI should undergo ultrasound to rule out major anatomical abnormalities, and DMSA scintigraphy to rule out kidney fibrosis, and, it may be necessary to conduct an ICUG.

SUMMARY

Over the past decade, the algorithm for the imaging diagnosis of children with UTI has been challenged based on evidence-based medicine and the experience of physicians.Among the practice guidelines under consideration, which each imaging modality includes, the routine use of ultrasound for the initial assessment of uncomplicated UTI in children has become controversial. This opinion is the result of several studies that have shown that ultrasound is ineffective in providing additional, clinically useful information. Nevertheless, given all the advantages of ultrasound, including its effectiveness in detecting structural abnormalities of the urethra, many practitioners continue to include ultrasound as a standard study in the algorithm for diagnosing UTI in pediatric practice.And for these studies, an ultrasound machine from the company Toshiba strong> – Aplio 300 is perfect.

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