AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Background

Bladder cystitis is defined as inflammation of the urinary bladder from any cause. It is a relatively common condition affecting both sexes and all ages. It has no racial predisposition, but female individuals, especially those younger than 50 years, are affected more often than male individuals. In fact, almost every woman will have had cystitis at least once in her lifetime. The high incidence in women is due to the short length of the urethra and its proximity to the anus. This anatomy makes the female urinary bladder relatively easily accessible to intestinal pathogens.

Cystitis may be symptomatic or asymptomatic. Patients with cystitis may present with symptoms of urgency, frequency, dysuria, hematuria, cloudy and offensive-smelling urine, or suprapubic discomfort. These symptoms can occur singly or in combination. The symptom of urgency is due to stimulation of the afferent arc of the micturition reflex, and bacterial conversion of urea to ammonia gives the urine the offensive smell.

Pathophysiology

Types of cystitis

Most patients with cystitis have nonspecific acute or chronic inflammation of the bladder. Hyperemia of the mucosa is occasionally associated with an exudate. When a hemorrhagic component is present, the cystitis is termed hemorrhagic cystitis. The accumulation of a large amount of mucosal suppurative exudate is designated suppurative cystitis. When large areas of mucosal ulceration accompany cystitis, the term ulcerative cystitis is applied. In patients with chronic indwelling urinary bladder catheters the mucosa hypertrophies and bulges into the bladder lumen in a polypoid fashion, this is termed polypoid cystitis.

Acute and chronic cystitis

Cystitis can be divided into acute and chronic forms. Acute cystitis is more common than chronic cystitis and occurs with gradual or sudden onset of the symptoms described above. In male patients, acute cystitis can generally be the presentation of someone with an underlying disorder and therefore should be thoroughly investigated. In female patients, a single episode of acute cystitis can usually be treated safely with antibiotics. However, recurrent episodes should be investigated.

Chemical cystitis

Chemical cystitis can occur in an acute setting. This produces cystitis in the absence of microorganisms. These chemicals can be deodorants sprayed in the perineal area or found on wipes. They can also be detergents added to bath water. One important chemical that commonly causes cystitis when used is the cytotoxic drug cyclophosphamide.

The metabolite of cyclophosphamide, acrolein is an oxidizing agent that is toxic to urothelial cells resulting in sloughing of these cells and hemorrhagic cystitis. This usually occurs when cyclophosphamide (Shanholtz, 2001) is given intravenously in high doses.

Repeated episodes of acute cystitis or an ongoing unresolved cystitis gives rise to chronic cystitis. Repeated episodes may result from resistance of the invading organism antimicrobials due to long courses of antibiotics. It may also result from the fact that the causative organism may not be an intestinal pathogen, and special microbiological tests are required to elucidate the organism. In certain cases, long-term, low-dose antimicrobial therapy may be necessary.

Tuberculous cystitis

Tuberculous cystitis is usually secondary to renal tuberculosis. It is more common in developing countries, but the incidence is rising in the United States and in Europe. The presenting symptoms are similar to those of any urinary tract infection (UTI) (Wise, 2003). Patients may also have systemic symptoms of tuberculosis, such as fever, night sweats, and weight loss.

Cystoscopy reveals a contracted bladder, edematous mucosa, and tubercles appearing as elevated spots. In early tuberculosis, the changes are around the ureteric orifices and the trigone of the bladder. If tuberculosis is suspected, 3 morning samples should be obtained for cultures. Tuberculous cystitis is treated with antituberculosis antimicrobials. In cases of a contracted bladder, augmentation cystoplasty may be necessary.

Schistosomiasis (bilharziasis)

Schistosomiasis (bilharziasis) is an infection with the trematodes Schistosoma haematobium. This disease is endemic in Africa, the Middle East, and the Nile valley. Man is the only definitive host.

The fluke embryos (cercariae) penetrate the skin of the host from infected water. They then migrate to the vesical venous plexus, where sexual reproduction takes place. The eggs are laid in the submucosal veins and penetrate the bladder wall to enter the urine. In the bladder, the eggs produce an acute inflammatory reaction with polyp formation. This produces symptoms of dysuria, frequency, and hematuria some 3 months after the initial infection.

Leukoplakia, squamous metaplasia, and carcinoma in situ may result (Ghoneim, 2002). Chronic inflammation can result in bladder fibrosis with ureteral or urethral strictures. Calcification of the dead eggs within the bladder can produce a calcified bladder or bladder stones.

The diagnosis is made by examining samples from the end of the early morning urine sample, which may need to be evaluated for several days. Treatment is with single dose praziquantel or metrifonate. Surgery is required to treat the bladder contraction or for resection of the bladder cancer.

Radiation cystitis

Radiation is used to treat pelvic malignancies such as rectal carcinoma. The bladder is sensitive to radiation, and early changes are vasodilatation and edema of the bladder. The late sequela is endarteritis obliterans with sloughing of the mucosa, ulceration, and eventual bladder fibrosis. Secondary bacterial infection may complicate the inflammation. Bleeding from telangiectasia can be problematic (Crew, 2001). Transfusion and diathermy of the bleeding area may be required.

Interstitial cystitis (Hunner ulcer)

Lynes and associates (1990) described the histologic features in bladder biopsy specimens obtained from patients with interstitial cystitis and compared them with biopsy specimens from a control population. Although the patients as a group had an increased incidence and degree of denuded epithelium, ulceration, and submucosal inflammation, none of these findings were considered pathognomonic. In addition, these findings occurred only in patients with interstitial cystitis and pyuria or a small bladder.

The inflammatory infiltrate seen in interstitial cystitis consisted predominantly of lymphocytes, with numbers of plasma cells increasing as the degree of inflammation increased. The inflammatory infiltrate has no specific predilection to be perineural. Submucosal inflammation is associated with denuded epithelium, ulceration, pyuria, and a clinical response to therapy that suggested a pathophysiologic relationship.

Interstitial cystitis is a painful bladder disease characterized by chronic urinary urgency, frequency, and pain without evidence of bacterial infection. Nearly 90% of patients with interstitial cystitis are women. Somatization disorder is a psychiatric diagnosis given most often to women who report a variety of symptoms, such as dysmenorrhea, a burning sensation in the sex organs, dyspareunia, irregular menstrual periods, and painful urination. Because the diagnosis of interstitial cystitis may take many years, healthcare providers must be alert to the risks of overdiagnosing psychiatric problems and underdiagnosing interstitial cystitis (Webster, 1993).

In 1 study, epithelial and basement membrane thickness, submucosal edema, vascular ectasia, fibrosis, and detrusor muscle inflammation and fibrosis were not substantially different in patients with interstitial cystitis compared with control subjects. The findings suggested that interstitial cystitis is a chronic submucosal inflammatory disease, at least in patients with pyuria or small bladder capacity.

Interstitial cystitis is best diagnosed from its clinical features. The histologic changes identified by means of bladder biopsy support this diagnosis.

Mast cells play a limited role in the diagnosis. Interstitial cystitis has no clear criteria for diagnosis, and the incidence is unknown. It most commonly occurs in middle-aged women. It causes suprapubic pain with urgency and frequency. The pain is relieved by micturition, and bladder capacity is reduced because of inflammation and fibrosis of the bladder wall. The urine is sterile, and cystoscopy at first may show no abnormality. However, when the bladder is filled and allowed to empty, linear ulcers appear with cascade hemorrhage. Biopsy of the bladder wall often shows a pancystitis with heavy mast-cell infiltration.

Several treatment options are available, none of which are highly successful. Distension of the bladder, cauterization of the ulcers, or instillation of dimethylsulphoxide have all had limited success. The symptoms usually recur. In some cases, the only remedy is cystectomy (Gousse, 2000).

Frequency

United States

UTIs are the most common infections seen in the hospital setting and the second most common infections in the general population.

Trotman and associates (1999) reported an incidence of hemorrhagic cystitis of 18.2% in 681 patients receiving hemopoietic stem-cell transplants.

Approximately 50-80% of patients with emphysematous cystitis have diabetes, and the incidence is higher in female patients than in male patients.

Roberts et al (2003) calculated the community-based incidence of interstitial cystitis. The age-adjusted incidence rates were 1.6 cases per 100,000 women and 0.6 per 100,000 men (P = .04). The median age at initial diagnosis was 44.5 years (range, 27-76 y) in women and 71.5 years (range, 23-79 y) in men (P = .26). The median number of episodes of care-seeking for symptoms before diagnosis was 1 for women and 4.5 for men (P = .03). The median duration from the onset of symptoms until the first diagnosis was 0.06 and 2.2 years in women and men, respectively (P = .2). These findings suggest that the incidence of interstitial cystitis in the community is extremely low. Although the sex difference may be real, the trend toward a later diagnosis in men than in women suggests a potential for missed diagnosis in men.

Curhan et al estimated that the prevalence of interstitial cystitis in the United States was more than 50% greater than previously reported and 3-fold greater than that reported in Europe.

International

In a Finish study, Leppilahti et al found that the prevalence of urinary symptoms corresponding to probable interstitial cystitis is 450 cases per 100,000 population (95% confidence interval: 100, 800). This rate is an order of magnitude higher than those previously reported.

Schistosomiasis is more common in the Middle East than in the United States, and tuberculous cystitis is more common in developing countries than in the United States.

Mortality/Morbidity

UTI results in clinically significant morbidity and mortality while consuming large amounts of national resources. The prevention, diagnosis, and treatment of UTI produce both costs and benefits, and economic analysis provides a rational framework for looking at these effects (Patton, 1991).

Chung et al reported the death of a patient due to gross encrustations of the entire upper urinary tract and bladder by a Corynebacterium group D2 organism in a man with no history of renal transplantation or prolonged catheterizations. The case demonstrates that debilitated patients who underwent an endoscopic procedure are at risk for this disease. Prolonged treatment with appropriate antibiotics, acidification of the urine, and removal of crusts is essential for proper management.

Chronic radiation cystitis after pelvic irradiation occasionally causes massive bleeding that is difficult to control with conventional means. Cheng and Foo (1992) evaluated 42 such cases, of which 9 were severe based on the need for repeat cystodiathermy, massive transfusions, and open surgical intervention. Six patients required emergency bilateral percutaneous nephrostomy for proximal urinary diversions to help stop the bleeding. Despite aggressive treatment, 2 patients died during their admission, and 2 died shortly after discharge. Three eventually required elective ileal conduit diversion of a contracted defunctionalized bladder. Therefore, this essentially benign condition has a relatively high morbidity and mortality rate. Increased physician awareness and timely percutaneous nephrostomy may improve the prognosis.

Maatman et al (1983) studied morbidity and mortality due to intracavitary irradiation for noninvasive papillary transitional cell carcinoma and carcinoma in situ of the bladder. Mortality was been associated with this form of therapy. Associated morbidity consisted of mild-to-severe radiation cystitis. Two patients with severe irradiation cystitis were reported: One was from a series of 65 patients with noninvasive bladder tumors treated with intracavitary irradiation at their clinic since 1965. The second had noninvasive bladder tumors and was treated elsewhere. In both, severe radiation cystitis developed and required simple cystectomy and urinary diversion. This potentially serious adverse effect must be considered when therapy for these cancers is chosen.

Supravesical urinary diversion without cystectomy is a common procedure performed to manage a variety of lower urinary tract pathologies, including intractable chronic cystitis. A variety of complications are associated with a defunctionalized bladder; these include pyocystis, hemorrhage, pain/spasm, and neoplastic transformation. The defunctionalized bladder also has implications on sexual function and pregnancy.

Risk factors for complications are chronic infection, inadequate drainage, interstitial cystitis, and previous irradiation. The incidence of neoplastic change in the defunctionalized bladder is low, but long-term follow-up is advised, as carcinoma can develop many decades after diversion. Sexual function is better preserved after urinary diversion when the bladder is retained (Adeyoju, 1998).

See also Special Concerns below.

Race

• Schistosomiasis is rare in the United States but common in Middle Eastern countries, notably Egypt and Yemen.
• Tuberculous cystitis is also rare in the United States but common in developing countries.

Sex

See also Frequency above.

• Because of differences in anatomy, UTIs are especially problematic in women and as many as one third of all women have a UTI at some point during their lifetime.
• Acute cystitis is approximately 3 times more common in female individuals than in male individuals, though the exact rates are not available.
• Interstitial cystitis is also approximately 3 times more common in females than in males.

Age

Cystitis can affect any age group.

Clinical Details

Disorders

A wide variety of focal and diffuse inflammatory or infectious disorders can affect the abdominal or pelvic cavity. Some of the diseases, such as pyelonephritis, cystitis, and pelvic inflammatory disease, are relatively benign and usually diagnosed without imaging and treated without complications. Some disorders, such as abdominal abscesses, are more serious and may defy clinical diagnosis. These disorders are associated with significant morbidity and mortality and may remain undetected or insufficiently characterized despite the use of several imaging studies.

Predisposing factors

Incomplete voiding of the bladder results in stasis of urine and, hence, the concentration of bladder bacteria. Incomplete voiding may result from bladder outflow obstruction. This can be caused by conditions such as a neurogenic bladder, urethral strictures, bladder diverticulum, and prostatic hypertrophy.

Other predisposing factors include the following:

• Foreign body or a neoplasm in the bladder
• Bladder instrumentation
• Improper hygiene
• Abnormal communication between the bladder and nearby structures (fistulae)
• Lowered local resistance e.g. in diabetes mellitus and low estrogen levels
• Bladder trauma as can occur with instrumentation of the bladder

Clinical presentation

Whatever the etiology of cystitis, it is generally characterized by triad of symptoms, which includes pelvic pain, dysuria, and frequency of micturition causing the patient to void every 15-20 minutes.

Associated systemic manifestations include fever, chills, and general malaise, though systemic manifestations with a bladder infection are unusual. Local bladder symptoms may be disturbing, but more importantly, these symptoms may antedate an acute pyelonephritis. It is also important to remember that cystitis may result from an underlying structural bladder abnormality, such as a neurogenic bladder, bladder outlet obstruction, calculi, tumor, or cystocele. These primary causes need to be corrected before the cystitis can be relieved.

Cystoscopic findings and infectious organisms

Cystoscopy reveals a red, inflamed mucosa that bleeds on contact. In both sexes, the most common causative organism is the coliform bacteria Escherichia coli (Ronald, 2003), which is found in more than 80% of non–hospital-acquired infections and in more than 40% of hospital inpatients. Other common causative organisms are Klebsiella species, Proteus mirabilis, and Streptococcus faecalis.

In patients with a neurogenic bladder or with a long-standing in dwelling catheter mixed organisms, including Pseudomonas organisms, Staphylococcus aureus, Enterobacter organisms, and other species of streptococci are commonly found. Rare causes include herpesvirus, Chlamydia species, and Neisseria gonorrhoeae. These organisms are most commonly found in people younger than 30 years.

Histopathologic findings

On pathologic evaluation, an acute form of cystitis differs from a chronic form only in the character of the inflammatory infiltrate. The acute form has more heaping up of the epithelium than the chronic form; this finding is often associated with the formation of a red, friable, granular, and occasionally ulcerated surface mucosa. Chronic bladder inflammation leads to fibrous thickening of the tunic propria and consequent thickening and inelasticity of the bladder with a reduction in its capacity.

In general, histologic findings in both acute and chronic cystitis are those of a nonspecific acute or chronic inflammation. However, a number of special forms of cystitis exist and are discussed in this article. One special form of chronic cystitis is the accumulation of lymphocytes into lymph follicles in the bladder mucosa and underlying wall, forming a variant of chronic cystitis known as cystitis follicularis.

Preferred Examination

In patients with suspected acute cystitis, a urine sample should be obtained and sent for microscopic analysis. It should also be cultured for bacteria, and the bacterial sensitivity should be analyzed.

Cystitis is a clinical diagnosis and requires no imaging in most patients. The diagnosis is generally made by means of cystoscopy. However, some clinicians use ultrasonography to exclude secondary causes of cystitis, such as bladder outlet obstruction, bladder calculi, and to look for associated renal disease. Sonography is also good modality for measuring bladder capacity, which may be a major concern in cystitis.

Common to all forms of cystitis are bladder-wall and mucosal thickening, irregularity, and mucosal ulceration of various intensities. These changes may be focal or diffuse. These findings are depicted with a variety of imaging modalities. Plain radiography is noninvasive and good for diagnosing renal and bladder calculi and bladder calcification, as seen in some forms of chronic cystitis.

Contrast-enhanced studies (intravenous urography [IVU] or cystography) are good at showing structural abnormalities of the kidneys, ureters, and bladder. IVU also permits a rough assessment of renal function. Mucosal bladder irregularity, polypoid bladder masses, bladder trabeculation, and diverticula are usually well depicted on cystograms, which can also be used to assess bladder emptying on postvoiding images.

Nuclear medicine and angiography has no defined role in the assessment and diagnosis of cystitis. Sinuses and fistulae formation may complicate certain chronic forms of cystitis. MRI is best for imaging these conditions. MRI is also the preferred modality in cases of postirradiation and hemorrhagic cystitis. CT scans show bladder calcification to advantage and is a preferred modality in the diagnosis of granulomatous and emphysematous cystitis.

Limitations of Techniques

The imaging features of cystitis are nonspecific and on imaging alone, one form of cystitis cannot be differentiated from another. Mucosal and bladder-wall changes similar to cystitis can be caused by bladder tumors, and vice versa. Problems may even arise with cystoscopy in differentiating malignancy from cystitis, and biopsy may be required. Bladder calcification is once again a nonspecific appearance and has several etiologies.

DIFFERENTIALS

Section 3 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Other Problems to be Considered

Tuberculous cystitis
Radiation cystitis
Genitourinary tumor
Chemical cystitis
Active genital herpes
Chlamydia trachomatous infection
Vaginitis
Vulvar vestibulitis
Urethral diverticulum
Neuropathic bladder dysfunction
Prostatitis
Urethritis
Urethral syndrome

RADIOGRAPH

Section 4 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

Acute bacterial cystitis

Acute bacterial cystitis is a clinical diagnoses, no imaging is usually required. This disease is present when more than 100,000 bacteria are present in 1 mL of fresh urine. Patients with acute cystitis can present with varying degrees of severity, and in women, associated hemorrhage is common.

IVU results are typically normal. However, in severe cases, generalized bullous mucosal edema may result in cobblestone appearance of the bladder wall. This appearance appears more pronounced on radiographs, which show a partially filled bladder, or on postvoiding images, if residual contrast material is still present.

Cystitis is common in sexually active women and may occur 2-3 times a year and respond well to antibiotics. However, in patients with more frequent episodes of cystitis or in those with antibiotic resistance, the possibility of an underlying cause should be considered. In such cases, the entire urinary tract should be image to exclude conditions such as calculus disease, bladder diverticula, colovesical fistula, and perivesical abscess.

Interstitial cystitis

Interstitial cystitis is a rare idiopathic disease pathologically characterized by fibrosis of the deeper layers of the bladder wall. The disease predominantly affects middle-aged women.

UTI is not thought to be responsible for the bladder-wall fibrosis because the urine is usually sterile. In advanced disease, the ureterovesical junction becomes dysfunctional, with the development of reflux. The bladder ultimately becomes thinned, and it may become ulcerated and bleed.

IVU results are usually normal unless reflux has developed, in which case nonobstructive hydroureteronephrosis may be present. Cystography demonstrates a bladder with a small volume and a smooth or irregular wall. Reflux may also be seen. The main role of radiology in interstitial cystitis is in the exclusion of other diagnosis.

Eosinophilic cystitis

Eosinophilic cystitis is a rare form of cystitis that may affect both children and adults. Predisposing factors include asthma, allergies, and eosinophilic gastroenteritis. Bladder biopsy reveals pancystitis and the presence of eosinophils among other inflammatory cells. Radiographic findings are nonspecific and include bladder-wall thickening and nodular mucosa. Both ureteral obstruction and vesicoureteral reflux are seen. Some authors consider eosinophilic cystitis to be a mild, relatively self-limiting form of interstitial cystitis.

Glandular cystitis (cystitis cystica)

Glandular cystitis, cystitis cystica, cystitis follicularis, and bullous cystitis are synonyms. These conditions usually affect the lamina propria, and expected findings include large cysts resembling cobblestones and/or multiple, rounded filling defects at the bladder base. These may closely resemble bladder carcinomas. The condition is potentially malignant.

Chemotherapy-related cystitis

The incidence of bladder carcinoma is significantly increased in patients treated with cyclophosphamide. Cyclophosphamide-induced cystitis characterized by marked bladder edema and hemorrhage. IVU or cystography shows bladder-wall thickening and irregularity, with intraluminal filling defects due to blood clots. In late stages, the bladder may become a fibrotic and have a small volume. Irregular bladder-wall calcification may develop, but this is rare.

Methicillin cystitis

Methicillin cystitis occurs in approximately 12% patients treated with the drug. Patients usually develop a hemorrhagic type of cystitis. This form of cystitis is a prime example of an allergic type of drug-induced cystitis. Similar reactions have been recorded with ticarcillin, disodium carbenicillin, and penicillin G potassium.

Emphysematous cystitis

Emphysematous cystitis is nearly always associated with diabetes mellitus, but rare in cases, emphysematous cystitis is seen in long-standing outlet obstruction, neurogenic bladder, or bladder diverticulum.

Conventional radiographs demonstrate irregular, streaky lucencies in the bladder wall. Gas may also be seen in the bladder or tracking proximally into the ureters. The appearances of gas may be those of localized clusters of gas-filled vesicles early in the process difficult to distinguish from bowel gas or gas within an abscess. On contrast-enhanced studies, these gas-filled vesicles may be obscured, and the appearance may resemble those of submucosal filling defects produced by inflammatory or neoplastic processes.

With the progression of disease, a ring of gas bubbles surrounding the bladder and separated from the bladder lumen may become obvious. IVU may show gas in the bladder as a horizontal air-contrast level on images obtained with the patient erect. Contrast-enhanced studies of the bladder may show a thickened, irregular, or nodular bladder mucosa.

Viral cystitis

Viral cystitis is predominantly a childhood condition, though rare cases have been described in adults, particularly those who are immunocompromised. The radiographic appearances vary with the severity of inflammation. In mild cases, contrast-enhanced radiographic studies may be normal, whereas in severe cases, large bullae and polypoid filling defects may be identified as protruding into the bladder lumen. Viral cystitis must not be confused with embryonal rhabdomyosarcoma in children.

Alkaline encrusting cystitis

Alkaline encrusting cystitis is a form of chronic cystitis in which the inflamed bladder mucosa is encrusted with a layer of calcium phosphate. Urinary infection due to urea-splitting bacteria leads to an increase in urinary pH, promoting the precipitation of calcium salts and struvite crystals. The calcium phosphate encrustation is usually dense enough to be depicted on plain abdominal radiographs and CT scans. Although calcification is the dominant feature, the bladder wall itself is strikingly abnormal. Thickness of the bladder wall, which is often irregular and focal, is increased. The bladder lumen may be filled with debris.

Verguts and associates (1987) described a case of alkaline encrusting cystitis with unusual but characteristic calcifications on plain radiographs and CT scans. These completely disappeared after adequate treatment.

Schistosomiasis

Calcification in the wall of the bladder or distal ureters can be identified on plain radiographs. However, plain radiographs are not useful until calcifications have developed in the bladder or ureters. IVU findings in the bladder and distal ureters and the kidneys remain normal until late in the disease. Mucosal irregularity, inflammatory pseudopolyps, ureteritis cystica, ureteral dilatation and stricture, and reduced bladder capacity can be found with IVU, retrograde ureterography, or cystography.

The ureters may be dilated and commonly have persistent filling in the lower segment. Ureteral strictures can be found, and, as the disease progresses, beading of the lower ureteral segment may be observed. Subsequent ureteral fibrosis leads to calcifications of the distal ureter, which have a characteristic pattern of linear or parallel calcifications on plain radiographs. About 80% of the strictures occur in the bladder wall near the junction with the ureters.

Ureteral dilatation is often caused by vesicoureteric reflux, stenosis of the ureter, or an edematous ureteral wall that causes deficient peristalsis. The bladder wall may be indistinct or hazy due to submucosal edema and pseudotubercles. An intense granulomatous reaction to the ova occurs, and fibrosis eventually develops in the tunica propria, which is the site of the calcification visible radiologically. The calcification does represent calcified fibrous tissue, but calcified ova cause it. The calcification spreads around the bladder wall and can completely encircle the bladder, appearing as a curvilinear ring. The bladder wall becomes fibrotic, but it is still distensible and maintains a normal capacity.

Kidneys, ureters, and bladder (KUB) images often reveal the pathognomonic eggshell calcification of the bladder walls and the ureters. Changes in the motility of the ureter and ureteric strictures can cause hydronephrosis and reflux nephropathy. In the kidney and bladder, stone formation and the incidence of squamous cell carcinoma is increased. A bladder carcinoma should be considered when follow-up imaging shows absence of wall calcification in areas that were previously calcified.

Tuberculous cystitis

Tuberculous cystitis is characterized by a gradual increase in the thickness of the bladder wall and increasing diminution of the volume the bladder. Bladder trabeculation may develop. The vesicoureteric orifices are affected by progressive fibrosis, with subsequent hydronephrosis and hydroureters. The latter may be shown on an IVU. The vesicoureteric junction orifice may become fixed and patulous, resulting in vesicoureteric reflux.

Bladder calcification is unusual, but when it occurs, it is patchy. Fistulae or sinus tract formation may complicate bladder tuberculosis, though these complications are rare and best demonstrated on CT scans and MRIs. When bladder calcification is seen on a plain abdominal radiograph, schistosomiasis is the diagnosis until proven otherwise. Tumor calcification must also be considered.

Foreign-body cystitis

One of the most common causes of foreign-body reaction in the bladder is an indwelling catheter. Catheter cystitis usually results from the prolonged catheterization of the bladder and is due to mechanical irritation. The areas of inflammation are usually discrete and generally confined to the posterior wall or the floor of the bladder. Bacteriuria is commonly associated with indwelling bladder catheters but is said not be the cause of the cystitis.

Radiographic changes are those of nonspecific inflammation or bullous edema. Indwelling catheters are associated with squamous cell carcinoma of the bladder. The development of carcinoma is related to the duration of catheter placement. Other foreign bodies may also cause cystitis. These foreign bodies may be related to surgical procedures, sexual misadventures, or psychiatric illness. These foreign bodies may become encrusted with calcium salts and eventually manifest as bladder calculus.

Metallic foreign bodies are readily identified on plain abdominal radiographs. Encrustation may unmask foreign bodies that are not radiopaque; these may appear with a lucent center on plain radiographs. A mass affect is appreciated on IVU or cystography.

Nephrogenic adenoma

Nephrogenic adenoma is a proliferative response to chronic bladder infection or irritation. The name is derived from the histologic appearance of the lesion, which is similar to that of the proximal renal tubules of the nephron. The appearance is usually that of a bladder mucosal irregularity and a large intramural mass resembling a carcinoma. Biopsy is normally required for tissue diagnosis. The lesion is not premalignant.

Malakoplakia

The bladder lesions of malakoplakia may produce single or multiple, smooth, rounded filling defects on contrast-enhanced studies of the bladder. Calcification has been reported within the lesion on plain radiographs and CT scans.

Actinomycosis

When actinomycosis affects the bladder, bladder-wall thickening is often observed. Cystography may show a mass attached to the bladder wall, projecting into the lumen of the bladder. Adjacent bone is often involved, and sinus tracts may form. These changes may be visible on plain abdominal radiographs, though contrast-enhanced studies or MRI may be required to depict the sinuses.

Pelvic lipomatosis

Pelvic lipomatosis is characterized by benign overgrowth of perivesical and pericolonic retroperitoneal fat. Pelvic lipomatosis can progress to cystitis, hydroureteronephrosis, and renal failure. Therefore, imaging follow-up is mandatory after diagnosis. Most cases are associated with proliferative cystitis, particularly cystitis glandularis. Pelvic lipomatosis often causes an inverted teardrop-shaped bladder deformity. The diagnosis is based on the detection of characteristic findings on conventional radiographs and CT images.

Extrinsic processes causing cystitis

A variety of neoplastic and inflammatory pelvic disorders may affect the urinary bladder, secondarily causing cystitis. These processes include gynecologic cancers, endometriosis, pelvic inflammatory disorders, Crohn disease, and diverticulitis to name a few. Fistulous communication with the bladder may develop, particularly with colonic cancers, Crohn disease, and diverticulitis. The radiologic changes depend on the underlying pathology and severity of disease. Fistulous communications may be diagnosed on contrast-enhanced studies of the urinary tract and/or bowel.

Cystitis associated with lupus erythematosus

Patients with systemic lupus erythematosus (SLE) may sometimes develop severe cystitis marked by urgency, frequency, and dysuria. No distinguishing radiographic or cystoscopic appearances are described.

Min and associates (2000) reviewed 413 patients with SLE to investigate the etiologies of urinary bladder involvement. They evaluated the clinicoradiologic features of gastrointestinal manifestations and the clinical outcomes in patients with lupus cystitis accompanied by gastrointestinal manifestations. Patients were selected on the basis of lower urinary tract symptoms, including urinary frequency, urgency, and urinary incontinence. Radiologic studies were analyzed in patients with lupus cystitis.

Ten consecutive patients with lower urinary tract symptoms were identified. Underlying etiologies were lupus cystitis in 5, neurogenic dysfunction secondary to transverse myelitis in 3, cyclophosphamide-induced cystitis in 1, and tuberculous cystitis in 1. All patients with lupus cystitis had gastrointestinal manifestations (eg, abdominal pain, nausea, vomiting, and/or diarrhea) during periods of cystitis symptoms.

In all patients with lupus cystitis, paralytic ileus was demonstrated on plain abdominal radiography, and ascites, bilateral hydroureteronephrosis, and thickened bladder wall were identified on abdominal sonography or CT. Abdominal CT revealed bowel-wall thickening in 4 of 5 patients. The main sites of thickened bowel on abdominal CT were the territory the superior mesenteric artery supplied. Two patients with lupus cystitis died during follow-up.

The authors concluded that diverse etiologies might cause lower urinary tract symptoms in patients with SLE. Lupus cystitis was strongly associated with gastrointestinal involvement, and abdominal CT can be a useful radiologic tool for investigating gastrointestinal tract involvement in patients with lupus cystitis.

Degree of Confidence

Plain radiography is noninvasive, with a reasonably modest radiation dose and shows calcification of the urinary tract, gas within the bladder wall in emphysematous cystitis, urinary calculus disease, and foreign bodies in the bladder well.

Contrast-enhanced studies are well suited to depict bladder mucosal irregularity, vesicoureteric reflux, bladder outlet obstruction, and abnormalities such as bladder diverticula and urachal anomalies. IVU also gives some measure of renal function.

False Positives/Negatives

Radiographic appearances on contrast-enhanced studies are nonspecific, and the causes of the various types of cystitis cannot be distinguished without clinical correlation. Sessile bladder neoplasms may have similar appearances.

In emphysematous cystitis, the localized clusters of gas-filled vesicles that appear early in the process may be difficult to distinguish from bowel gas or gas in an abscess. On IVU or cystography, the gas-filled vesicles may be indistinguishable from other submucosal filling defects that inflammatory or neoplastic processes produce. Therefore, comparison of radiographs obtained with and without contrast enhancement is always advisable.

Infection and gas formation in the lumen of the urinary bladder but not in the bladder wall is often regarded as separate entity and called primary pneumaturia or pneumocystitis. However, the etiology of the 2 conditions appears the same, and both are usually caused by E coli and Aerobacter aerogenes infections and often occur in patients with diabetes. Gas gangrene as a result of clostridial infection is rare, and the condition manifests with severe sepsis. Gas is often seen in the bladder lumen, with enterovesical fistulas.

Foreign bodies and bladder calculi can have similar radiographic appearances.

Inverted teardrop-shaped bladder deformity is often caused by pelvic lipomatosis, the perivesical accumulation of extravasated blood or urine, or both.

O'Dea and Malek (1976) described a similar deformity of the bladder due to a foreign body (eg, toothpick) lodged in the bladder. Resulting urinary infection and perivesical inflammation can also cause this unusual bladder deformity. The bladder contour returned to normal after the foreign body was removed and the infection treated. An obstruction of the inferior vena cava can cause a similar appearance.

Calcification within the bladder is also a nonspecific appearance and has several causes (see False Positives/Negatives in the CT SCAN section below).

CT SCAN

Section 5 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

Acute bacterial cystitis

In patients with frequent episodes of cystitis or antibiotic resistance, the possibility an underlying abnormality should be considered by imaging the entire urinary tract. CT is useful when calculus disease, bladder diverticula, colovesical fistula, or perivesical abscess is considered.

Eosinophilic cystitis

Ichikawa et al (1999) performed 3-dimensional (3D) CT cystography in 2 patients with eosinophilic cystitis, which occurred as submucosal elevated lesion of the bladder mimicking a tumor. 3D CT cystography clearly demonstrated submucosal tumorous lesions and enabled the evaluation of mucosae of lesions. The scans especially showed the bridging, foldlike appearance of the submucosal tumorous lesion in eosinophilic cystitis.

Chemotherapy-related cystitis

CT findings in the acute phase of chemotherapy-induced cystitis include thickening of the bladder wall and irregularity with intraluminal filling defects due to blood clots. In late stages, the bladder may become fibrotic, and it is recognized at imaging as a small-volume bladder. Irregular calcification of the bladder wall may develop. The incidence of bladder carcinoma may be markedly increased in patients treated with cyclophosphamide; this finding may be readily identified on CT scans.

Emphysematous cystitis

CT findings in emphysematous cystitis are usually diagnostic. Intraluminal gas, however, must be differentiated from gas entering the bladder from iatrogenically introduced gas or from an enteric fistula.

Fungal cystitis

On CT scans, the thickened bladder wall is apparent, but this finding lacks specificity. In patients with poorly controlled diabetes, a bladder fungus ball may develop. When gas has been present, the bladder fungus ball may have a laminated appearance, producing the double-fungus-ball wall sign. The diameter of the fungus ball is 2-10 cm. The prostate may be infected with Candida albicans in male patients with diabetes of any age. CT may identify foci of low attenuation within the prostate.

Gangrenous cystitis

Gangrenous cystitis is rare when the bladder epithelium is necrotic and ulcerated, and it forms a pseudomembranous cast of the bladder wall, which may detach itself. The causes include virulent bladder infections, particularly in cases involving immunocompromise, arterial ischemia, trauma, pressure necrosis from prolonged labor, chronic overdistension of the bladder, and intravesical corrosive agents. The necrosis may sometimes involve the bladder wall, leading to perforation.

No specific radiologic findings are identified, and the correct diagnosis is made with a high index of clinical suspicion in light of the patient's history. Likewise, no typical symptoms or clinical findings are described in gangrenous cystitis; this limitation hampers diagnosis and may worsen the prognosis.

Braganca and associates (2001) described the case of a diabetic male patient who was hospitalized because of poor general condition, dehydration, and diffuse abdominal pain. The diagnosis was made by using pelvic CT findings. Medical treatment must be intensive and begun as soon as possible. As in this case, the outcome may be favorable.

Foreign-body cystitis

Foreign bodies in the urinary bladder may be readily identified on nonenhanced CT scans, though some radiolucent foreign bodies with no encrustation may be missed. Enhanced CT shows a mass lesion in the bladder.

HIV cystitis

HIV cystitis affects 22% patients with HIV infection. The organisms involved include gram-negative bacteria, Candida species, beta-hemolytic streptococci, Salmonella organisms, and cytomegalovirus. Adenovirus is also a potential cause of hemorrhagic cystitis in patients with AIDS whose immunosuppression is aggravated by cytotoxic drugs. The appearance is that of nonspecific thickening.

Alkaline encrusting cystitis

See Alkaline encrusting cystitis in the X-RAY section above.

Pyocystis

Pyocystis (empyema of the urinary bladder) may develop in as many as 15% of patients with urinary diversion in whom the bladder is left in situ. If the bladder is innervated and incapable of emptying, the infection essentially becomes a closed-space infection. The diagnosis is usually made with bladder cauterization. Imaging is usually not necessary, but debris and/or pus in the bladder may be detected on sonograms or CT scans. The diagnosis should be considered in a patient with a defunctionalized bladder.

Schistosomiasis

Compared with other techniques, CT best delineates the extent of the calcifications related to schistosomiasis. Bladder calcifications are characteristically linear, coarse, or floccular in schistosomiasis. The calcifications are usually first seen in the base of the bladder on plain radiographs, but they most commonly appear in the anterior wall of the bladder on CT scans. The thickness of the ureteral wall is better evaluated with CT than with any other modality.

Tuberculous cystitis

See Tuberculous cystitis in the X-RAY section above.

Actinomycosis

Kawahara and associates (1998) reported bladder actinomycosis in a 46-year-old woman who presented with a hypogastric mass. The preoperative diagnosis was a malignant ovarian tumor involving several organs, including the urinary bladder. Surgical exploration was performed with wide resection of the right ovary and uterus and the affected ileum, sigmoid colon, and omentum. Intraoperative histopathologic examination of the paravesical tissue revealed abdominal actinomycosis. As a consequence, bladder resection was not done. The cause of abdominal actinomycosis in this patient was probably implantation of an intrauterine device 3 years before this presentation.

Dhamborvorn and associates (2001) described a 49-year-old woman with 2-year history of urinary frequency. She had a mass at the anterior bladder wall and at the anterior abdominal wall. Cystoscopy showed an impression in the anterior bladder wall and revealed hyperemic edematous bladder mucosa. Preoperative CT findings suggested a tumor on the bladder. Laparotomy revealed a firm, inflammatory mass at the anterior bladder wall and another mass at the anterior abdominal wall. Partial cystectomy and excision of the mass at the anterior abdominal wall were performed. After pathologic examination confirmed actinomycosis, the patient was postoperatively treated with penicillin. She recovered well.

Lee et al (2002) describe a case of primary vesical actinomycosis, a rare disease. Most often, this is misdiagnosed as vesical or urachal tumor and usually confirmed with postoperative pathology. In their patient, it was confirmed with repeated preoperative transabdominal biopsy. The 49-year-old woman had frequency, dysuria, and intermittent gross hematuria for 2 months. CT and cystoscopy showed a broad-based, edematous, protruding mass at the dome and anterior part of the bladder. Clinical and imaging findings initially suggested vesical malignancy. Transurethral resection and several biopsy procedures were performed. Pathology showed fibrosis with chronic inflammation. Histopathology of needle-biopsy specimens confirmed the typical sulfur granules highly suggestive of actinomycosis.

Heer and associates (1986) describe a 73-year-old woman with extensive abdominal actinomycosis. Ultrasonography, CT, and surgical exploration revealed an extensive inflammatory tumor of the sigmoid colon involving the urinary bladder and uterus. Histologic examination revealed typical sulfur granules that were highly suggestive of actinomycosis.

Malakoplakia

Malakoplakia is characterized by the formation of multiple yellow-gray plaques in the bladder mucosa. The etiology is unknown, but it can be seen in patients with pulmonary tuberculosis, chronic osteomyelitis, chronic malignancies, or coliform cystitis.

Histologic evaluation reveals histiocytes, lymphocytes, plasma cells, and Michaelis-Gutmann bodies, which are thought to represent phagocytosed bacteria. Radiographically, these plaques appear as rounded contour defects, primarily of the trigone, as shown on cystography and CT.

Epstein and associates (1983) described CT findings in a case of malakoplakia of the bladder. Although the CT findings were not considered specific for this condition, the presence of a solid bladder mass with or without extension beyond the confines of the bladder in a young woman with UTI should suggest the possibility of this diagnosis.

Pelvic lipomatosis

CT is well suited for the diagnosis of pelvic lipomatosis. Nonenhanced CT images show the excessive pelvic fat to advantage, and contrast-enhanced images may show complications, such as cystitis, and features of obstructive uropathy.

Extrinsic processes causing cystitis

CT is useful in defining the morphology of the underlying extrinsic abnormality, the extent of disease, and the causative neoplasia and their staging.

Cystitis associated with lupus erythematosus

See Cystitis associated with lupus erythematosus in the X-RAY section above.

Degree of Confidence

CT scans demonstrate the calcifications better than plain radiographs, IVU images, or sonograms. CT is also helpful in the staging of bladder carcinomas. CT is more sensitive than conventional radiography in the detection of calcifications and depicting emphysematous cystitis.

False Positives/Negatives

The prostate may be infected with C albicans in male patients with diabetes of any age. CT may depict foci of low attenuation in the prostate, but these are nonspecific findings. The differential diagnosis includes cystitis cystica and, occasionally, a tumor.

Irwin and associates (1982) observed that calcification is seen in bladder lesions on plain films with an incidence of 0.5-7.0%. Four cases of calcification were noted on 38 consecutive bladder CT scans (11%). Calcifications were noted both on the surface and in the lesions. One of the cases with malakoplakia had calcification. This may be the first reported of this finding.

With CT, calcification in bladder lesions is expected to be found with increasing incidence and should be sought. Other causes of bladder-wall calcification include tuberculosis schistosomiasis, bladder tumors, and postirradiation cystitis.

MRI

Section 6 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

In vitro studies showed that the normal bladder wall appears as a band of intermediate signal intensity on T1-weighted images and as bands of low (inner) and intermediate (outer) signal intensity on T2-weighted images.

Inflamed bladder walls demonstrate 2 additional inner bands of intermediate (inner) and high (innermost) signal intensity on T1-weighted images and high (inner) and low (innermost) signal intensity on T2-weighted images. The thickness of the 2 bands of differing intensity on T2-weighted images are well correlated with the muscle layers in histopathologic specimens, and the different signal intensities in the muscle layer represent a compact inner and loose outer arrangement of smooth muscle bundles.

The appearances of cystitis on MRI are nonspecific and characterized by focal or diffuse thickening of the bladder wall. On T2-weighted images, 4 layers of the bladder wall are appreciated. An innermost low-signal-intensity and an inner high-signal-intensity band represent thickened and lamina propria, respectively. An outer hypointense band and outermost band of intermediate signal intensity represent the inner compact muscle layer and outer loose muscle layer, respectively.

After the intravenous administration of gadolinium-based contrast agent, variable enhancement of the bladder wall is observed. The intensity of enhancement depends on the severity of the inflammatory process. The feasibility of using magnetic resonance hydrometry to noninvasively quantify bladder volume has been demonstrated (Heverhagen, 2002).

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. As of late December 2006, the FDA had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble movingor straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Acute bacterial cystitis

In patients with frequent episodes of cystitis or antibiotic resistance, the possibility an underlying abnormality should be considered by imaging the entire urinary tract. MRI is useful for evaluating colovesical fistula and perivesical abscess.

Hemorrhagic cystitis

MRI is particularly suited for the diagnosis of hemorrhagic cystitis. MRI may demonstrate changes of hemorrhagic cystitis and may permit a determination of disease activity. The appearances of hemorrhagic cystitis are complex and based on the T1 and T2 characteristics of aging blood products, as follows:

• Active hemorrhage (oxyhemoglobin) has only limited paramagnetic properties, and the blood at this stage behaves like simple fluid with low signal intensity on T1-weighted MRIs and high signal intensity on T2-weighted MRIs. At this stage, differentiation form urine may not be possible.
• Acute blood (intracellular deoxyhemoglobin) has low signal intensity on T1- and T2-weighted MRIs.
• Intracellular methemoglobin has high signal intensity on T1-weighted images and low signal intensity on T2-weighted images.
• Extracellular methemoglobin has high signal intensity on T1-weighted MRIs and high signal on T2-weighted MRIs.
• Intracellular hemosiderin in an old hematoma has medium signal intensity on T1-weighted images and low signal intensity on T2-weighted images.

MRI findings were reported in 2 patients with hemorrhagic cystitis secondary to radiation therapy. In 1 patient, the bladder wall was hyperintense on T1-weighted fat-suppressed spoiled gradient-echo image and hypointense on T2-weighted fat-suppressed spin-echo images. These findings were consistent with intracellular methemoglobin in the setting of subacute intramural hemorrhage.

In the second patient, the bladder wall had hypointense regions on T1-weighted fat-suppressed spin-echo MRIs and hyperintense regions on T2-weighted fat-suppressed spin-echo images. Other regions were high in signal intensity on T1- and T2-weighted fat-suppressed spin-echo images; these findings that were consistent with active bleeding and late subacute hemorrhage, respectively. The imaging findings correlated with the patients' clinical findings.

Cystitis cystica

Cystitis cystica usually affects the lamina propria, and expected findings include large cysts resembling cobblestones.

Granulomatous cystitis

The earliest changes in tuberculosis involving the bladder are those of mucosal edema and ulceration surrounding the vesicoureteric junction, which may produce ureteric obstruction and hydronephrosis. Focal intravesical granulomas are depicted with high signal intensity on T2-weighted images.

Radiation cystitis

Radiation affects are typically seen in the region of the trigone of the bladder. T2-weighted images show mildly increased signal intensity in the bladder mucosa with a relative preservation of the bladder-wall thickness. However, the bladder wall may be thickened to over 5 mm in a fully distended bladder. Two signal-intensity characteristics are described: (1) uniform high signal intensity in the bladder wall, and (2) low signal intensity in the inner layer with high signal at the periphery. Fistulae and/or sinuses may develop with extensive irradiation. Gadolinium enhancement may occur as long as 2.5 years after pelvic radiation therapy.

AIDS-related cystitis

A case of cystitis due to Toxoplasma gondii infection in a patient with AIDS has been reported. Pelvic CT and MRI demonstrated thickening of the bladder wall and seminal vesicles. Cystoscopic results confirmed intravesical proliferation with a pseudoneoplastic appearance. The diagnosis of Toxoplasma cystitis was confirmed by the discovery of Toxoplasma cysts on histologic examination of bladder biopsies. Toxoplasma cystitis is a rare cause of pseudoneoplastic bullous cystitis in HIV-seropositive patients.

Chemotherapy-related cystitis

Chemotherapy-related cystitis is particularly associated with the use of cyclophosphamide. As many as 40% of patients treated with cyclophosphamide develop an acute cystitis, which is characterized by marked bladder edema and hemorrhage.

Radiologic findings in the acute phase that may be seen at IVU, ultrasonography, CT, or MRI include bladder-wall thickening and irregularity with intraluminal filling defects due to blood clots. In late stages, the bladder may become a fibrotic, small-volume structure. Irregular bladder-wall calcification may develop. In addition, the incidence of bladder carcinoma is significantly increased in patients treated with cyclophosphamide.

Schistosomiasis

Schistosomiasis may affect the prostate and urethra, and in rare case, it may cause destructive urethral fistula formation similar to tuberculosis. The fistulas may drain into the perineum, scrotum, suprapubic skin, or buttocks. MRI provides the best images of fistulous communications.

Actinomycosis

Koshiyama and associates (1999) described a patient who presented with a pelvic tumor that mimicked an advanced ovarian carcinoma with invasion into urinary bladder, rectum, and uterus, as detected on MRI. After surgery, however, actinomycosis of the left ovary was diagnosed by means of pathologic examination. In this patient, ovarian actinomycosis was complicated by diabetes mellitus.

Malakoplakia

Nukui and associates (1997) described a 63-year-old woman who presented with urinary symptoms and bilateral hydronephrosis. Ultrasonography, CT, and MRI revealed bilateral hydronephrosis due to stenosis of the vesicoureteral junction, which was caused by a nodular mass on the posterior wall of the bladder. Cystoscopy revealed a yellowish white mass on the trigone. Bilateral percutaneous nephrostomy was performed to treat chronic renal failure due to bilateral hydronephrosis, with transurethral resection of the tumor of the bladder. Histologic findings indicated a chronic granuloma with a Michaelis-Gutmann body; the tumor was diagnosed as vesical malakoplakia. The condition was successfully treated with oral medication.

Ollier and associates (2000) described a patient with histologically proven bladder malakoplakia associated with pelvic lymphadenopathy mimicking a neoplasm. The nodes appeared hyperattenuating on CT and hyperintense on MRI.

Pelvic lipomatosis

Pelvic lipomatosis can progress to cystitis, hydroureteronephrosis, and renal failure. Therefore, imaging follow-up is mandatory after diagnosis. Most cases are associated with proliferative cystitis, in particular, cystitis glandularis.

The diagnosis is based on the detection of characteristic findings on conventional radiographs and CT images. Multiplanar MRI allows diagnostic confirmation comparable to that with CT and also provides delineation of cephalad displacement of the bladder base, elongation of the bladder neck and posterior urethra, and elevation of the prostate gland and signs of cystitis. MRIs show characteristic medial and superior displacement of the seminal vesicles and show fatty tissue separating the prostate gland from the rectum. The noninvasive nature and low biologic risk of MRI are desirable features, particularly when a serial evaluation of pelvic anatomic distortion is necessary.

Extrinsic processes causing cystitis

MRI is an extremely useful tool not only for defining the underlying pathology but also for noninvasively delineating fistulous communications and sinuses.

Degree of Confidence

MRI is a promising modality for evaluating the pelvis. Its major role appears to be in the staging of known malignancies. With rational use of the diagnostic tools now available and with continued improvement in MRI technology, safe and accurate diagnoses might be expected in practically all patients with diseases of the urinary tract. MRI is best for imaging these diseases. MRI is also a preferred modality in cases of postirradiation and hemorrhagic cystitis.

False Positives/Negatives

Epithelial granulomas secondary to immunotherapy for malignant bladder tumors may appear similar to the bladder tumors on MRI; other tuberculomas may also simulate bladder tumors.

ULTRASOUND

Section 7 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

There are many causes of inflammation of the bladder wall, including infection, radiation, drugs (eg, cyclophosphamide), and trauma (eg, indwelling catheter, surgery). The bladder appears sonographically normal in most cases but may show thickening of its wall due to edema. The bladder mucosa is normally less than 2 mm thick when measured at full distension and less than 5 mm thick when nondistended.

Ultrasonography shows that residual urine is found to be significantly increased in children with cystitis compared with control subjects.

Acute bacterial cystitis

Ultrasonography is useful when an underlying cause for recurrent cystitis is being considered. Such causes include associated renal disease, renal and bladder calculus disease, bladder diverticula, colovesical fistula, and perivesical abscess.

HIV cystitis

HIV cystitis has a nonspecific appearance of bladder-wall thickening. Emphasis has been placed on the incidence of nephrolithiasis secondary to therapy with protease inhibitors over the last few months after the introduction of this new therapeutic tool, prostatitis due to salmonella, and inlaid cystitis, among other situations.

Alkaline encrusting cystitis

Ultrasonography is expected to show bladder-wall thickening, endoluminal debris, and lesion calcification.

Emphysematous cystitis

Ultrasonography may depict bladder-wall air as intramural echogenic foci with dirty shadowing.

Radiation cystitis

Ultrasonography may show bladder-wall thickening. Renal ultrasonography is complimentary to IVU and can be used to distinguish hydronephrosis from bladder/ureteric scarring, renal tumors (as another cause of bleeding), and calculus disease.

Pseudotumoral cystitis (eosinophilic cystitis)

Also known as eosinophilic cystitis, pseudotumoral cystitis is an uncommon inflammatory process seen in both children and adults. In children, it is a self-limiting condition that resolves spontaneously and that usually requires no treatment. Therefore, its recognition is important.

Sonographic features of pseudotumoral cystitis include the following: (1) broad-based intravesical masses with a smooth or irregular outline, (2) mass confined to the bladder mucosa with preservation of the muscle layers, (3) trigone primarily involved with variable extension, (4) generalized bladder-wall thickening with mucosal irregularity, and (5) unilateral or bilateral hydronephrosis as a result of mucosal thickening or obstruction at the vesicoureteric junction.

Interstitial cystitis

In interstitial cystitis, the bladder has a small capacity, often 30-50 mL. No associated conditions are described. The disease is extremely debilitating because of the limited bladder capacity and because of pain associated with overfilling. Ultrasonography is an accurate means of calculating bladder capacity and of excluding cystitis with an underlying pathology such as calculi.

Fungal cystitis

C albicans infections are opportunistic and range from asymptomatic infections to life-threatening ones. C albicans cystitis is common with other forms of cystitis. These can produce bladder-wall thickening and a discrete, well-defined, dense fluid-fluid interface in the bladder. Debris can contain the long, threadlike pseudomycelia of the fungus. This fluid-fluid interface shifts with changes in position. The sonographic appearance is not pathognomonic. Sonography has been used to monitor the progress of therapy.

Chronic granulomatous disease

Chronic granulomatous disease is a genetically inherited disease of childhood, one characterized by repeated bacterial and/or fungal infections. The genitourinary tract is rarely involved. A case of chronic granulomatous disease with involvement of the urinary bladder is reported, with its pertinent clinical and sonographic findings.

Tuberculous cystitis

See Tuberculous cystitis in the X-RAY section above.

Schistosomiasis

Granuloma formation within the wall may lead to sonographic findings of polypoid-like thickening of the wall.

Other parasitic cystitis

In urogenital amebiasis, infection may reach the bladder via the blood stream or the lymphatics or occasionally from an intestinovesical fistula. Cystitis is the usual manifestation. Although hematuria and frequency may disappear spontaneously, they nearly always recur later. The urine contains pus, blood, debris, and amoebae. Cystoscopy reveals edema and superficial ulceration. The basal mucosa may become polypoidal.

In strongyloidiasis, the worm may be passed into the bladder from the ureter with resultant cystitis.

Another rare cause of parasitic cystitis is myiasis, in which the larvae of certain flies invade the urethra and into the bladder, resulting in cystomyiasis. Symptoms include dysuria, hematuria, pyuria, albuminuria, and/or strangury. The larvae are often passed spontaneously, after which the symptoms subside.

Chagas disease may lead to abnormal dilatation of the ureters, bladder, and seminal vesicles. Cystitis is rare in trichomoniasis.

Foreign-body cystitis

Foreign bodies, both radiopaque and radiolucent, can be identified in the bladder by means of noninvasive ultrasonography.

Bladder calculi

Bladder calculi are usually secondary to chronic incomplete bladder emptying and stasis and often associated with cystitis. Calculi are seen as echogenic masses in the bladder lumen; these are usually mobile and cause distal shadowing. Similar appearance occurs with blood clots, foreign bodies, and tumors encrusted with calcium salts. Sonography is particularly good at depicting lucent calculi, which may not be visualized on plain abdominal radiographs.

Neurogenic bladder

Neurogenic bladder is often associated with cystitis. Therefore, the bladder should be routinely scanned before and after micturition. Loss of normal neurologic control of bladder function may affect bladder volume and appearance. Lesions of the posterior nerve roots usually give rise to a spastic bladder, which is trabeculated and which may have multiple diverticula. In long-standing cases, the bladder volume may be markedly reduced.

Malakoplakia

Malakoplakia is a granulomatous disease associated with chronic E coli infection. The bladder is the most common site affected, but the kidney can be involved. Most occur in middle-aged women, and by far, the majority are unilateral and multifocal. Sonography shows an enlarged kidney associated with distortion and compression of the central echo-complex by ill-defined solid or cystic masses. When unifocal a nonspecific echogenic mass can be seen. Calcification is unusual.

Chronic cystitis associated with bladder extrophy

Bladder extrophy is a congenital anomaly of the urinary bladder in which the posterior wall of the bladder lie exposed. Most cases of bladder extrophy are now diagnosed antenatally by means of ultrasonography. The exposed bladder mucosa is subject to irritation as a result of altered environment that eventually develops into cystitis cystica and cystitis glandularis. No imaging is normally required unless there are associated changes in the upper urinary tract, where sonography can be used to look for morphologic changes in the kidneys.

Pelvic lipomatosis

Marked increase in the deposition of fat in the pelvis usually affects obese, middle-aged men. This results in bladder compression increasing its craniocaudal length and narrowing it from side to side. The fat is seen as echogenic material filling the pelvis around the bladder. Most other diseases, which result in bladder compression, give rise to hypoechoic masses.

Bladder extrophy

In this anomaly, the bladder epithelium is exposed. This altered environment causes irritation of the mucosa and eventually the development of cystitis cystica.

Bladder extrophy is now diagnosed on antenatal sonograms. Sonographically, bladder extrophy may appear as an external, well-defined, solid or complex bladder mass immediately superior to the fetal genitalia. Prolonged and repeated scans fail to reveal the fetal bladder. The bladder is exposed on the abdominal wall, and diastasis of the symphysis pubis is observed. If the mucosa of the posterior bladder wall protrudes through the abdominal defect, it may cause a prominence on the abdominal wall. Free communication between the bladder and amniotic cavity prevents bladder distension.

The renal collecting system and ureters need not be dilated, whereas unilateral or horseshoe kidneys may be found. Uterine and adnexal anomalies are relatively frequent findings. The pubis is abnormally wide, and the umbilical cord insertion may be abnormal.

Degree of Confidence

Renal and pelvic ultrasonography is an excellent screening test for a wide range of urologic anomalies and pathologies. Pelvic, vaginal, or rectal sonography are studies usually reserved for screening the genitourinary organs for etiologies of localized pain without any relation to the voiding cycle or voiding dysfunction following pelvic surgery. Pelvic ultrasonography is also an excellent modality in the diagnosis of predisposing causes of cystitis, such as bladder calculi.

False Positives/Negatives

Any fluid-filled mass in the pelvis can mimic the urinary bladder. If 2 fluid-filled masses (eg, urinary bladder with a lymphocele or ovarian cyst) are seen in the pelvis, t it may be necessary to place a catheter or to have the patient void to differentiate the bladder from the other cysts.

A rectus sheath hematoma may also mimic a urinary bladder. A markedly distended urinary bladder (as in bladder outlet obstruction) may be confused with other cystic masses, particularly when the patient is unable to completely empty the bladder.

Reverberation echoes in the anterior part of the bladder may mimic a mass that either seems cystic or contain echoes. Partially emptying the bladder may eliminate this artifact. Care should also be taken not to confuse the ureteral jet with an intramural mass.

Causes of increased muscle thickness include urethral valves, prostatic hypertrophy, neurogenic bladder, and cystitis and bladder malignancy. Bladder calculi may be mimicked by a subureteric Teflon injection, which gives rise to echogenic mounds, possibly with shadows. Pseudotumoral cystitis can mimic bladder tumors and vice versa.

NUCLEAR MEDICINE

Section 8 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

The limited diagnostic value of clinical evaluation and plain radiography in the detection of abscesses has lead to widespread use of sophisticated imaging techniques, including gallium-67 scintigraphy and indium-111 WBC scintigraphy. However, scintigraphy has not been applied in the imaging of cystitis apart from a single study of lupus cystitis, in which ⁶⁷Ga was used.

Degree of Confidence

⁶⁷Ga and ¹¹¹In WBC scintigraphy has been widely used in the diagnosis of abdominal inflammatory and infective disorders. The role of these diagnostic tools is limited in the workup of cystitis but may prove useful for investigating inflammatory disorders affecting the bladder extrinsically.

False Positives/Negatives

Goodgold and Samuels (1986) reported misleading findings on ¹¹¹In leukocyte images. ¹¹¹In leukocyte imaging usually yields images that are interpreted easily. However, 5 potentially misleading cases were noted among more than 200 scans obtained over 4 years. These included scans from 2 cases of bladder visualization without bladder inflammation and 3 cases of abdominal activity without intra-abdominal abscess or inflammatory bowel disease. Migration of leukocytes from other true pathologic sites and technical factors were responsible for the activity seen.

Dimercaptosuccinic acid (DMSA) scanning may be useful. In one study, the sensitivity and specificity of ultrasonography was 27% and 89%, respectively. The authors concluded that the clinical, biological, and ultrasonographic parameters did not permit the accurate distinction of cystitis from pyelonephritis in children with UTI and that that it did not allow the identification of children with severe renal damage. Accordingly, they recommend that DMSA scanning should be added to the initial workup of children with UTI.

ANGIOGRAPHY

Section 9 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

Hietala and Duchek (1975) performed angiography in 6 cases of bacteriologically and microscopically verified tuberculosis of the urinary bladder. As a rule, general or locally accentuated hypervascularization in the bladder wall could be demonstrated in the arterial phase, but no venous abnormalities were observed. The circulation time was usually not changed. Therefore, the angiographic appearances were nonspecific.

Duchek and associates (1976) correlated the histopathologic and angiographic findings in 6 cases of tuberculosis of the urinary bladder. The numbers of vessels were only slightly increased in the initial and fibrotic stages, whereas hypervascularization was observed in the exudative and productive stages.

Degree of Confidence

Angiography has no role in the diagnosis of cystitis.

False Positives/Negatives

The angiographic changes of tuberculous cystitis are nonspecific. Tuberculous cystitis cannot be distinguished from cystitis of other genesis, and, in some instances, from tumors of the urinary bladder.

INTERVENTION

Section 10 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Ultrasound
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Treatment of acute cystitis

Treatment should be started immediately. The selected antimicrobial (eg, trimethoprim) should be active against the most common causative organism. It should also be relatively inexpensive. A patient who had previous episodes will usually know which antimicrobial works best. The treatment should be given for 5-7 days, and the patient should also be encouraged to drink clear fluids and empty his or her bladder regularly. Expensive and broad-spectrum antimicrobials should be reserved for cases in which the bacterial culture results and sensitivity are known.

Transcatheter angiographic therapy

The therapeutic uses of transcatheter angiographic techniques can be applied in intractable hematuria secondary to cystitis. It has been particularly useful in radiation cystitis and recurrent bladder tumor.

Hendrickx and associates (1995) described long-term outcomes and survival after emergency embolization of life-threatening bleeding caused by small, nonmalignant pelvic lesions. They analyzed the techniques and the type of embolization materials used. Emergency transcatheter embolization was performed in 11 patients who had heavy bleeding from uterine arteriovenous malformations (4 patients), pelvic fractures (4 patients), cyclophosphamide-induced cystitis (1 patient), hemorrhoids (1 patient), or polyposis recti (1 patient). Patients received Gianturco, Anderson, and Wallace (GAW) coils. Alcoholic prolamine solution (Ethibloc, Ethicon; Johnson & Johnson, New Brunswick, NJ) and gelatin sponge strips (Gelfoam strips; Pfizer, New York, NY) were used as embolization materials, alone or in combination.

Follow-up was as long as 7.5 years. Recurrent bleeding occurred in only 1 patient with terminal hepatic insufficiency and severe disturbance of coagulation at 1 month after embolization. Two other patients died during follow-up, for other reasons (cardiac insufficiency at 17 months, ileus at 52 months). Complications due to embolization did not occur. The authors concluded that percutaneous transcatheter embolization is a safe and effective procedure in severe hemorrhage resulting from nonmalignant lesions of the pelvis.

Thelen and Bruhl (1978) described the successful use of transcatheter arterial embolization in intractable hematuria in a patient with pyocystis.

Although cystoscopy is routinely performed in the diagnosis of cystitis, further invasive and noninvasive investigations may be required, particularly in cases of interstitial cystitis. These include urodynamic studies of the lower urinary tract and investigations of the pelvic floor.

Medical/Legal Pitfalls

• Both the oral and intravesical treatments for interstitial cystitis are noncurative, and few are based on a plausible mechanism or scientific evidence.
• Surgical treatment for interstitial cystitis should be considered with extreme caution; it is the last therapeutic option because failure rate can be substantial (Gousse, 2000).

Special Concerns

• UTIs (asymptomatic bacteriuria, cystitis, and pyelonephritis) are frequent medical complications of pregnancy.
• • Most infections in pregnancy are asymptomatic. However, even covert bacteriuria places the mother at risk for having a low-birth-weight, preterm baby.
  • Pyelonephritis can result in clinically significant maternal and fetal morbidit