Term
| what characterizes most congenital anomalies involving the bladder? |
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Definition
| most have little clinical significance, though some can contribute to obstruction of urine flow or cause clinical disease |
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Term
| what characterizes the congenital anomaly of double and bifid ureters? |
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Definition
| double and bifid ureters may be associated with distinct double renal pelves or anomalous development of a large kidney w/partially bifid ureters terminating in separate ureters. these double ureters may pursue separate courses into the bladder wall and then drain into a single ureteral orifice. *most double ureters are unilateral* and are of *no clinical significance*. |
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Term
| what characterizes the congenital anomaly of ureteropelvic junction obstruction? |
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Definition
| ureteropelvic junction obstruction results in *hydronephrosis and is due to the *abnormal organization of smooth muscle bundles which create abnormal stromal collagen deposition*. the kidney becomes large and swollen, but ureteropelvic junction obstruction generally doesn't come to clinical signifigance for a while b/c it is unilateral and the other kidney can pick up the slack. there may also be *congenital compression of the polar renal vessels* associated with this. |
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Term
| who is more affected by ureteropelvic junction obstruction? |
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Definition
| ureteropelvic junction obstruction is more common in infant boys, but in adult cases - women are more commonly affected |
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Term
| what characterizes the effect of diverticuli on the ureters? |
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Definition
| diverticuli, or outpouchings of mucosa are usually asymptomatic - though multiples *can cause stasis and lead to secondary infections*. the ureters may become dilated, tortuous and elongated as a result. |
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Term
| what are two kinds of inflammation seen in the ureters? |
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Definition
| ureteritis follicularis: an accumulation of *lymphocytes which form follicles w/germinal centers* and elevate the mucosa w/a varying degree of *granularity and ureteritis cystic: the mucosa is *lined by very small cyst structures lined themselves by flattened urothelium*. |
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Term
| what characterizes the incidence of tumors in the ureters? |
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Definition
| ureteral tumors are rare relatively rare. *fibroepithelial polyps are benign tumors w/loose vascularized connective tissue presenting as a mass projecting into the lumen. *transitional cell carcinomas are malignant tumors which closely resemble those seen in the renal pelvis, calyces, and bladder and are usually seen in men >60 yrs old. both can cause obstruction. |
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Term
| what are the intrinsic obstructive lesions? how commonly are they the cause of ureteral problems? |
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Definition
| intrinsic obstructive lesions such as diverticuli, fibroepithelial polyps, malignancies, strictures, caliculi, blood clots (if hypercoagulable state) and neurogenic problems (w/peristalsis) are more commonly the cause of ureteral problems than extrinsic. |
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Term
| what are the extrinsic obstructive lesions? |
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Definition
| extrinsic obstructive lesions consist of anything surrounding and compressing the ureter such as pregnancy, periureteral inflammation (general pelvic inflammation), endometriosis (deposits of endometrial tissue outside the uterus), and tumors (ovarian/pelvic - hydronephrosis: common cause of morbidity) |
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Term
| what are the results of ureteral obstruction? |
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Definition
| hydroureter (ureter itself expands and becomes enlarged/dilated), hydronephrosis (kidney expands, usually unilateral - but if bilateral, more symptomatic), and pyelonephritis (infection due to stasis of urine flow, tends to be ascending) |
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Term
| what is sclerosing retroperitoneal fibrosis? |
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Definition
| *fibrous proliferation of inflammatory processes encasing the retroperitoneal structures* (including ureters) leading to hydronephrosis that occurs in late to middle age and is often due to drugs and associated with other inflammatory conditions: *vasculitis, diverticulitis, and crohn disease*. it is uncommon, but distinct. |
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Term
| what are two congenital anomalies which can affect the bladder? |
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Definition
| diverticula and exstrophy |
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Term
| what characterizes the incidence diverticula in the bladder? |
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Definition
| congenitally: bladder diverticula emerge due to *failure of normal musculature development and increased intraluminal pressure leading to outpouchings of mucosa. acquired: obstruction of urinary flow leads to increased intraluminal pressure and thickening of the bladder wall - the musculature is normal, but pressure exceeds its limits and produces outpouching. diverticula are often multiple, particularly w/congenital forms, and can lead to infections and reflux from the bladder into the ureter. *most of the time diverticula are asymptomatic - but can predispose pts to calculi formation*. CA rarely arises from diverticuli. |
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Term
| what is exstrophy of the bladder? |
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Definition
| when the bladder communicates with a *congenital defect in the abdominal wall. this is surgically correctable, though the bladder may undergo *glandular or squamous metaplasia due to abnormal function. once fixed, pts usually fare well - however it raises the red flag for other anomalies. |
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Term
| what is the most commonly seen bladder pathology? |
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Definition
| cystitis: acute and/or chronic inflammation of the bladder |
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Term
| what are the common infectious agents responsible for acute/chronic cystitis? |
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Definition
| *e. coli, which is the most common due to the close proximity of rectum/ureters, followed by *proteus, klebsiella, and enterobacter*. candida may infect bladders of immunocompromised, *schistosomiasis may be seen more in the middle east (association w/SCC), and less commonly viruses/chlamydia/mycoplasma may infect the bladder. |
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Term
| what is a major cause of cystitis in men? |
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Definition
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Term
| how does acute hemorrhagic cystitis appear grossly? histologically? |
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Definition
| grossly: the mucosal wall is hyperemic w/focal areas of hemorrhage. histologically: transitional epithelium may be fragmented/denuded off w/hemorrhage below the epithelial surface. |
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Term
| what characterizes chronic cystitis histologically? |
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Definition
| more inflammatory infiltration, epithelial cell changes, often fragmentation of epithelial lining - seen often in congenital problems or pts w/long indwelling catheterization. |
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Term
| what is radiation cystitis? |
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Definition
| after decades of radiation exposure, *reactive hyperplastic epithelial cells invade the lamina propria* and may form bizarre squamous cell-like nests exhibiting nuclear polymorphism. fibrin deposits and hemorrhage are usually seen. if these changes are seen w/o hx of radiation - may indicate SCC or transitional cell CA |
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Term
| what are some predisposing factors for cystitis? |
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Definition
| bladder calculi (can be the result/cause of inflammation), urinary obstruction (BPH in men), DM (neuropathy), instrumentation, immunodeficiency, *cytotoxic antitumor drugs (hemorrhagic cystitis), and radiation cystitis |
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Term
| what is the morphology of cystitis? |
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Definition
| hemorrhagic cystitis features edema/hyperemia and focal areas of hemorrhage. nonspecific acute and chronic inflammation are generally concurrent. if the inflammation becomes severe, suppurative/ulcerative cystitis may occur. |
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Term
| what characterizes the histological presentation of chronic cystitis? |
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Definition
| thickening of the bladder wall (over years), infiltration of lymphocytes, granularity, *infiltration of fibroblasts (further decrease in elasticity = increase in cystitis), and then there are also specific follicular/eosinophilic types of chronic inflammation. |
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Term
| what are the clinical features of cystitis? |
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Definition
| frequency (constant urge to urinate), dysuria (burning feeling), lower abdominal pain, and possible fever |
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Term
| what is interstitial cystitis/hunner ulcer? |
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Definition
| this describes *inflammation and fibrosis of all layers in the bladder as well as fissures w/hemorrhage that heal poorly (hunner ulcers)*. it is seen mostly in women (possible autoimmune etiology), and is a cause of high morbidity and lower abdominal pain. on bx, abnormal cells due to chronic inflammation may be visible. |
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Term
| what is the morphology associated with interstitial cystitis/hunner ulcers? |
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Definition
| bladder walls are thickened, fissures are scattered throughout and pts present with abdominal pain, dysuria, and frequency |
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Term
| what is malakoplakia? what is an important histologic structure associated with this? |
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Definition
| infiltration of large foamy macrophages, chronic inflammatory cells, giant cells, and lymphocytes which appear as *raised yellow mucosal plaques and are due to *chronic bacterial infection - as often seen in immunosuppressed transplant pts. *michaelis-gutmann bodies* are important structures associated with malakoplakia consisting of *laminated mineralized concretions* engulfed by macrophages and between cells*. |
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Term
| what is polypoid cystitis? |
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Definition
| inflammation which results in polyp formation of the bladder mucosa - usually in response to some kind of chronic infiltration (catheter) as a reparative measure and is associated with submucosal edema. polypoid cystitis can mimic papillary CA. |
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Term
| what is cystitis glandularis/cystitis cystica? |
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Definition
| metaplastic changes where *nests of transitional epithelium transform into cuboidal or columnar epithelium*. these may undergo further cystic change, but are *relatively common findings in normal urinary bladders. |
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Term
| how does cystitis glandularis/cystitis cystica appear histologically? |
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Definition
| normal transitional epithelium at the top layer, but nests of cuboidal/columnar change in the lamina propria |
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Term
| when is squamous cell metaplasia usually seen in the bladder? how does it usually appear histologically? |
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Definition
| in response to injury - histologically, it is associated with increased keratin production |
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Term
| what is nephrogenic metaplasia? |
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Definition
| focal replacement of transitional cells with cuboidal epithelium in papillary structures that can mimic CA. this may occur in response to injury. |
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Term
| what characterizes the over all incidence of bladder tumors? |
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Definition
| bladder CA rates are increasing. most are transitional cell CA, but SCC or mesenchymal tumors may also be seen. |
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Term
| what are the 2 basic morphologies of bladder CA? how do they usually present? |
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Definition
| papillary and flat - either of which can be invasive and usually both will present w/some kind of hematuria as well as flaking of abnormal cells (detectable w/urinary cytology) |
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Term
| what is transitional cell hyperplasia? |
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Definition
| in transitional cell hyperplasia, transitional cells are simply increasing in number. |
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Term
| what characterizes transitional cell tumors in the bladder? |
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Definition
| transitional cell tumors can range from benign to malignant and many are multifocal. there are 2 precursor lesions leading to CA: *noninvasive papillary tumors and *CA in situ - however, invasive CA is often not associated with precursor lesions (rises denove). grossly, transitional cell tumors can range from purely papillary (red excrescences) to flat (hyperemic). |
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Term
| what characterizes papillomas as seen in the bladder? |
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Definition
| papillomas are composed of fibrovascular tissue covered w/benign epithelium and are seen in younger pts. *inverted papillomas* are also possible, which consist of benign epithelium extending into the lamina propria (dimpling in). |
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Term
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Definition
| a papillary urothelial neoplasm of low malignant potential, these are similar to papillomas - but tend to be larger. they have a thicker urothelium or nuclear enlargement and may recur - though they rarely progress to higher grade lesions. |
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Term
| what is a low grade papillary urothelial CA? |
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Definition
| low grade papillary urothelial CA is a kind of transitional cell CA characterized by orderly structures, nuclear atypia, mild pleomorphism, and rare invasion but common recurrence. |
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Term
| what is high grade papillary urothelial CA? |
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Definition
| high grade papillary urothelial CA is a kind of transitional cell CA characterized by large hyperchromatic nuclei, frank anaplasia (lack of differentiation), loss of polarity, increased mitosis, higher invasion risk and greater metastatic potential |
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Term
| what characterizes CA in situ? |
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Definition
| w/transitional cell CA in situ, malignant cells are in flat urothelium and may shed into urine due to lack of cohesiveness. the mucosa is reddened and thick, there are no intraluminal masses, and they are often multifocal. if left untreated, CA in situ can lead to invasive CA. |
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Term
| what characterizes transitional CA in situ histologically? |
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Definition
| malignant cells are observed with high n/c ratios, much disorganization, stratification of nuclei, fragmentation, and *non-invasion of the basement membrane*. |
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Term
| what determines prognosis for invasive transitional cell CA? |
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Definition
| the extent of invasion determines the prognosis, for example invasion of the muscularis propria is more ominious than if the lamina propria is invaded. |
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Term
| what characterizes the incidence of SCC in the bladder? |
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Definition
| SCC is less common than transitional cell CA in the bladder and has a *strong association with schistosomiasis (egypt/sudan). SCC is more invasive and fungating and will cover large areas of the bladder. SCC has a poor 5 yr survival rate. |
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Term
| how common are adenocarcinomas in the bladder? what characterizes their appearance? |
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Definition
| rare. if seen they are histologically identical to those seen in the GI tract, but with some serologic differences. these will secrete a significant amount of mucin, which enables invasion. most adenocarcinomas develop from *chronic irritation of the surface urothelium. |
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Term
| what are some of the risk factors for bladder CA? |
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Definition
| bladder CA affects mostly males 50-80 yrs old, whose risk increases with *smoking, arylamine exposure, schistosomasis, long term analgesis use, cyclophosphamide (tumor drug) use, and radiation exposure. |
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Term
| what is the clinical course of bladder CA? |
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Definition
| painless hematuria, occasional frequency/urgency/dysuria, possible pyelonephritis, and a higher recurrence rate (f/u cytology w/various urine markers) |
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Term
| what characterizes the incidence of mesenchymal tumors in the bladder? |
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Definition
| mesenchymal tumors are relatively rare, the *most common of which in adults being leiomyoma and embryonal rhabdomyosarcoma in infants*. sarcomas tend to appear as large, soft, fleshy masses and *sarcoma botroides appear as polypoid grape-like masses in children and infants*. |
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Term
| what are the more common metastatic tumors to the bladder? |
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Definition
| breast, melanoma, lung, kidney, stomach, pancreas, and ovary |
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Term
| what are the important components of a bladder CA path report? |
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Definition
| grade, configuration (sessile/papillary), depth of penetration, lymphatic/blood vessel penetration, and changes in the adjacent mucosa |
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Term
| what are things which can result in bladder obstruction? |
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Definition
| prostatic hyperplasia/CA, narrowing of the urethra, invasion by perivesicular lesions, cystitis, bladder tumors, foreign bodies/calculi, and injury to bladder innervation (neurogenic bladder associated with DM and trauma) |
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