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JU INSIGHT: Bladder Mucosal Cystitis Cystica Correlates With Recurrent UTI in Postmenopausal Women
By: Marianne M. Ligon, MD, PhD, Washington University School of Medicine, St Louis, Missouri; Brooke Liang, MD, MA, Washington University School of Medicine, St Louis, Missouri; Stacy M. Lenger, MD, MSCI, University of Louisville School of Medicine, Kentucky; Priyanka Parameswaran, MD, Washington University School of Medicine, St Louis, Missouri; Siobhan Sutcliffe, PhD, Washington University School of Medicine, St Louis, Missouri; Jerry L. Lowder, MD, MSCI, Washington University School of Medicine, St Louis, Missouri; Indira U. Mysorekar, PhD, Washington University School of Medicine, St Louis, Missouri, Baylor College of Medicine, Houston, Texas | Posted on: 18 May 2023
Ligon MM, Liang B, Lenger SM, et al. Bladder mucosal cystitis cystica correlates with recurrent UTI in postmenopausal women. J Urol. 2023;209(5):928-936.
Study Need and Importance
Postmenopausal women are particularly susceptible to recurrent urinary tract infections (rUTIs). There remains a great need to understand the clinical factors that drive the increase in susceptibility and frequency of rUTIs in this population, and we sought to identify potential pathological correlates. Previous work had identified that aged female mouse bladders develop lymphoid aggregates, and we systematically defined these structures as bladder tertiary lymphoid tissue (bTLT). bTLT formed with increasing age and following reproductive senescence, formed bona fide germinal centers, and was associated with a significant increase in rUTIs.
What We Found
Bladders of postmenopausal women harbor inflammatory lesions evident as cystitis cystica (CC) on cystoscopy that were structurally bTLT in form and composition and that are better described in pathologic terms as follicular cystitis (see Figure). To further understand the relationship between CC and rUTIs, we performed a retrospective and observational analysis of a cohort of 138 women with culture-proven rUTIs and who underwent cystoscopy. Our study showed that approximately 40% of women had bTLT/CC lesions and were significantly more likely to have multiple rUTIs in a given year. Furthermore, the presence of these lesions was strongly associated with a shorter time to next urinary tract infection (UTI). Tertiary lymphoid tissue in postmenopausal bladders have been shown to be associated with co-localization of Escherichia coli species. The presence of tertiary lymphoid tissues may potentiate overexuberant or ineffective immune responses that promote inflammation rather than resolution of UTIs. We could demonstrate that a multimodal regimen of therapy, which was successful in limiting UTIs, showed regression of bTLT lesions upon repeat cystoscopy.
Limitations
Limitations of this study were the overall small sample size of women and a lack of standardized methods to cystoscopically assess the severity of CC. Developing a validated severity scale would improve CC lesion monitoring over time.
Interpretation of Patient Care
We suggest that identifying CC in patients with rUTI may be useful in stratifying future UTI risk and tailoring appropriate treatment strategies.
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