Malakoplakia Causing Poor Bladder Compliance and Bilateral Hydroureteronephrosis

An 81-year-old female presented with lower urinary tract symptoms (LUTS) including frequency, urgency and urge incontinence. She had a 2-year history of recurrent urinary tract infections (UTI) with Escherichia coli of varying susceptibility. Background history included rheumatoid arthritis treated with long-term corticosteroids, and stage-4 chronic kidney disease due to hypertensive nephrosclerosis.

Non-contrast CT imaging showed severe bilateral hydroureteronephrosis to the level of the vesicoureteric junction and circumferential bladder wall thickening. The patient had a creatinine level of 221 μmol/L and eGFR rate of 18mL/min/1.73m2. Cystoscopy revealed diffuse erythema and white-yellow nodules (Figure 1). Histopathological examination of bladder biopsies demonstrated numerous Michaelis-Gutmann bodies, pathognomic for the rare chronic inflammatory condition malakoplakia (Figure 2) [1,2,3,4,5]. There was no evidence of dysplasia or malignancy. Urodynamic assessment revealed increased bladder sensation and poor bladder compliance with impaired detrusor contractility.

Malakoplakia is usually associated with recurrent UTI, particularly Escherichia coli, Staphylococcus aureus, Proteus, and Klebsiella [4]. The patient was commenced on trimethoprim/sulfamethoxazole 150/100mg daily prophylaxis, which was switched to cephalexin 500mg daily prophylaxis due to poor tolerance. She was also commenced on methenamine hippurate, supplemental vitamin C, and completed a course of Uromune for UTI prophylaxis.

The nodules had largely resolved on progress cystoscopy four months later. At this time, she was treated with intravesical antibiotic wash using gentamicin 480mg diluted in 1L 0.9% sodium chloride.

This case demonstrates that malakoplakia can cause obstructive uropathy. It serves as a reminder to consider malakoplakia as a differential, particularly in women with recurrent UTI and immunosuppression.