Incidental findings on cystoscopy, a video tutorial. This video will demonstrate three classes of incidental findings on cystoscopy that the gynecologist might find useful. These three classes are benign pathology, malignant pathology, and foreign body pathology. All of the following findings should be evaluated by a urologist unless otherwise noted. Step one, benign pathology. Squamous metaplasia. This might be one of the most common findings encountered on female cystoscopy, here seen on the trigone between the ureteral orifices. This is normal in women and there is no risk for carcinoma. It does not need further evaluation. Duplicated ureteral orifice. This is a congenital anomaly usually caused when the ureteral bud splits twice. This typically is only unilateral. This left-sided duplication demonstrates ureteral jets of urine out of both orifices. Ureteroseal. This is another congenital anomaly of the ureter. This intravesical ureteroseal has a stenotic opening causing it to balloon. Hutch diverticulum. This congenital diverticulum is found lateral to the ureteral orifice and is caused by a congenitally deficient bladder wall. Here you can see the left-sided ureteral orifice with a large lateral diverticulum. Bladder diverticuli and trabeculation. Bladder trabeculation is caused by diffuse hypertrophied muscle bundles in the bladder wall. A bladder diverticulum is shown here on the lateral wall. Uricle cyst. This cyst at the dome of the bladder occurs in the remnant urecus between the umbilicus and the bladder. It is typically asymptomatic but can develop infections, abscess, intermittent drainage into the umbilicus or adenocarcinoma. Interstitial cystitis with post-hydrodistension glomerulizations. This patient is undergoing hydrodistension of the bladder at 80 cm of water pressure under anesthesia. The bladder looked perfectly normal prior to filling. The pinpoint petechial hemorrhages that develop throughout the bladder after drainage and reinspection are known as glomerulizations. Glomerulizations are not specific for interstitial cystitis but are only considered significant if seen in conjunction with diagnostic symptoms. Interstitial cystitis with Hunter's lesion. While these are frequently referred to as Hunter's ulcer, they're not actually an ulcer but a mucosal lesion found in some forms of interstitial cystitis. This well-defined erythematous lesion located on the left lateral bladder wall has a white eschar in the middle. Severe interstitial cystitis, biopsy proven. This bladder mucosa demonstrates patchy erythematous areas concerning for malignancy. Biopsy multiple times demonstrated inflammation without malignancy and the patient's symptoms consistent with interstitial cystitis have responded well to bladder installation therapy. Endometriosis in the bladder. Ectopic endometrial tissue can be found outside the uterus but is rarely found in the bladder. This patient had a prior hysterectomy for endometriosis. A cystoscopy was performed for chronic pelvic pain and presumed interstitial cystitis. An MRI demonstrated the endometrioma was invading into the bladder and required a partial cystectomy for therapy. Port wine stain. This is caused by a capillary malformation typically found in the skin but can be encountered in the bladder. This patient had a known disorder, Klippel-Trenoune-Weber syndrome, so this abnormality in the bladder was not biopsied. She was asymptomatic and cross-sectional imaging confirmed the vascular malformation continued external to the bladder. Nephrogenic metaplasia. This polypoid papillary lesion is found throughout the bladder. This is an extremely severe case of nephrogenic, otherwise known as mesonephric, metaplasia. These papillary and cystic structures are composed of small, hollow tubules. It is a rare finding and the etiology is unclear, but most patients present with lower urinary tract symptoms. Cystitis glandularis. These polypoid lesions are within the submucosa and can have goblet cells that produce mucin like colonic epithelium. Part 2, malignant pathology. Papillary urophelial neoplasm of low malignant potential. This lesion, known as a pun lump, is an exophytic pre-malignant lesion. Here you can see the delicate, slender, fibrovascular cores of each stalk with very few branches. High-grade superficial urophelial cancer. This is also an exophytic lesion, but it is a non-invasive papillary carcinoma. It's more complex appearing with more branching. Carcinoma in situ. This lesion on the posterior and lateral walls is a superficial, high-grade urophelial cancer. CIS is often described as a red velvety lesion and is very subtle. Only with biopsy can malignancy and stage be determined. This video clip demonstrates a more severe example of carcinoma in situ with active bleeding at the dome of the bladder from the CIS lesions and there is evidence of prior biopsy scars on the right lateral wall. High-grade urophelial carcinoma. These are examples of larger papillary urophelial cancers. These lesions are high-grade and require transurethral resection for accurate staging. Some of these long-standing lesions are encrusted with stones. Uracle adenocarcinoma. The uracle cyst seen previously in this video can sometimes have an epithelium-lined lumen. This uncommonly gives rise to a uracle adenocarcinoma, which can be very aggressive. This lesion at the dome of the bladder was confirmed to be a uracle adenocarcinoma. Part 3, foreign body pathology. Edema from ureteral stents. Edema commonly develops from ureteral stents of even a short duration and do not require biopsy. This will resolve with removal of the stent. Stone-encrusted mesh. Mesh in the lumen of the bladder can be asymptomatic and incidentally discovered. With time, these become encrusted with stones. These video clips demonstrate various types of mesh encountered in different locations in the bladder. In summary, many incidental pathologies can be encountered on routine cystoscopy. Most patients will be asymptomatic or have only nonspecific complaints. Hand cystoscopy of the bladder is critical when documenting the bladder has been evaluated. Finally, many pathologies can be biopsied or treated immediately during the procedure. Therefore, early urology consultation for any abnormalities is encouraged.

Incidental Findings on Cystoscopy

benign pathology

malignant pathology

foreign body pathology

urology consultation