What is the recommended treatment for a 33-year-old African-American male with cystitis glandularis and hematuria?

Management of Cystitis Glandularis with Hematuria

For a 33-year-old African-American male with cystitis glandularis and hematuria, the recommended initial treatment is transurethral resection of the affected bladder tissue, followed by symptomatic management with bladder irritation-relieving medications such as anticholinergics and non-steroidal anti-inflammatory drugs.

Initial Evaluation and Management

1. Urine Culture: First perform a urine culture to exclude hemorrhagic cystitis or infection as a cause of hematuria 1, 2

   • If positive culture: Treat with appropriate antibiotics based on sensitivity
   • If negative culture: Proceed with further evaluation

2. Cystoscopic Evaluation:

   • Assess extent of cystitis glandularis
   • Evaluate for presence of bladder tumor
   • Take mapping biopsies if needed to rule out carcinoma in situ or other malignancy 1

Treatment Algorithm

First-Line Treatment:

1. Transurethral Resection (TURBT) of affected bladder tissue 3, 4

   • Provides both diagnostic confirmation and therapeutic benefit
   • Allows for histopathological examination to rule out malignancy
   • Immediately improves symptoms in many patients

2. Symptomatic Management for mild symptoms 1:

   • Bladder irritation-relieving drugs (e.g., phenazopyridine)
   • Anticholinergics for frequency/urgency
   • Non-steroidal anti-inflammatory drugs for pain and inflammation

For Persistent Hematuria:

1. If macro-hematuria occurs 1:

   • Consider indwelling catheter with continuous bladder irrigation
   • Perform endoscopic hemostasis if necessary

2. For persistent symptoms after initial treatment:

   • Consider intravesical instillation therapy with:
     • Mitomycin C 5
     • Hyaluronic acid 6

For Refractory Cases:

1. Consider steroid therapy for intractable cases 5, 4

   • Oral steroids have shown dramatic improvement in resistant cases
   • Typically administered for 3-6 months
   • Monitor for steroid-related side effects

2. COX-2 inhibitors may be beneficial in combination with other therapies 4

3. For severe cases with extensive involvement:

   • Consider partial cystectomy if localized 5
   • In extreme cases, radical cystectomy may be necessary if symptoms are debilitating and other treatments have failed

Follow-up Protocol

1. Short-term follow-up (4-6 weeks after treatment):

   • Assess symptom improvement
   • Repeat urine culture if symptoms persist
   • Cystoscopy to evaluate treatment response

2. Long-term surveillance:

   • Cystoscopy every 3-6 months for the first year, then annually 1
   • Imaging of the upper tract collecting system every 1-2 years 1
   • Monitor for recurrence of symptoms

Important Considerations

• Premalignant potential: While controversial, some consider cystitis glandularis a premalignant condition, necessitating regular follow-up 3

• Differential diagnosis: Rule out bladder cancer, especially in patients with risk factors

• Recurrence risk: Cystitis glandularis may recur, requiring repeated treatments

• Quality of life impact: Address urinary symptoms aggressively as they significantly impact quality of life

Common Pitfalls to Avoid

1. Misdiagnosis as simple UTI: Cystitis glandularis may be initially misdiagnosed as recurrent UTI, delaying proper treatment

2. Inadequate resection: Incomplete TURBT may lead to rapid symptom recurrence

3. Overlooking upper tract evaluation: Always assess for upper tract involvement, especially with persistent symptoms

4. Delayed follow-up: Regular surveillance is essential to monitor for recurrence or progression

By following this structured approach to management, the patient's hematuria and associated symptoms can be effectively controlled while monitoring for any potential progression of the condition.