Chronic cystitis can present variably with common appearances including cystitis cystica or follicularis. Over the years, we have observed and reported on a different appearance of cystitis, termed vesicular cystitis [1]. This is a rather uncommon form of chronic cystitis identified by the recognition of tiny clear vesicles spread diffusely over the bladder wall surface in some women suffering from recurrent urinary tract infections (RUTIs).

This video demonstrates the typical cystoscopic appearance of these vesicular lesions commonly observed on the floor of the bladder including the trigone and also very anteriorly (fig 1), near the bladder neck area.  The vesicles are many, small, mostly clear but sometime pus-filled, in fields next to each other, and without mucosal reaction of redness or inflammation when compared to the more common cystitis cystica, although they can co-exist as shown. During fulguration with a bugbee electrode on a low setting of 20 or even 25, these lesions blanch out but do not shrink or go away. In several instances, it is clear that they are deeply rooted and have spread out underneath the urothelial surface, confirming they are well embedded in the tissues. A roller ball has been used at times when there is a myriad of them over a large field since fulgurating them one by one is too tedious. During routine biopsy, the vesicles tend to collapse and cannot be retrieved for study.

In a recent report of 18 RUTI women treated with electrofulguration in the absence of durable response to oral or intravenous antibiotics [1], we observed a reduction in the rate of subsequent infections in some; but in others, new lesions interspersed with healed areas of prior fulguration were noted prompting repeat fulguration; and in a few cases, frank RUTI progression with repeated urosepsis and only 1-2 IV antibiotics available due to near complete antibiotic resistance led to a robotic cystectomy/urinary diversion.

Vesicular cystitis is a fairly uncommon form of chronic cystitis recently recognized. The tiny vesicles are spread out over large surfaces of the bladder wall, often located anteriorly and sometimes interspersed with cystitis cystica. This phenotype remains unelucidated at present. However, in our limited experience, this finding portends a fairly poor outcome, with frequent UTI recurrences and a limited level of success even with extensive fulguration of the involved areas.

Vesicular cystitis remains an enigma in terms of development, progression and appearance of these clear vesicles predominantly situated on the bladder base and anterior bladder wall. In our limited experience, the management of this form of chronic cystitis has been very challenging, routinely defying antibiotic therapies and even fulguration procedures at times.

Crivelli and Zimmern Urol Int 105:131, 2021