Pseudomembranous trigonitis of the bladder: hormonal aetiology.

Abstract

SUMMARY Fourteen formalin fixed and paraffin wax embedded biopsy specimens from 10 women (age range 34-68) presenting with pseudomembranous trigonitis were studied using a combination of anti-oestrogen receptor monoclonal antibodies in an avidin-biotin immunoperoxidase technique. All epithelial areas showing vaginal metaplasia exhibited staining confined to the nucleus in the basal and parabasal layers of the squamous epithelium while no staining was encountered in adjacent trigonal transitional epithelium included in nine of the biopsy specimens.The selective expression of nuclear oestrogen receptor in trigonal epithelium affected by vaginal metaplasia in a distribution similar to that reported in vaginal epithelium by other workers lends further support to oestrogen mediated aetiology in this condition and is consistent with an embryological derivation of the trigone, distinct from that of the rest of the bladder.Pseudomembranous trigonitis, a recognised cause of the "urethral syndrome", is characterised by urgency and frequency of micturation. A characteristic lesion of the bladder trigone is seen on cytoscopy. Biopsy specimens show squamous metaplasia of the trigonal epithelium closely resembling vaginal squamous epithelium. The epithelial cells are vacuolated and contain abundant glycogen, while the lamina propria shows noticeable venous dilatation associated with oedema. ' Originally described by Heymann as "trigonal cystitis",2 the lesion has since been termed pseudomembranous trigonitis, granular trigonitis, urethrotrigonitis, and squamous or vaginal metaplasia of the trigonal epithelium. The lesion is almost exclusively found in women, although in one study of 31 cases' three were in men, one ofwhom was receiving oestrogen for carcinoma of the prostate.While some reports have considered vaginal metaplasia of the trigone to be an adaptive response to inflammation of the bladder,315 other studies have suggested that it develops under the hormonal influence of oestrogens.6' In particular, Tyler correlated variations in the histological appearance of the vaginal metaplasia with phases of the menstrual cycle.8 Although no study ofthe presence of oestrogen receptor has been reported in pseudomembranous

The Sex Hormone Receptors in the Bladder in Childhood - I: Preliminary Report in Male Subjects

“…In the examined full-size biopsies the receptors could not be demonstrated in the subepithelial and deeper tissues of the bladder. These findings suggest that the receptors are mainly localised in transitional epithelium as proposed in previous studies (4,14,15,17). Original Article…”

Is trigonitis a neglected, imprecise, misunderstood, or forgotten diagnosis?

“…Because the trigone has a separate embryologic origin from the rest of the bladder, it is possible that the trigonal urothelium responds preferentially to estrogen stimulation . Stephenson et al obtained bladder samples from 10 women (age range 34‐68 years) presenting with pseudomembranous trigonitis and reported on the selective expression of nuclear estrogen receptor (ER) in the trigonal epithelium in a distribution pattern similar to that reported for the vaginal epithelium. This distinct finding from the rest of the bladder lends credence to the selective effect of estrogen mediated‐changes in the trigone …”

“…This distinct finding from the rest of the bladder lends credence to the selective effect of estrogen mediated-changes in the trigone. 15 Pacchioni et al 8 studied the presence of ERs and progesterone receptors (PRs) using immunohistochemistry in the normal urinary bladder of 14 women, as well as in 15 women with trigonitis (recurrent non-bacterial cystitis and histologically confirmed trigonitis). All women underwent two biopsies from the trigone and lateral bladder wall.…”

Cellular basis of urothelial squamous metaplasia

“…(6) It is well known that the trigone area of the normal human female bladder tends to undergo squamous metaplasia with histological features that are somewhat similar to vaginal epithelium (vaginal metaplasia; Long and Shepherd, 1983 ; Shirai et al, 1987 ). Stephenson et al (1989) reported that the basal and suprabasal cells of such metaplastic epithelial cells express nuclear estrogen receptor and, thus, are distinct from the neighboring normal trigonal urothelial cells. Although these results are said to support the notion that trigone epithelium is embryologically distinct from the urothelial lining of the rest of the bladder, we believe that this reflects the propensity of the proximal urethra–derived urothelial cells to invade the trigone region—a process frequently associated with chronic inflammation ( Ito et al, 1981 ; Long and Shepherd, 1983 ).…”