Malacoplakia is one of the rare bladder and urinary tract disorders that can occur at other sites. It is diagnosed by laboratory tests and various imaging techniques. It can usually be treated with medication, which is why surgical measures are rarely required.
What is malacoplakia?
Malakoplakia is a chronic urinary tract inflammation of the gastrointestinal tract and other organ systems such as the kidney, ureter, and gastrointestinal tract. In addition, malacoplakia may also affect the lungs, throat, tongue, genital tract, skin, and central nervous system. Cystoscopically, there are multiple flat protrusions of the mucosa, some of which present as raised, whitish-gray, and plaque-like. Macroscopically, the mucosa presents as described cystoscopically, possibly with a hemorrhagic rim. Due to scarring processes, the lesion may solidify over time. Although the urinary bladder of the woman is most frequently affected, other urinary tract organs may also become diseased from the beginning or in the course of the disease. It is not uncommon for there to be an immune deficiency, an immunodeficiency or a tumor. Mostly affected are people over the age of 50 with a chronic E. coli infection. Women are four times more likely to develop the disease than men. The prognosis in cases of malacoplakia of the urinary bladder or unilateral involvement of the kidney is good after adequate therapy. However, if bilateral renal involvement is present, mortality within six months is high.
Causes
One cause of malocoplakia is nonintact intraphagosomal bacterial decomposition of macrophages triggered in association with chronic bacterial infection. The nidus for the formation of intracellular Michaelis-Gutmann bodies is the undegraded remnants of bacterial settlement. Risk factors include chronic urinary tract infections with E. coli (in 90 percent of cases), immunodeficiency or malignant disease, or other systemic diseases with debilitating effects. A defect in the monocytes or macrophages must also be considered as a possible cause. Here, the monocytes circulating in the bloodstream are responsible for the formation of macrophages. After their transformation into large and mobile cells, these macrophages belong to the cellular immune system. There, they absorb pathogens and bacteria, digest them and render them harmless in this way. This is why macrophages are also called phagocytes. If this defense process is disturbed, the macrophages take up the bacteria, but only incompletely digested. The improperly digested bacteria accumulate. The result is a granulomatous cellular accumulation in response to the immune cells.
Symptoms, complaints, and signs
If the urinary tract is affected by malakoplakia, this is manifested by chronic urinary tract infections, an increased urge to urinate but also red blood cells in the urine, which is called hematuria. If the intestine is affected, symptoms include constant or recurrent diarrhea, abdominal pain, and a feeling of fullness. Vaginal bleeding clearly indicates genital tract disease. Papules, itchy skin rashes but also ulcers in the abdominal area or in the face or anal region indicate that the skin is affected by malacoplakia. Non-specific symptoms include pain and fever. It is quite possible that malakoplakia is associated with granulomatous diseases such as tuberculosis or carcinomas, for example, prostate carcinoma.
Diagnosis and course of the disease
At the beginning, there is a medical history with questions about current symptoms and problems. This is followed by localization and determination of when, how often, and in what intensity they occur. This differential diagnosis forms the basis for the subsequent examinations and therapies. Laboratory diagnostics are performed by means of a urine culture and a blood culture to determine the laboratory values. This is followed by radiological diagnostics with a sonography and a CT of the abdomen. During the urogram, also called urography, an X-ray contrast image is obtained. The imaging findings of early urography after a few minutes of contrast injection are compared to late urography within 24 hours.Kidney dysfunction, excretory obstruction, but also obstruction of the urinary tract can be detected. During urothomography excretory urography, slice images are taken (approximately five to ten minutes p.i.). A late urogram may be attached. Infusion urography is used to visualize the urinary tract after intravenous administration of a large quantity of contrast medium. This examination can also be performed in cases of renal insufficiency as well as in cases of insufficient preparation. The imaging has a high intensity. in a CT abdomen, images of the abdomen are obtained slice by slice. This makes it possible to assess not only the shape and location, but also the condition of tissues and organs. Pathological changes and tissue alterations can be assessed directly. Endoscopy is often the method of choice for reliable diagnosis. For the examination of the urinary bladder, in men including the urethra, it is a cytoscopy with the cytoscope, also called urethrocystoscopy. For this examination, the pale is filled with a sterile liquid. With the small camera on the cytoscope, the doctor can view and diagnose the urinary bladder as if under a magnifying glass. The yellowish-white nodules and plaque deposits on the tissue can thus be clearly detected. The final certainty can be achieved with histological findings. Detectable lesions and other changes are subjected to tissue sampling (biopsy) for this purpose. Histology shows large histiocytes, so-called Hansemann cells, but also small basophilic as well as intracytoplasmic inclusion bodies (Michaelis-Gutmann bodies) from an extracellular matrix, which are pathognomonic. If the urinary bladder is affected, dysuria must be clarified as well as pollakiuria and hematuria. Urinary stasis kidney and renal involvement with radiological signs of space-occupying lesions must also be clarified, as they may be in close consensus. In men, the testis should be included in the investigations.
Complications
As a result of malacoplakia, affected individuals suffer from discomfort, mainly of the bladder or urinary tract. These complaints not infrequently affect the patient’s psyche as well, resulting in psychological discomfort or depression. Furthermore, patients suffer from abdominal pain and a feeling of fullness. Women may be affected by unexpected vaginal bleeding and mood swings. Similarly, rashes and itching occur on the skin, so that the quality of life of the affected person is significantly reduced by malacoplakia. Ulcers can form in the abdominal area, leading to pain. It is not uncommon for the patient to experience fever and general fatigue. In many cases, various cancers develop, which in the worst case can lead to the death of the patient. In this case, the life expectancy of the patient is also significantly reduced. Treatment of malacoplakia is carried out with the help of medications. Complications usually do not occur, but not all symptoms can always be completely limited. In the worst case, affected individuals suffer renal insufficiency and die from the symptoms of malacoplakia.
When should you see a doctor?
If the affected person repeatedly suffers from a urinary tract infection, this should be discussed with the attending physician. If there is persistent pain or disturbances during urination, a visit to the doctor is necessary so that the cause of the complaints can be determined. An urge to urinate that recurs shortly after a successful visit to the toilet is an indication of an existing irregularity in the organism. If this complaint persists for several weeks or days, a doctor should be consulted. In case of digestive disorders, bowel sounds or diarrhea, medical care by a doctor is necessary. If there is an inner restlessness, an increasing irritability, if the performance of the affected person decreases or if there is an increased need for sleep, a doctor should be consulted. If there are changes in the skin’s appearance, further medical tests are needed to determine the cause. If a rash appears or if there is itching of the skin, the abnormalities should be evaluated by a physician. In the case of open wounds, sterile wound care is necessary so that no further illnesses or complications develop.If blood is noticed in the urine or if vaginal bleeding occurs that is not related to female menstruation, a visit to the doctor should be made as soon as possible.
Treatment and therapy
Medication is long-term antibiosis with fluoroquinolones (gyrase inhibitors). Known are cotrimocazole, rifampicin, sulfanamides and dozycycline, respectively. So far, however, there is no uniform duration of treatment, so that long-term therapy is usually assumed. In rare cases, surgical remediation by resection or ureteral splinting (nephrectomy) is necessary. For example, surgical resection is required for pseudotumorous stages of development. Nephrectomy or partial nephrectomy is often followed by long-term chemotherapy with, for example, trimethoprim-sulfamethoxazole. In any case, the decision should be made depending on the symptoms and organ function. The prognosis is now positive. However, renal failure may occur after completed treatment of urinary tract involvement or urinary tract disease due to recurrence.
Outlook and prognosis
Chronic inflammation of the urinary tract has a good prognosis if the affected person seeks the cooperation of a physician. In most cases, long-term therapy is needed so that significant relief of symptoms can occur and recovery can be achieved if the course is favorable. The administration of medication is necessary so that the organism is sufficiently strengthened in the healing process. Without medication, the symptoms will normally persist permanently for a long time. In addition, the risk of secondary diseases is increased. The impairments usually spread to other physical areas or affect the stability of the psyche. This can lead to the development of additional diseases in the further course of the disease. For a good prognosis, it has been shown that, in addition to drug treatment, a significant improvement in the situation was achieved if psychotherapeutic support was also provided. States of emotional and mental stress have a considerable share in physical irregularities. Especially in the case of chronic underlying diseases, this circumstance should be taken into account in medical care. Improvements are seen in a large number of cases as soon as the affected person eliminates existing stressors of everyday life, processes experienced events and cognitive restructuring takes place. In addition, for many patients, improvement in lifestyle contributes significantly to a good prognosis.
Prevention
To date, neither classical orthodox medicine nor homeopathic naturopathy has known ways to prevent malacoplakia. In order for this disease to be detected in its early stages, a urological examination should be performed at least once a year. If symptoms occur, a direct examination by the urologist is advisable. In the early stages, drug treatment as described here is almost always sufficient.
Follow-up care
Because treatment of malacoplakia is relatively complex and lengthy, follow-up care focuses on safe management of the condition. Affected individuals should try to focus on a positive healing process despite the adversity. To build the appropriate mindset, relaxation exercises and meditation can help calm and focus the mind. This is fundamental to recovery. Due to malacoplakia, sufferers primarily suffer from severe diarrhea, abdominal pain and bloating. Due to the constant diarrhea, dehydration also occurs, so the general condition of the affected person deteriorates. In women, the disease can cause bleeding in the vaginal area. Many patients struggle with inferiority complexes as they are ashamed of the symptoms. If this is reflected in serious depression and other psychological distress, consulting a psychologist may be helpful to clarify the extent to which therapy is appropriate.
Here’s what you can do yourself
Malacoplakia must be evaluated and treated by a physician. Accompanying long-term antibiotics, the patient should take it easy. The most important measure is to support the function of the urinary tract by sufficient fluid intake.The diet should not include foods that could stress the bladder and urinary tract. For example, foods containing citrus, lemon juices and alcoholic beverages should be avoided. Antibiotic treatment can be supported by bed rest and later by gentle exercise. The intimate area must be kept warm to prevent further urinary tract disease. Depending on the symptoms present and how much the organ function is impaired, homeopathic treatment may be useful. Effective are, for example, belladonna and arnica as well as globules from the active ingredients of devil’s claw. To avoid interactions with the antibiotics taken, an alternative treatment should be discussed with the responsible physician beforehand. After the therapy has been completed, the patient must have regular control examinations. Only close monitoring can detect a new outbreak at an early stage. If the typical symptoms occur, immediate clarification by the urologist is indicated.
