Case Report Cystitis Cystica and Cystitis Glandularis

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Clinical Radiology Extra (2003) 58: 43–44 doi:10.1016/S1477-6804(03)00008-6, available online at www.sciencedirect.com

Case Report

Cystitis Cystica and Cystitis Glandularis— Presentation with Acute Ureteric Obstruction

J. RAJA*,K.ANSON†,U.PATEL*

Departments of *Radiology, and †Urology, St George’s Hospital, London, UK

INTRODUCTION wall posteriorly (Fig. 3) indicating possible carcinoma. A small calculus (2 mm) was also seen at the lower end of the left ureter, which merged with the thickened bladder wall. Subsequent cystoscopy revealed a solid growth Cystitis cystica and cystitis glandularis represent a range of of soft reddish tissue over the base of the bladder and around the left metaplastic changes of the urothelium, thought to originate in ureteric orifice. Endoscopically the diagnosis was felt to be consistent with solid buds of urothelium (von Brunn’s nests) within the lamina bladder carcinoma. propria. Similar histological changes are also seen with Multiple biopsies were taken and pathological examination showed prominent von Brunn’s nests in the lamina propria with areas of cystitis pyeloureteritis cystica. Cystic degeneration of the buds—the cystica. Additional cystic areas showed glandular cells with intestinal cavities contain mucin—is termed cystitis cystica; while florid metaplasia. The final diagnosis was cystitis cystica and glandularis with no intestinal metaplasia with gland formation is described as malignancy. cystitis glandularis. Both conditions are thought to be benign An antegrade ureteric stent was inserted into the left ureter. At repeat [1]. It has been reported as a normal urothelial variant, but in cystoscopy and ureteroscopy performed 7 days after stent insertion a calculus at the lower left ureter was removed along with the stent. The patient was others chronic irritation of the urothelium secondary to discharged and remained well on follow-up without further treatment. infection or catherization has been causally implicated. Of Cystoscopy 1 year later showed minimal oedema over the trigone only. those cases described in the literature most presented with haematuria or symptoms of urinary tract infection, but some cases are asymptomatic. Radiological features of cystitis DISCUSSION glandularis are also non-specific [2,3]. We describe an unusual case that presented with acute ureteric obstruction. Cystitis cystica and cystitis glandularis usually appear as

CASE REPORT

A 54 year-old man of West African origin presented with a history of left-sided renal colic, dysuria and urinary frequency. He had had a similar episode 2 months earlier and was pyrexial on admission (temperature 37.78C). Urinalysis revealed microscopic haematuria, blood white cell count was 8000 £ 109/l and C-reactive protein level was normal. An intravenous urogram showed a delayed left nephrogram and excretion consistent with acute ureteric obstruction with a filling defect at the vesico– ureteric junction (Fig. 1). Pyonephrosis was suspected, antibiotics were given and a nephrostomy tube was inserted on the day of admission. Urine was clear and subsequent analysis showed pyuria but no growth on culture. Nephrostogram 3 and 11 days later showed a persistent radiolucent filling defect at the left vesico- uteric junction (VUJ) (Fig. 2). Among the diagnostic possibilities considered were radiolucent calculus, blood clot, sloughed papilla or tumour. Computed tomography (CT) confirmed thickening of the bladder

Guarantor and correspondent: U. Patel, Department of Radiology, St Fig. 1 – Bladder view as part of an intravenous urogram. A filling defect is George’s Hospital, Blackshaw Road, London SW17 0QT, UK. Tel: þ44- seen around the left ureteric orifice and extending into the bladder trigone. 208-725-3667/1481; Fax: þ44-208-725-2936; E-mail: uday.patel@ Other views (not shown) confirmed left-sided hydronephrosis and stgeorges.nhs.uk hydroureter in keeping with ureteric obstruction.

Table 1 – Causes of benign ﬁlling defects/mass lesions in the bladder

Eosinophilic cystitis Cystitis cystica/glandularis Blood clot Endometriosis Leukoplakia/malakoplakia Radiolucent calculus Ureterocoele Benign tumours: Nephrogenic adenoma Leiomyoma Haemangioma Paraganglioma Neuroﬁbromatosis

Acute presentation with colic has not been described before, neither has an association with ureteric calculus, although one paper reported cystitis glandularis in association with large bladder calculi [4]. Any association between urolithiasis and cystitis glandularis is however speculative. It is possible that the stone in our case was either not important, because it was so small, or was a secondary event that completed an already critically narrow ureteric stricture. The cause of cystitis glandularis in our case is unknown as there was no preceding history of urinary infection, although urine on presentation did show mild pyuria but no growth. Neither was there any evidence of pelvic lipomatosis, another reported association with cystitis glandularis [5]. Fig. 2 – Nephrostogram carried out 11 days after insertion of a nephrostomy catheter showing an irregular stricture of the lower ureter, with a filling defect just above the stricture. The filling defect proved to be a REFERENCES stone. 1 Weiner DP, Koss LG, Sblay B, Freed SZ. The prevalence and multiple and discrete masses elevating the urothelium, most significance of Brunn’s nests, cystitis cystica and squamous metaplasia commonly seen at the bladder base. The radiological in normal bladders. J Urol, 1979;122:317–321. appearances are non-specific, and as shown by our case, easily 2 Harris VJ, Javadpour N, Fizzotti G. Cystitis Cystica masquerading as a bladder tumour. AJR Am J Roentgenol, 1974;120:410–412. mistaken for bladder carcinoma, and this should be noted by 3 Alijani M, Ng KJ, Dickinson IK, Thebe P. An unusual case of cystitis radiologists. The diagnosis can only be made on histology. This cystica. BJU International, 2002;89:634. condition should be considered with a number of other rare 4 Fein RL, Winton L, Gomez RR, Needell MH. Bladder calculi enveloped radiographic filling defects mimicking bladder carcinoma by extensive cystitis glandularis. J Urol, 1983;130:558–559. 5 Heyns CF, De Kock ML, Kirsten PH, van Velden DJ. Pelvic lipomatosis (Table 1) associated with cystitis glandularis and adenocarcinoma of the bladder. J Urol, 1991;145:364–366.

Fig. 3 – Axial computed tomographic view of the bladder, showing thickening of the posterior bladder wall, extending into the lower left ureter, with a small calculus.