Cystitis in Men

Differential Diagnosis: Urinary Tract Tumors

Neoplasms may hide under the guise of dysuric disorders. Urothelial thickening in the upper urinary tract is associated with a malignant process in almost half of the cases. If the pathology affects the proximal parts of the collecting system, wall thickening almost always indicates neoplasia. In the ureters, filling defects are also most often tumors.

Superficial and non-muscle-invasive bladder tumors require mandatory treatment. Even benign papillomas with low malignant potential (PUNLMP) cause hematuria and require pathomorphological verification. Transurethral resection (TUR) is the primary treatment method, often supplemented by intravesical therapy. Despite a good initial response (up to 80% of cases), most patients experience recurrences within several years, necessitating regular follow-up.

Muscle-Invasive Cancer and Metastasis

If the tumor grows into the muscular layer of the bladder, radical cystectomy becomes the gold standard of treatment. To achieve optimal results, the surgery should be performed within three months of diagnosis. Lymph node dissection is a routine part of the intervention, with the extended version yielding better oncological outcomes. To preserve quality of life, nerve-sparing techniques and various options for urinary diversion (orthotopic replacement or ileal conduit formation) are offered to patients.

At the diagnostic stage, it is important to assess lymph node involvement. 18F-FDG PET/CT allows the detection of metastases (typical zones are para-aortic and left supraclavicular nodes). The presence of lymph node metastases at the time of cystectomy (found in 25% of patients) sharply reduces the five-year survival rate from 40–80% to 20–25%. In such cases, the use of radiation or chemotherapy is mandatory.

Bladder Injuries

The differential diagnosis of acute pelvic pain and hematuria includes traumatic injuries. The most common is blunt trauma against the background of pelvic fractures.

There are two main types of ruptures:

• Extraperitoneal ruptures (EPR): the most common variant. In the vast majority of cases (about 90%), they are successfully treated conservatively using transurethral or suprapubic drainage for 10 days.
• Intraperitoneal ruptures (IBR): require urgent surgical intervention to prevent peritonitis.

Computed tomography cystography is used for diagnosis. Missed injuries can lead to serious complications: infections, pelvic abscesses, fistula formation, and persistent urinary incontinence.

Male Urethral Injuries

Posterior urethral injuries are typical for young men who have undergone high-speed blunt pelvic trauma. The anterior urethra is more often affected by iatrogenic or penetrating impacts (for example, the bulbar section is injured when compressed against the pubic symphysis).

Clinical signs of urethral injury:

1. Appearance of blood at the external meatus (meatus).
2. Acute urinary retention (inability to urinate).
3. High position of the prostate gland on digital rectal examination.
4. Pronounced edema or hematoma in the perineal region.

Before bladder catheterization in such patients, retrograde urethrography is mandatory. Erroneous catheter insertion in unrecognized trauma can aggravate the injury. On urethrograms, complete rupture is characterized by contrast extravasation into the surrounding soft tissues. If Buck's fascia is damaged, the contrast agent spreads through the perineum and scrotum within Colles' fascia.

Class and exam questions

What else to study on this topic

• Urinary diversion techniques after radical cystectomy (ileal conduit, neobladder)
• Goldman & Sandler classification of urethral injuries in radiology
• The role of MRI in evaluating chronic complications of urethral injuries
• Pathogenesis and radiation diagnostics of aresorptive hydrocephalus in SAH
• Clinical masks and differential diagnosis of brain tumors
• Psychiatric correction and stages of traumatic brain injury

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.