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Malacoplakia of the urinary tract

Malacoplakia of the urinary system is the commonest manifestation of malakoplakia. The latter, meaning soft plaque, is a rare chronic granulomatous condition that can affect any organ.

Epidemiology

Malacoplakia has a peak incidence in middle age, and has a female-to-male ratio of 4:1 1. The disease is more common in patients who are immunocompromised or those with diabetes mellitus. 

Clinical presentation

Presenting symptoms include gross hematuria and signs of urinary tract infection, with Escherichia coli infection being very commonly found to coexist.  

Pathology

Although infection with E. Coli is very commonly observed, and it is thought to play a part in the pathogenesis of malacoplakia, other factors are also suspected, particularly impaired host defenses and defective phagocytosis 1.

The histologic hallmark of the disorder is the presence of basophilic inclusions, caIled Michaelis-Gutmann bodies in large eosinophilic macrophage2.

Location

Within the urinary tract, the bladder is the most frequently affected organ (40% of patients with malacoplakia)

Radiographic features

Imaging characteristics of malacoplakia are varied, and most commonly observed within the bladder, although plaques may also occur in the ureters.

Malacoplakia may present as multiple, polypoid, vascular, solid masses or as circumferential wall thickening, associated with vesicoureteral reflux and dilatation of the upper urinary tract. These masses vary in size from a few millimeters to several centimeters. 

Treatment and prognosis

Although malacoplakia may be extremely aggressive, invading the perivesical space, and it can even cause bone destruction, non-surgical medical management is the mainstay of treatment, and as such biopsy for accurate diagnosis is essential. 

Treatment regimens include antibiotics, ascorbic acid, and a cholinergic agonist 1.

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