History

A detailed history should include specific questions regarding gynaecological and urinary symptoms. Frequency, urgency and nocturia in association with incontinence are likely to reflect underlying detrusor overactivity. In contrast, chronic severe urgency and bladder pain without incontinence are likely to be secondary to intravesical pathology such as infective or non-infective cystitis. A history of present and past medications [e.g. diuretics, tiaprofenic acid (Surgam) and cyclophosphamide], previous urinary tract infection (UTI) and pelvic surgery should be sought. Predisposing or exacerbating factors may include sexual intercourse (e.g. ‘honeymoon cystitis’), barrier contraception (e.g. diaphragm, condoms) and contact irritants (e.g. vaginal douches, spermicidal agents). More general irritant factors can include washing powder, soaps and gels.

Voiding dysfunction should be suspected with symptoms of hesitancy, poor urinary stream, straining and incomplete bladder emptying. Impaired bladder emptying due to detrusor underactivity or urethral obstruction may be idiopathic or secondary to neurological disease, pelvic surgery or uterovaginal prolapse.

Examination

Abdominal examination may reveal a palpable bladder secondary to urinary retention, pelvic mass or bladder tenderness from cystitis. Neurological examination with directed assessment of the S2–4 nerve roots, which innervate the bladder, should be performed. Vaginal examination using a Sims speculum allows visualization of the anterior and posterior walls, and may reveal genital prolapse, atrophy, inflammation or infection. Urethral inspection may reveal a mass, mucosal prolapse or caruncle. Paraurethral masses can be identified on bimanual examination by compressing the urethral and paraurethral tissues against the back of the pubic symphysis; expression of urethral pus suggests a urethral diverticulum.

Investigations

Urinary diary

A detailed 3-day urinary frequency–volume diary is an important part of the initial and ongoing assessment (Figure 56.2). These diaries are more accurate than patient recall, allowing rapid and accurate diagnosis of urinary frequency, nocturia, estimation of voided volumes, functional bladder capacity, and assessment of episodes of urgency, pain and incontinence as well as their temporal relationship. A diary will also educate the patient regarding voiding habits, and is essential for bladder retraining.

Figure 56.2 Urinary frequency–volume diary.

Imaging

Imaging of the urinary tract can be performed using ultrasound or contrast radiography, either alone or synchronously with urodynamic assessment [videocystourethrography (VCU)]. VCU demonstrates voiding function and can identify urethral obstruction, a urethral diverticulum or external compression due to fibroids or prolapse. Haematuria in the absence of identifiable uropathogens, negative cystoscopy or recurrent UTI is an indication for assessment of the upper urinary tract using contrast intravenous urography or urinary tract ultrasound. Ultrasound can also determine bladder residual volume and bladder wall thickness, and identify any structural abnormalities, including urethral diverticulae (Figure 56.3) (Doumouchtsis et al 2008).

Figure 56.3 Transperineal high-frequency ultrasound and corresponding line diagram demonstrating a large urethral diverticulum. U, urethra. (A) The arrows indicate the paraurethral lesion (diverticulum. (B) Enlarged ulltrasound image of the diverticulum in (A) demonstrating mixed reflective echogenic pattern.

In women with recurrent UTI, 5% have an abnormality of the urinary tract (e.g. calculus, duplex system, tumour). In women with irritative lower urinary tract symptoms and a paraurethral mass, a micturating cystogram or double balloon contrast urethrogram may identify a communicating tract with a urethral diverticulum. Transperineal ultrasound provides comparable information, is less invasive and allows differentiation between solid (e.g. fibroid, lipoma), cystic lesions (diverticulum, Skene’s cyst or abscess, Gartner’s duct cyst) and vascular lesions (haemangioma, fibroid). Mixed echogenic contents suggest an infected diverticulum or paraurethral abscess.

Plain abdominal X-ray will demonstrate 90% of calculi present in the kidney, ureters or bladder due to the presence of calcium or cystine. Computed tomography (urogram or magnetic resonance imaging) may be required to provide accurate imaging of upper and lower urinary tract pathology. The automated bladder ultrasound machine is a simple, inexpensive tool used to measure urinary residual volume. However, it does have relatively poor sensitivity for volumes of less than 100 ml or more than 400 ml. In addition, artefacts may be introduced by the presence of pelvic pathology (e.g. uterine fibroids, pelvic haematoma, ovarian cysts) (Cooperberg et al 2000). The automated bladder ultrasound machine is a useful screening tool in older women with urge-frequency syndrome and/or recurrent cystitis with suspected voiding difficulty.

Cystourethroscopy

Evaluation of the lower urinary tract by cystourethroscopy is an essential skill for all gynaecological surgeons, not only in the assessment of urinary symptoms and pain but during pelvic surgery for the prevention and early treatment of bladder and urethral injury. Cystoscopy is undertaken in an inpatient or outpatient setting using a flexible or rigid system. Rigid cystosocopy is well tolerated by women under local anaesthetic in an outpatient setting (Lee et al 2009). Cystoscopy is indicated for haematuria, abnormal urinary cytology, recurrent UTI or persistent symptoms despite conservative treatment. At cystourethroscopy, the lower urinary tract should be carefully visualized using a 70° or 30° scope for the bladder and a 0° scope with Sasche sheath for the urethra. Features such as mucosal trabeculation, bladder diverticula, tumours, squamous metaplasia, bladder calculi and foreign bodies are readily identifiable (Figure 56.4). Women with misplaced intravesical sutures (e.g. colposuspension), eroded mesh following slings for incontinence or grafts for prolapse surgery, exposed urethral bulking agents or sterile abscess (e.g. Zuidex) may present with urgency, bladder pain and/or recurrent UTI. A biopsy should be taken of any suspicious localized lesions to exclude carcinoma.

Figure 56.4 Cystoscopy. (A) Bladder calculi. (B) Suture material in bladder. (C) Urethral mesh erosion. (D) Postmenopausal recurrent bacterial cystitis. Squamous metaplasia/cystitis cystica involving trigone and above (benign). Treated with topical oestrogens and rotational antibiotic prophylaxis. (E) Trabeculation, bladder tumour of the right side of bladder wall (malignant). Transurethral resection of bladder tumour undertaken.

Painful bladder syndrome/interstitial cystitis

The European Society for the Study of Interstitial Cystitis (ESSIC) recently proposed the term ‘bladder pain syndrome/interstitial cystitis’ (van de Merwe et al 2008). Guy Hunner first described this condition in 1914, and the mucosal tearing and fissuring which he described as an ‘ulcer’ carries his name. PBS/interstitial cystitis is a chronic bladder condition seen mainly in women (10 : 1 female:male ratio). The main presenting symptoms are frequency, urgency, nocturia and bladder pain, which often increase as the bladder fills and reduce after micturition. Pain may be experienced in the urethra, loin area and/or perineum. Chronic pelvic pain, dyspareunia and dysmenorrhoea are also common symptoms, and coexistence with other causes of pelvic pain (e.g. endometriosis) is well recognized. There are cystoscopic and histological features which are considered typical, but in many cases, the diagnosis is one of exclusion, having ruled out specific causes such as infection and malignancy.

OAB shows some similarity in its clinical presentation but without the pain, which is the defining symptom of PBS/interstitial cystitis.

The reported prevalence of PBS/interstitial cystitis varies widely due to different diagnostic criteria. It has been estimated at 18 per 100,000 women in Finland (Oravisto 1975), eight to 16 per 100,000 in the Netherlands (Bade et al 1995), 30 per 100,000 in 1987 in the USA, and 865 per 100,000 women in 1994 in the USA (Rosamilia 2005). Delay between onset of symptoms and diagnosis can be 5–7 years. Leppilahti et al (2005) found that the prevalence of clinically confirmed probable interstitial cystitis in women was 230/100,000 and the prevalence of possible/probable interstitial cystitis was 530/100,000.

The pathophysiology is poorly understood and the condition is considered multifactorial (Nickel 2002). Proposed aetiologies include an infective agent, allergic or autoimmune conditions, ‘leaky’ urothelium secondary to a defective glycosaminoglycan layer, urinary toxins, lymphatic or vascular abnormalities and neurogenic inflammation. Any of these pathological changes may be a result rather than cause of the disease process. Loss of integrity at the epithelial surface of the bladder, secondary to an infective or other inflammatory insult, has been implicated along with sensory nerve upregulation and enhanced mast cell activation (Sant 2002), resulting in regional neuropathy. Other gynaecological and gastrointestinal manifestations may be present, including pain and voiding symptoms (Nickel 2002).

The ESSIC group (van de Merwe et al 2008) proposed that a diagnosis of PBS should be made on the basis of exclusion of confusable diseases and by the recognition of the specific combination of symptoms and signs of PBS. Confusable diseases include carcinoma, infection, urethral diverticulum, prolapse, endometriosis, OAB and pudendal nerve entrapment. Symptoms and signs for use in diagnostic criteria do not need to be specific. On the contrary, if a specific symptom or sign existed for the target disease, a diagnosis would only require the presence of the specific feature, and diagnostic criteria would not be necessary. PBS should be diagnosed on the basis of chronic (>6 months) pelvic pain, pressure or discomfort perceived to be related to the urinary bladder, accompanied by at least one other urinary symptom such as persistent urge to void or frequency. Further classification of PBS is based on findings at cystoscopy using hydrodistension and bladder biopsies. Cystoscopic features accepted as positive signs are glomerulations, Hunner’s lesions or both (Figure 56.5). Hunner’s lesion is ‘a circumscript, reddened mucosal area with small vessels radiating towards a central scar, with a fibrin deposit or coagulum attached. This site ruptures with increasing bladder distension, with petechial oozing of blood from the lesion and mucosal margins in a waterfall manner. A rather typical, slightly bullous edema develops post-distension with varying peripheral extension’. Biopsy findings accepted as positive signs of PBS are inflammatory infiltrates and/or granulation tissue and/or detrusor mastocytosis and/or intrafascicular fibrosis (van de Merwe et al 2008). Only 50% of cases have positive histopathology findings, and the purpose of biopsy is often to exclude malignancy.

Figure 56.5 Cystoscopic images demonstrating progressive petechial haemorrhaging on bladder emptying under direct vision in a patient with painful bladder syndrome/interstitial cystitis.

As the aetiology of the syndrome is multifactorial, treatment efficacy may vary among different patients, and multiple treatment modalities are often necessary, directed at different disease processes (e.g. bladder retraining, neuromodulation, polypharmacy), if a successful outcome is to be achieved. Although many options are available for controlling symptoms, cures are rare and relapse is common. Sympathetic support by family, medical staff and self-help groups are invaluable. In order to identify the most effective treatment for a patient, they should be tried one at a time. Limited evidence is available from randomized controlled trials. A placebo effect is probably significant in these treatment modalitities.

A simple treatment is dietary manipulation. Eliminating substances that may cause bladder inflammation can help some patients (e.g. caffeine, spicy foods). Other non-invasive measures include bladder retraining and relaxation techniques in order to gradually prolong the time periods between voids.

There are several oral or intravesical options with variable efficacy, and to date there is no consensus regarding which treatment is best. Pentosan polysulfate sodium (Elmiron) is a polysaccharide which decreases urothelial permeability by substituting for a defect in the glycosaminoglycan layer. The recommended oral dose is 100 mg three times a day between meals. Response to treatment is likely to be slow, and patients may not notice any benefit until several months of treatment. Antihistamines prevent activation of mast cells. Cimetidine, an H₂ receptor antagonist, has also been tried with variable results. Tricyclic antidepressants have anticholinergic, analgesic and sedative effects on the bladder. Amitriptyline has also shown some benefit. The dose can be increased up to 100 mg. Anticholinergic drugs may be effective, especially if frequency and urgency are predominant symptoms. Oxybutynin has been used orally as well as intravesically. Dimethyl sulfoxide is a chemical solvent that is used intravesically. It penetrates cell membranes and has anti-inflammatory, analgesic and muscle-relaxant properties. It is thought to inhibit mast cells and dissolve collagen. The treatment is repeated at intervals of 2 weeks. Over 50% symptom improvement is common with this treatment, which may be long lasting. Intravesical heparin instillation has also been used, but the evidence for its efficacy is poor. Other medications include bacillus Calmette-Guérin (BCG), hyaluronic acid, chondroitin sulphate and resiniferatoxin.

Botulinum toxin A has been used in the treatment of PBS with variable results. A Cochrane review on intravesical therapy showed that BCG and oxybutynin are reasonably well tolerated, and evidence is most promising for these. Resiniferatoxin has limited efficacy and causes pain, reducing treatment compliance (Dawson and Jamison 2007). Major urological surgery involving ulcer resection, bladder denervation, and partial or total cystectomy with urinary diversion should be considered as a last resort.

Drug-induced cystitis

The bladder is susceptible to the adverse effects of drugs because of the excretion of several drug metabolites in the urine. A history of present and past medications is important as drug-induced cystitis can occur immediately following administration or may manifest many years later. The term ‘drug-induced cystitis’ is therefore dependent on evidence of the onset of irritative symptoms and inflammatory changes at cystoscopy following drug administration, resolution following withdrawal, and recurrence with readministration of the drug. Implicated drugs include cyclophosphamide, tiaprofenic acid (Surgam), sulphasalazine, fenfluramine, fluoxetine, simvastatin, danazol and a number of non-steroidal anti-inflammatory drugs. Drugs that cause cystitis should be withdrawn if a patient develops irritative symptoms or haematuria. Adverse effects of cyclophosphamide can be reduced with prophylactic administration of Mesna (2-meracaptoethane sulfonate sodium) and adequate hydration. Mitomycin, doxorubicin or BCG instilled locally to treat bladder tumours can also cause cystitis, contracture and calcification. Their administration should therefore be limited to 1 h/week for a maximum of 8 weeks (Drake et al 1998).

Radiation cystitis

Radiation cystitis may occur as an early or late complication. The bladder can be irradiated intentionally for the treatment of bladder cancer, or incidentally for the treatment of pelvic malignancies. Radiation cystitis is characterized by dysuria and increased urinary frequency (Chuang et al 2008). Acute cystitis is caused by the inflammatory response to radiation, and consists of urgency, frequency, dysuria and haematuria. Chronic cystitis is the end result of the inflammatory process. Ischaemia and fibrosis may result in a small contracted non-functional bladder with severe frequency, urgency and incontinence. Radiation cystitis can range from minor temporary irritative voiding symptoms to severe haematuria, incontinence, fistula formation, necrosis and death. The total single dose, duration of radiotherapy, treatment cycle, preceding surgery, pre-existent infection and previous radiotherapy all influence the risk of radiation cystitis.

Eosinophilic cystitis

Eosinophilic cystitis is a rare inflammatory condition of the bladder which has been associated with allergy, bladder tumours, bladder injury, infections and drugs. It is characterized by the antigen–antibody reaction and probably represents a type 1 hypersensitivity reaction to exogenous allergens. Transmural inflammation of the bladder, predominantly with eosinophils, is followed by fibrosis in the chronic phase. Affected individuals typically have a history of atopy and present with frequency, dysuria, suprapubic pain, haematuria, proteinuria and pyuria. Eosinophiluria occurs in 30% of cases, but up to 50% will have a raised serum eosinophil count. Cystoscopy and biopsy are the gold standard for diagnosis. Medical therapy, such as non-steroidal anti-inflammatory agents or steroids, may provide symptomatic relief, but long-term follow-up is mandatory as the lesion tends to recur (Teegavarapu et al 2005).

Granulomatous cystitis

This condition may arise following bladder resection, bladder biopsy, bacterial infection or BCG instillation, and should be distinguished from tuberculosis. The patient may be asymptomatic or present with haematuria, frequency, urgency and pain. Discrete plaques or nodules may be evident at cystoscopy. At histology, diffuse granulomas or histiocytic inflammation are usually identified.

Proliferative and metaplastic lesions of the bladder

‘Brunn’s nests’, cystitis cystica, cystitis glandularis and squamous metaplasia are common findings at cystoscopy, which are likely to represent normal histological variants. They are usually located on the trigone and anterior wall of the female bladder. Coexistent symptoms of frequency, urgency or bladder pain are more likely to be associated with infection or other inflammatory pathology.

Proliferative cystitis typically starts with ‘Brunn’s nests’, which are clusters of pale yellow cells, 1–5 mm in diameter, within the lamina propria. These lesions are usually confined to the trigone but may be diffuse; differentiation from carcinoma requires biopsy for histological analysis. Cystitis cystica is a result of dilatation of the Brunn’s nests within the lamina propria, which are lined by stratified or squamous epithelium, and in cystitis glandularis by columnar epithelium.

Squamous metaplasia is a well-delineated ‘white patch’ confined to the trigone, and is present in oestrogen-producing women. Keratinizing squamous metaplasia is also known as ‘leukoplakia’. It is generally diffuse and associated with recurrent infection and chronic irritation. It often occurs in association with bladder calculi, urethral diverticula or a foreign body. Macroscopically, the affected areas of the bladder have a thickened white and shiny appearance interspersed with areas of bladder inflammation. Bladder biopsies typically demonstrate mature keratinized stratified squamous epithelium. Its clinical significance remains unclear, but has been linked to the development of invasive squamous cell carcinoma. Both synchronous diagnosis of urothelial tumour and subsequent tumour development on follow-up have been identified. The risk of malignancy is increased in cases with dysplasia as well as extensive keratinization. Lesions should be treated with local transurethral resection. Although dysplasia is considered to be a premalignant condition, there is not enough evidence to identify keratinizing squamous metaplasia of the bladder as premalignant. However, all patients should undergo regular surveillance (Ahmad et al 2008).

Lower urinary tract tumours

Carcinoma in situ (CIS) may be asymptomatic or present with microscopic or gross haematuria, urgency, frequency and dysuria. Diagnosis is often delayed because symptoms are attributed to UTI. More than 50% of patients with CIS have coexistent papillary cancer. Cystoscopic appearance varies from normal to erythema or oedema. Histology usually demonstrates abnormal pleomorphic transitional cells confined to the urothelium. Investigation includes urine cultures for fungi and tuberculosis, and cytology studies. Urine cytology is positive in 80–90% of cases. Intravesical BCG instillation is considered the preferred treatment. Surgical resection with radical cystectomy or ablation using transvesical laser or diathermy are indicated for persistent disease, but recurrence or progression to muscle invasion will occur in more than 40% of these women. Chemotherapy, α-interferon and photodynamic therapy are other treatment options for BCG-refractory cases. Outcomes vary and depend on whether CIS is de novo, secondary or concomitant to papillary bladder cancer (Nese et al 2009).

The majority of primary invasive lower urinary tract tumours present with painless haematuria or irritative bladder symptoms. UTI is a frequent association. The most common histological type of primary bladder carcinoma is transitional cell (>90%). In the developing world, however, schistosomiasis is associated with an increased incidence of squamous carcinoma. Adenocarcinoma is uncommon but may arise in the embryological remnants of the urachus.

Lower urinary tract calculi

Bladder and urethral calculi in women often arise secondary to a foreign body (e.g. suture material, mesh erosion) or structural abnormalities such as a bladder or urethral diverticulum. They commonly present with recurrent UTI or irritative bladder symptoms. Treatment is directed at removal of the calculus by cystoscopy or lithotripsy, and correction of the underlying abnormality.

Urethral diverticulum

Female urethral diverticula are an uncommon variable in presentation, and the diagnosis is sometimes difficult and delayed. They represent an outpouching of the urethral mucosa through a defect of the periurethral fascia, and may be congenital (embryonic cystic remnants) or more commonly acquired. Obstruction of the periurethral glands, infection and subsequent rupture into the urethral lumen may lead to a urethral diverticulum. Weakening of the periurethral fascia following intraurethral trauma (urethral dilatation), continence surgery or childbirth may result in a diverticulum. Diverticula may be asymptomatic or present with a variety of symptoms, including urgency, recurrent cystitis, haematuria, urethral discharge, vaginal pain or dyspareunia (Romanzi et al 2000). Depending on the patency of the diverticular ostium, contents may stagnate, predisposing to infection or abscess in up to 30% of cases (El-Mekresh 2000), calculi in 1.5–10% of cases or metaplasia leading to malignancy. Investigations include cystourethroscopy, retrograde urethrography, magnetic resonance imaging, and high-resolution transvaginal or transperineal ultrasound (Rovner 2007).

Urethral pressure profilmetry may demonstrate a bifid profile where the urethral diverticular ostium crosses the high-pressure urethral zone.

Surgical excision is necessary in symptomatic women. The aim of surgical repair is to excise the diverticular wall, close the ostium and repair the periurethral fascial defect in layers without tension to reduce the risk of recurrence or fistula formation. In the presence of a large defect or poor tissue integrity, reinforcement of the repair is required. Autologous pubovaginal slings with rectus abdominis fascia or local vaginal, labial or bladder wall flaps have been used. The Martius labial fat graft uses a sleeve of adipose tissue mobilized from the labia majora, still attached to its vascular pedicle. This is rotated and tunnelled under the skin into the vagina (Leach 1991). Complications of diverticulectomy include stricture or scarring, recurrence, stress incontinence, fistula, sloughing, urethral pain and dyspareunia. Stress incontinence is more common where the diverticular ostium crosses the urethral sphincter.

Urethral syndrome

Urethral syndrome is a non-specific group of lower urinary tract symptoms, which include pain (suprapubic or urethral) with urinary frequency and urgency. The pain is typically exacerbated by micturition. The diagnosis is one of exclusion. Investigations should exclude infectious and non-infectious causes of cystitis, inflammation secondary to trauma, foreign bodies, contact irritation or localized paraurethral lesions (Skene’s abscess, urethral stricture, diverticulum, tumour), and urethral manifestations of systemic disorders (Reiter’s syndrome, Stevens–Johnson syndrome). Cystourethroscopy is necessary to exclude local pathology. An MSU and urethral swab should be performed for microscopy and culture. In women with recent-onset dysuria and frequency (acute urethral syndrome), and an MSU specimen demonstrating pyuria with less than 10⁵ micro-organisms/ml, an infective cause is often identified (Stamm et al 1980). The most common organisms isolated on culture of urinary specimens or urethral swabs include coliforms, C. trachomatis, S. saprophyticus and N. gonorrhoeae. If cultures are negative, empirical antibiotic therapy with doxycycline alone or in combination with a sulphonamide should be considered, and is frequently associated with symptomatic resolution (Latham and Stamm 1984).

In women with chronic urethral symptoms, an infective cause is less likely. In the past, urethral dilatation was frequently performed based on the assumption that the condition was due to urethral obstruction, with 80% of women reporting symptom improvement. Symptomatic improvement is also noted following cystoscopy alone, and urethral dilatation may be associated with urethral fibrosis or damage to the urethral sphincter with secondary stress incontinence. Pharmacological agents (e.g. benzodiazepines) have also been used. Their presumed effect is to reduce urethral spasm, although there is no evidence to support this hypothesis.

Urethral syndrome may represent another variation of chronic pain syndromes which are complex and poorly understood (e.g. PBS, vulvodynia). There is no consensus on appropriate management of this condition. Amitriptyline, used for the treatment of other chronic pain syndromes, is often helpful and also has a beneficial anticholinergic effect. Pharmacological therapy should be combined with education and psychological counselling.