Cystitis Glandularis

Cystitis glandularis is glandular metaplasia of the bladder urothelium, in which von Brunn nests develop glandular lumina lined by cuboidal or columnar cells.

Two forms are described: the usual (typical) form, and the intestinal form with mucin secreting goblet cells.

It is associated with chronic irritation from infection, stones, catheters, bladder outlet obstruction, neurogenic bladder, pelvic lipomatosis and bladder exstrophy. It is more common in women and is often found at the trigone and bladder neck.

The intestinal form has been linked with bladder adenocarcinoma, but whether it is truly premalignant is uncertain, and the absolute cancer risk is low.

Pathophysiology. Chronic inflammation and urothelial injury cause metaplasia of nests in the lamina propria into glandular epithelium. Extensive involvement forms nodular or polypoid masses that can obstruct the bladder neck or ureteric orifices.

Haematuria, frequency, urgency, dysuria, suprapubic pain, recurrent infection, poor stream, and occasionally hydronephrosis. Some patients have no symptoms. Ask about previous bladder surgery, catheters, exstrophy repair and irradiation.

• Urinalysis, culture, urine cytology and creatinine.
• Ultrasound for wall thickening, residual urine and hydronephrosis, and MRI of the pelvis when pelvic lipomatosis or an extensive mass is suspected.
• Cystoscopy: papillary, polypoid or nodular red lesions, or oedematous patches, most often at the trigone and bladder neck.
• Biopsy deep enough to include muscle. Mucin stains (periodic acid-Schiff, mucicarmine) define the glandular type and help distinguish the intestinal form with goblet cells. Look for atypia and invasion, which indicate adenocarcinoma.

Differential diagnosis.

• Papillary urothelial carcinoma
• Adenocarcinoma of the bladder
• Cystitis cystica
• Nephrogenic adenoma
• Urachal remnant lesions
• Inflammatory polyp
• Villous adenoma

• Remove the cause: relieve obstruction, treat stones, treat infection with culture directed antibiotics and remove or replace catheters.
• Transurethral resection of visible lesions, complete where practical, for diagnosis and symptom control, with histology to exclude adenocarcinoma.
• Intestinal type: complete resection, then surveillance cystoscopy at 3 months, 6 months and 12 months, then yearly for at least 5 years.
• Typical type without atypia: cystoscopy at 3 to 6 months, then as symptoms and haematuria direct.
• Cystectomy only for adenocarcinoma or severe intractable disease.
• No drug has proven benefit. Some reports describe anti-inflammatory therapy, but evidence is weak.

Monitoring. Periodic surveillance cystoscopy, urine cytology, and ultrasound for hydronephrosis when the trigone or ureteric orifices are involved.

Referral and escalation. Refer to urology. Urgent referral for haematuria with a mass, hydronephrosis, or atypia on biopsy.