Adenoid cystitis is a relatively rare non-neoplastic inflammatory lesion, a lesion in which epithelial hyperplasia and chemosis coexist. The process is epithelial hyperplasia recessed into Brunn’s nest, within which fissures appear, forming branching, annular lumen, and in the center, glandular chemosis forms a glandular structure, with the simultaneous presence of lymphocyte and plasma cell infiltration, so it is called adenoid cystitis. It has a special pathological development and clinical pathogenesis.
Etiology of adenoid cystitis
1, the normal urethral epithelium chemosis: research that adenoidal cystitis is a proliferation and chemosis of lesions at the same time. The normal bladder mucosa is chronically stimulated by inflammation, stones, foreign bodies, and indwelling catheters, and the mucosal epithelium proliferates easily to form Brunn’s nests. The epithelial nest is composed of well-differentiated metaplastic epithelium with a superficial metaplastic epithelium in the center, surrounded by basement membrane and connective tissue.
The center of the epithelial nest may liquefy to form a cavity containing clear fluid, which is known as cystic cystitis; if the center of the cavity is metastatic to columnar epithelium or cuboidal epithelium, forming mostly mucous-like structures within the lamina propria of the bladder, which is known as adenoid cystitis. Cystic cystitis and glandular cystitis are two stages or different degrees of the same pathological process.
2, Embryologic origin: It has been proposed that the intravesical glands may be formed by the continued development of endodermal cells that remain in the bladder when the rectum is separated from the urogenital sinus.
Clinical manifestations
Adenocystitis is an inflammatory lesion of the bladder mucosa, and the clinical manifestations are mostly nonspecific. Clinical manifestations include microscopic hematuria, carnal hematuria, dripping urination, urethral discomfort, urinary frequency, urinary urgency, urinary pain, lower abdominal discomfort, pain in the pubic area, etc. Discomfort symptoms such as lumbar acidity and lumbar distension may occur. Further examination of the disease should be considered, especially when anti-infective treatment is not effective, and cystoscopy plus tissue biopsy should be performed if necessary.
Female patients may have urethral meatus and male patients may have prostatic hyperplasia. Routine urinalysis may have normal and various abnormal manifestations, such as white blood cells ten to ten to ten, red blood cells ten to ten, etc.
Clinical diagnosis
The clinical diagnosis of adenoid cystitis relies on cystoscopy and pathology. Adenoid cystitis is closely related to bladder tumors, and most scholars believe that epithelial nests and cysts in adenoid cystitis are precancerous, most commonly developing into bladder adenocarcinoma; therefore, patients with this disease should be closely followed up with regular cystoscopy, and malignancy should be highly suspected if tumor-like hyperplasia is present.
Adenoid cystitis occurs in the bladder triangle, bladder neck and around the ureteral opening. It is generally considered to be associated with the following factors.
1. The bladder triangle and bladder neck are the focal point of urinary flow dynamics, without submucosa, in a fixed position and lacking the contraction discretion of other parts;
2, bladder triangle and bladder neck and around the ureteral opening is a high incidence of bladder inflammation;
3, stimulation by chemical components in the urine.
Adenoid cystitis can be classified according to the morphology of the lesion as.
1, follicular edema type, manifested as a sheet infiltration type of follicular edema bulge or villi-like hyperplasia, clinically this type is common;
2, papilloma-like type, manifested as papillae with tips, mucosal congestion, edema, easily misdiagnosed as papilloma;
3, chronic inflammatory type, manifested as local mucosal roughness, increased vascular texture;
4, no significant changes in the mucosa type, the mucosa is generally normal, random biopsy found, this type is easy to miss the diagnosis.
Treatment
There are various treatment methods for adenoid cystitis, mainly transurethral bladder electrodesiccation, laser cautery, BCG, mitomycin and other anti-cancer drugs bladder instillation, etc. All of them have certain effect.
Personally, I think transurethral bladder mucosal electrosurgery is a mature operation with the features of easy operation, less bleeding, less pain, quick recovery and significant curative effect. It is less traumatic to the patient, can be repeatedly operated, and has high safety. During transurethral electrodesiccation, attention should be paid to the mucosa of the lesion when electrocautery should be repeated 2 to 3 times to cauterize thoroughly, and lesions near the ureteral orifice can be electrodesicced to the superficial muscular layer to prevent narrowing of the ureteral orifice, and intraoperative hemostasis should be complete to prevent secondary bleeding.
During the operation, attention should be paid to the electric incision when the cut should not be too deep to prevent bladder perforation and injury to the large pelvic vessels, especially in the triangle and bladder neck trauma exposed to cause urinary irritation to make the bladder unstable resulting in discomfort such as urinary frequency, urinary urgency and hematuria. The bladder should not be overfilled during electrodesiccation, generally 150 to 200 ml, too much filling of the bladder is prone to thinning and perforation.
In case of concurrent urethral meatus, urethral meatus resection is performed; in case of concurrent bladder neck elevation, bladder neck electrosurgery is performed; in case of concurrent bladder stones, vigorous forceps lithotripsy is performed at the same time; in case of concurrent prostatic hyperplasia, TUVP is performed; in case of concurrent urethral stricture, urethral dilatation is performed. The open surgery such as partial cystectomy and bladder mucosal debridement is very traumatic and has many surgical complications, and there is still a possibility of recurrence of adenocystitis after surgery, so it is not used at present.
There is no specific treatment for this disease, and the evaluation of the effectiveness of various treatment methods lacks uniform standards. It includes treatment of the etiology and treatment of local lesions within the bladder. There is increasing evidence that the disease is associated with chronic irritation of the bladder mucosa and that treatment is ineffective mainly because attention is paid to the pathologic diagnosis of “adenocystitis” without further clarification of the cause.
Treatment is often directed at the pathologic diagnosis but not at the cause. Most adenoid cystitis is a secondary pathology that may have many hidden causes that go unnoticed. Satisfactory results can only be achieved if the etiology is targeted and chronic irritants are eliminated. We believe that the first step should be to eliminate chronic irritants such as infection, obstruction and stones, and that anti-infective therapy alone is often not effective. In female patients, attention should be paid to the presence of urethral meatus, hymenal umbrella, external urethral orifice malformation, etc.