Ureteritis refers to inflammation of the ureters , the muscular tubes connecting the kidneys to the bladder.
It is rare and usually occurs in association with:
- Cystitis (bladder infection)
- Pyelonephritis (renal infection)
Classification of Ureteritis
Ureteritis can be subdivided based on etiologic factors into:
1. Infective Ureteritis
- Most common cause
- Associated with ascending urinary tract infections
- Pathogens:
- Escherichia coli
- Klebsiella spp.
- Proteus mirabilis
- Aerobacter aerogenes
2. Postoperative Ureteritis
- Due to manipulation, instrumentation, or surgical trauma (e.g. ureteric stents)
3. Noninfective Ureteritis
Includes rare, immune-mediated, or idiopathic causes:
- Ureteral amyloidosis
- Eosinophilic ureteritis
- IgG4-related ureteritis
- Idiopathic segmental ureteritis
- Ureteritis cystica
Ureteritis Cystica (UC)
Definition
A rare, benign condition characterized by:
- Cystic metaplasia of Brunn's epithelial nests in the urothelium
- Presence of numerous subepithelial cysts (1–10 mm), filled with clear fluid and lined by flattened epithelium
- Often found incidentally on imaging
Etiology and Risk Factors
- Chronic urothelial irritation (recurrent UTIs, long-term catheterization, urolithiasis)
- Vitamin A excess
- Immunoglobulin A overproduction
- Typically affects adult females
- When affecting the bladder , it is termed cystitis cystica
Pathophysiology
- Chronic inflammation leads to proliferation of epithelial nests (Brunn’s nests)
- These undergo cystic transformation , forming mucin-filled cysts beneath the urothelial lining
- May be due to:
- Persistent infection
- Foreign body (e.g., stents)
- Chemical irritants
- Autoimmune conditions
Clinical Features
- Symptoms overlap with UTIs or pyelonephritis :
- Flank or suprapubic pain
- Dysuria
- Hematuria
- Fever
- Elevated white cell count
- Ureteritis cystica may be asymptomatic , detected incidentally during:
- Evaluation for UTIs (82%)
- Renal stones (53%)
- Hematuria
Imaging and Diagnosis
Laboratory Findings
- Leukocytosis
- Positive urine cultures if infection present
Imaging
- CT Urography :
- Shows circumferential wall thickening
- Periureteric fat stranding (if active inflammation)
- Excretory urography / Retrograde pyelography :
- Multiple smooth, round filling defects
- "Scalloping" of ureteral wall
- Ureteroscopy :
- Enables direct visualization
- Biopsy for histopathology (confirm diagnosis, rule out malignancy)
Treatment
General Approach
- Treat underlying cause :
- Antibiotics for infection
- Stone removal or management of obstructive uropathy
- Removal of foreign bodies (e.g., stents) if implicated
- In rare cases:
- Surgical resection of affected ureteral segment (e.g., in IgG4-related ureteritis or segmental obstruction)
- Immunosuppressive therapy for autoimmune-associated ureteritis
High-Yield Summary for Exams
| Feature | Ureteritis | Ureteritis Cystica |
|---|---|---|
| Etiology | Infection, stents, autoimmune, idiopathic | Chronic irritation, often idiopathic |
| Symptoms | Dysuria, hematuria, fever, flank pain | Often asymptomatic |
| Imaging | Wall thickening, fat stranding | Multiple smooth filling defects, scalloping |
| Diagnosis | Imaging + ureteroscopy + histology | Imaging + ureteroscopy biopsy |
| Treatment | Etiologic management | Usually conservative unless symptomatic |
