Disorders of the urinary bladder Either congenital or

Disorders of the urinary bladder

Either congenital or acquired. The congenital anomalies include. Ectopia vesica (bladder exstrophy). Exstrophy of the urinary bladder is a complete ventral defect of the urogenital sinus & the overlying skeletal system. q. The lower central abdomen is occupied by the inner surface of the posterior wall of the bladder, whose mucosal edges are fused with skin. q. Urine spurt onto the abdominal wall from the uretera orifices.

q. The rami of the pubic bone are widely separated. q. Epispadias almost always accompanies it q Many untreated exstrophic bladder reveal fibrosis, & chronic infection. q. Adenocarcinom is common, q. Renal infection & hydronephrosis caused by ureterovesical obstruction Treatment. Usually accomplished by surgical repair as early as 1 st week

Persistent urachus. Embryologically, the allantois connects the urogenital sinus with the umbilicus. Normally the allantois is obliterated & is represented by a fibrous band called urachus extending from the dome of the bladder to the navel. Urachal formation is directly related to bladder descent. Lack of descent is more commonly associated with patent urachus than with bladder outlet obstruction.

Incomplete obliteration is some time occurs, -if obliteration is complete except at the superior end, a draining umbilicus sinus may be noted. -If the inferior end remains open, it will communicate with the bladder, but this does not usually produce symptoms. -Rarely the entire tract remains patent, in which case urine drains constantly from the umbilicus.

This is apt to become obvious within few days of birth, -if only the ends of the urachus seal off, cyst of that body may form & may become quite large, presenting a low midline mass. -Adenocarcinoma may occur in a urachal cyst, -Stones may be seen in a cyst of the urachus.

Treatment. Consist of excision of the urachus, which lies on the peritoneal surface with bladder cuff If adenocarcinoma is present radical resection is required. Unless other serious congenital anomalies are present, the prognosis is good. The complication of adenocarcinoma offers a poor prognosis.

Acquired diseases of the bladder Interstitial cystitis (Hunner`s ulcer). Is primarily disease of middle aged women. It is characterized by fibrosis of vesical wall, with consequent loss of bladder capacity. Frequency, urgency, & pelvic pain with bladder distension are the principle symptoms.

Pathogenesis. Infection does not appear to be the cause of fibrosis of the bladder wall, because the urine is usually normal. The cause still unknown, but the primary change is fibrosis in the deeper layer of the bladder. The capacity of the organ is decreased, sometimes markedly.

The mucosa is thinned, especially where mobility is greatest as the bladder fill & empties (ie, over the dome), and small ulcers or cracks In the most sever cases the normal mechanism of the ureterovesical junctions is destroyed, leading to vesicoureteral efflux. Hydroureteronephrosis & pyelonephritis may ensue.

Clinical findings. Interstitial cystitis should be considered when vmiddle aged woman with clear urine complains of sever frequency & nocturia & suprapubic pain on vesical distention. v. There is long history of slowly progressive frequency & nocturia, both of which may be sever.

v. Suprapubic pain is usually marked when bladder is full. Pain may also be experienced in the urethra or perineum, its relieved on voiding. v. Gross hematuria occasionally noted v. The patient is tense & anxious, v. A history of allergy may be obtained. v Physical examination is usually normal. Some tenderness in the suprapubic area may be noted.

x-ray finding. q. Excretory urograms are usually normal unless reflux has occurred qcystogram reveals a bladder of small capacity, reflu into dilated upper tract may be noted on cystography. Instrumental examination. Cystoscopy is usually diagnostic. • The vesical capacity as low as 60 ml. • the bladder lining may look fairly normal. • punctuate hemorrhagic areas • glomerulation.

Differential diagnosis. -Tuberculosis of the bladder. -Schistosomiasis. -Nonspecific vesical infection Treatment. There is no definitive treatment for interstitial cystitis. The therapy employed affords partial relief, but it may be completely ineffective.

q. General or vesical sedative q. Hydraulic overdistension qinstillation ofdimethyl sulfoxide (DMSO) into the bladder q. Cortisone acetate or prednisone q. Antihistamine q. Heparin sodium q. Surgical management in a form of iliocystoplasty may be done to augment the vesical capacity.

Vesical fistulas are common. The bladder may communicating with the skin, intestinal tract, or female reproductive organs. The primary disease is usually not urologic. The causes are as follows: 1 - primary intestinal disease diverticulitis (50 -60%), cancer of the colon (20 -25%), & crohn disease (10) 2 - primary gynecologic disease, pressure necrosis following difficult labor, advanced cancer of the cervix.

3 - treatment for gynecologic disease following hysterectomy, low cesarean section, or radiotherapy for tumor. 4 - trauma. Clinical finding A –vesicointestinal fistula. Symptoms include vesical irritability, the passage of feces & gas through the urethra, & usually a change in bowel habit Signs of bowel obstruction may be elicited, abdominal tenderness may be found if the cause is inflammatory. The urine is always infected

Cystogram may reveal gas in the bladder or reflux of the radiopaque material into the bowel. Cystoscopic examination, the most useful diagnostic procedure, show sever localized inflammatory reaction from which bowel content may exude. Catheterization of the fistulous tract may be feasible; the instillation of radiopaque fluid often establish the diagnosis.

B –vesicovaginal fistula. This relatively common fistula is secondary to obstetric, surgical, or radiation injury or to the invasive cancer of the cervix. The constant leakage of urine is most distressing to the patient. Pelvic examination usually reveals the fistulous opening, which also can be visualized with the cystoscope.

Vaginography often successfully shows ureterovaginal, vesicovaginal, & rectovaginal fistulas. Biopsy of the edges of the fistula may show carcinoma.

Treatment. A –vesicointestinal fistula. If the lesion is in the rectosigmoid, treatment consist of proximal colostomy. When the inflammatory reaction has subside, the involved bowel may be resected, with closure of the opening of the bladder. The colostomy can be closed later. Small bowel or appendiceal vesical fistula require bowel or appendiceal resection & closure of the vesical defect.

B –vesicovaginal fistula. o. Tiny fistulous opening may become sealed following the introduction of an electrode into the fistula. o Large fistulas secondary to obstetric or surgical injuries respond readily to surgical repair, o. Fistulas develop secondary to radiation therapy, or direct extension by cancer are difficult to close.

Non infectious hemorrhagic cystitis Some patients following Ø radiotherapy for carcinoma of cervix or bladder, ØCyclophosphamide using To control bleeding, ü Cystoscopic fulguration üThe instillation of 3. 9% formalin is more efficacious.

üinflation of balloon inside the bladder ü embolization of internal iliac artery, ücontinuous irrigation with 1% alum solution To reduce the incidence of cyclophosphamide induced hemorrhagic cystitis, they produce diuresis & patient void frequently