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The Inflammatory Contracted Bladder

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The Inflammatory Contracted Bladder Current Bladder Dysfunction Reports (2019) 14:67–74 https://doi.org/10.1007/s11884-019-00507-w INFLAMMATORY/INFECTIOUS BLADDER DISORDERS (MS MOURAD, SECTION EDITOR) The Inflammatory Contracted Bladder Hector Cantu1 & Siti Nur Masyithah Maarof1 & Hashim Hashim1,2,3 Published online: 22 April 2019 # The Author(s) 2019 Abstract Purpose of Review This review will present the inflammatory contracted bladder as a clinical entity and will address its pathophysiology, diagnosis and treatment. Recent Findings The inflammatory contracted bladder is relevant since it is not a recognised urological condition and it can be found in several affections to the urinary tract. Its medical management depends on its aetiology and severity. Summary The inflammatory contracted bladder (ICB) is an ambiguous term that is used to describe the morphology of the inflamed bladder with a reduced volumetric capacity and compliance. This condition is found in some urological pathologies such as bladder outlet obstruction, infections, drug toxicity, radiation cystitis and other inflammatory diseases like interstitial cystitis, malacoplakia and eosinophilic cystitis. This entity is usually presented at the end stage of disease and represents an irreversible damage to the urinary tract. Keywords Inflammatory contracted bladder . Volumetric capacity . Compliance Introduction Background The term inflammatory contracted bladder (ICB) is included Recent descriptions of the functional abnormalities of the in a diverse spectrum of urological diseases that affects the bladder were initially described in the French literature in function of the bladder, its volumetric capacity and compli- 1897 by Jean Casimir Félix Guyon [1]. During 1917 in ance; this condition could also cause deterioration of the upper San Francisco, Krotoszyner postulated the clinical diag- urinary tract and renal impairment. The presentation of the nosis of the contracted bladder and reported some cysto- ICB involves a wide range of storage and voiding symptoms. scopic characteristics of this condition. He stated that the There is considerable ambiguity about the aetiology, morphol- underlying causes of the contracted bladder may share a ogy and clinical significance of the contracted bladder; how- similar disordered physiological process; however, it may ever, it is important to assess and treat this condition because occur on the basis of a variety of vesical and extravesical of the potential irreversible damage to the urinary tract. factors [2]. A volumetric capacity of less than 50 mL was used as a reference. The current standardisation of terminology of lower uri- This article is part of the Topical Collection on Inflammatory/Infectious Bladder Disorders nary tract function reported by the sub-committee of the International Continence Society, does not present the ICB * Hashim Hashim as an associated condition with lower urinary tract dysfunction [email protected] and urodynamic studies [3••]. This review presents a compre- hensive analysis of the ICB according to the database findings Hector Cantu [email protected] in the medical literature. Siti Nur Masyithah Maarof [email protected] 1 Bristol Urological Institute, Bristol, UK Pathophysiology 2 Urodynamic Unit Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK Several theories could be postulated in the pathophysiology of the ICB. It is important to recognise that it is challenging to 3 University of Bristol, Senate House, Tyndall Ave, Bristol BS8 1TH, UK determine specific tissue changes because this condition 68 Curr Bladder Dysfunct Rep (2019) 14:67–74 involves several pathological pathways in the development of Diagnosis and Investigations bladder dysfunction. Basic foundation for subsequent evaluation can be obtained from medical history and physical examination. Factors such Urothelium as medication use, specific past medical history such as tuber- culosis, ketamine abuse or pelvic radiotherapy must also be Alterations on the urothelial cells like the loss of tight junc- factored into the decision and diagnostic paradigm [9]. Certain tions or modifications on the membrane cell structure are com- physical examination factors must also be evaluated such as promised by several conditions such as infections, inflamma- enlarged prostate gland, hydronephrosis or any associated tion, chemical exposure or radiation. The impairment of the neurologic abnormalities. epithelial impermeability could manifest with elevation of in- Both men and women with history of lower urinary tract flammatory and fibrosis markers together with reduced blad- symptoms will require urinalysis [10]. Assessment modal- der capacity and ICB [4, 5•]. ities include estimation of bladder capacity, post void re- sidual assessment, cystoscopy, radiographic techniques such as ultrasound of the urinary tract, CT urogram, Stroma voiding cystourethrogram (VCUG) and MRI of the bladder outlet and urethra can be performed. Further attempts at The main elements of the bladder stroma are collagen and refining the diagnosis of ICB may require urodynamic as- elastin surrounded by fibroblasts and a matrix of proteogly- sessment [9, 11]. cans. The normal bladder responds well to changes in bladder Bladder capacity can be determined either from the maxi- volume and pressure. Bladder collagen and elastin are related mum amount voided on the bladder diary, with non-invasive to tissue compliance; there are several collagen isoforms, type uroflow study or during urodynamics. Men and women re- I and III are the most important. An increased type III to I ratio quire a quality of life questionnaire such as the ICIQ-LUTS has been reported in the non-compliant bladder tissue where questionnaire. Men [10] can also fill the International Prostate there is an increased expression of type III collagen mRNA Symptom Score (IPSS) questionnaire, have a digital rectal [6]. Elastin gene suppression has also been reported in the examination and serum prostate-specific antigen (PSA) anal- non-compliant human bladder [7]. yses. In women [10], a pad test may be required if they complained of urinary incontinence. To confirm tuberculosis infection as the cause of ICB, it is Hypertrophy important to demonstrate mycobacterium in urine and radio- graphic examination [12]. ‘Sterile pyuria’ is not very sensitive Molecular alterations on the signalling pathways have been or specific for urogenital tuberculosis, but persisting sterile documented on animal models with bladder dysfunction. pyuria in an individual at risk should increase the index of Decompensated bladders present smooth muscle hypertrophy suspicion [13]. For the anatomical and functional details of and this change of morphology has an effect on urinary fre- kidneys and ureters, intravenous urography (IVU) has been quency [8]. A direct link between ICB and detrusor hypertro- considered to be one of the most useful tests. Pyelograms phy has not been documented. However, it can be disclosed abnormalities in 94% of cases [14]. Unfortunately, hypothesised that ICB pathophysiology might share some bio- pyelogram is useful only for late cavernous forms. If a patient chemical cascades. has renal failure, MRI of the urinary tract can be used [12]. It may also be useful to perform provocation test with injection of 20, 50 or 100 units of tuberculin subcutaneously [15]. Highly sensitive examinations such as radiometric liquid cul- Clinical Scenarios ture systems (i.e. BACTEC®, Becton Dickinson, USA) and polymerase chain reaction (PCR) can also identify the myco- The ICB is a morphologic feature that can be presented in bacterium [12]. some stages of multiple urological conditions. Radiological Schistosomiasis, also known as bilharzia, is a common characteristics include a reduced volumetric capacity, bladder intravascular infection caused by the parasitic Schistosoma wall thickening with or without associated vesicoureteral re- trematode worms which can predispose to ICB [16, 17]. flux. Cystoscopic findings (when possible to execute due to ‘Sandy patches’ which are areas of roughened bladder mucosa poor capacity) may differ, but mostly is a disturbed mucosa in surrounding egg deposits are identified on cystoscopy exam- the form of erythema, ulcers, petechial, haemorrhage, and ination. The trematode worm eggs are released in urine and trabeculations [2]. Table 1 summarises all the clinical scenar- are detected by microscopy in a urine sample. In cases where ios in which the ICB can be recognised. no egg is detectable in the urine, biopsy of the bladder may be Curr Bladder Dysfunct Rep (2019) 14:67–74 69 Table 1 Clinical scenarios of the ICB Clinical scenarios Features that meet the criteria of ICB Bladder outlet obstruction Decompensation stage Congenital obstructed bladder Delayed treatment Neurogenic bladder Deferred stages (e.g. spinal shock) Infections When source and type of infection compromises Tuberculosis the bladder, especially in advanced disease Schistosomiasis Inflammatory conditions With positive cystoscopy and histology Interstitial cystitis Multifocal presentation Malacoplakia Fibrotic stage Eosinophilic cystitis Drugs and medications ICB as part of natural history of Ketamine bladder syndrome Ketamine Toxicity from chemotherapy or immunotherapy is rare presentation, Bacillus Calmette-Guérin (BCG) evidence mostly presented as side effect and based on case reports Mitomycin C Epirubicin Gefitinib Radiation cystitis Associated with high dose of radiation Indwelling catheter When used for more than 6–12 months on free drainage
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