Robyn M. Potts, M.D. and Barbara L. Bane M.D. Last update: May 30, 2003.

Department of Pathology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma

Initial clinical information provided: 42 year-old man presented with microscopic hematuria. A cystoscopic biopsy yielded the following specimen.

Additional clinical information:  The patient also has a history of urinary diversion for unclear reasons at the age of 2, leaving him with cutaneous ureterostomy and a de-functionalized bladder. This part of the history was withheld  to increase the challenge level of this case. The importance of history checking cannot be over emphasized.

Gross pathology of the case: 

    A questionable mass and several areas of bullous edema near the dome of the urinary bladder were found by cystoscopy. The suspicious areas were biopsied and yielded the material being shown here.

Histopathology of the case: 

A.	B.	C.	D.	E.	F.	G.

    The biopsy material showed polypoid fragments with cystically dilated glands lined by columnar to cuboidal cells (Panel A, B, and C). Some of the glands were lined by transitional epithelium (Panel D), some were lined by a mixed transitional epithelium and mucin producing columnar epithelium (Panel E), and some were lined entirely by mucin producing columnar epitheliuim (Panel F) that closely resembled colonic epithelium. A mild to moderate degree of chronic inflammatory cell infiltration was also present. A mixed population of mucin producing columnar epithelium with transitional epithelium was also noted in many of the non-glandular surface epithelium (Panel G). No dysplasia was found.

Discussion: General Information    Pathology    Differential diagnosis

General Information    

    Cystitis glandularis and cystica usually occurs in chronically irritated bladders such as the non-functional bladder in paraplegics or in patients with long-term catherization, as in our case, or stone. ^{1, 2}

    Von Brunn’s nest refers to nests of transitional cells within the lamina propria of the urinary bladder that arise from invagination of the overlying urothelium.  It is the most common reactive proliferative change within the urothelium and is common enough to be considered a normal feature of the bladder mucosa by some investigators. Cystitis glandularis is a common change that occurs most often in the trigone.  It is an inflammatory process that arises within and merges imperceptibility with von Brunn’s nests. With cystic dilatation of the glands, a progressive flattening of the lining cells occurs, and the lesion takes on the form of cystitis cystica. ^{3, 4} Cystitis glandularis is microscopic or occurs as small mucosal nodules in most occasions but it may occur as polypoid mass that suggests a neoplastic process macroscopically and endoscopically.  

Pathology 

    The typical type of cystitis glandularis contains simple cuboidal to columnar cells. Small amount of mucin may be present but the amount is usually not impressive. The intestinal type contains epithelium with intestinal metaplasia. These type has numerous goblet cells and tubular epithelium that morphologically resemble colonic epithelium and contains colonic type mucin ^{5, 6} . Paneth cells metaplasia can also be seen in this type. Cystitis glandularis is associated with increased risk of adenocarcinoma ^{1, 3, 4, 5, 7, 8}. Patients with extensive and diffuse intestinal metaplasia are particularly prone to develop adenocarcinoma ⁸.