Urology Case Reports 33 (2020) 101283

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Urology Case Reports

journal homepage: http://www.elsevier.com/locate/eucr

Functional medicine

Melanosis of the bladder: A rare diagnosis

Diana M. Lopategui a, Roger C. Griffith b, Janice Santos Cortes c, *
a
Urology Department, Mount Sinai Medical Center, Miami Beach, FL, USA
b
Department of Pathology, Brown University, Lifespan Health System, Providence, RI, USA
c
Urology Department, Brown University, Lifespan Health System, Providence, RI, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Melanosis of the bladder is characterized by dark, velvety bladder mucosa due to melanin deposition. Less than
Bladder melanosis 25 cases have been reported. We present a 45-year-old male undergoing work up for obstructive and storage
Cystoscopy irritative lower urinary tract symptoms, found to have diffuse bladder melanosis on cystoscopy with bladder
Overactive bladder
biopsy, and detrusor overactivity on urodynamic study. Although bladder melanosis has been found before in
conjunction with storage voiding symptoms, this is the first report to our knowledge of an association with
overactive bladder with urodynamic and histologic confirmation.

Introduction and muscular propia. The urothelial cells (Fig. 2) contained intra­
cytoplasmic golden brown granular pigment focally that focally
Melanosis of the bladder is an uncommon condition characterized by involved macrophages of the superficial lamina propria, which was
a dark, velvety aspect of the bladder epithelium due to deposition of congested with focal hemorrhage and focal chronic inflammation. Dif­
melanin within the vesicle urothelium and/or lamina propia in absence ferential diagnosis of the pigment includes hemofuchsin, hemosiderin
of melanocytes. With less than 25 cases reported in the literature, its and melanin. Histochemistry studies were directed by the cystoscopic
clinical significance is currently uncertain.1 We present a case where findings and consisted melanin (Fontana-Mason) and iron (Prussian
bladder melanosis was encountered during the work up of an unusual blue) stains that demonstrated that the pigment represented melanin
case of overactive bladder (OAB) in a 43-year-old man. deposition and not hemosiderin (Fig. 2) - in this circumstance, diag­
nostic of melanosis of the urinary bladder or urinary melanosis, a benign
Case presentation but very rare condition of unknown etiology with melanosis. Evidence of
malignancy was not present.
A 43-year-old male was referred to our clinic for evaluation of uri­ Patient was treated according to symptoms with alfa-blockers and
nary tract symptoms, including both obstructive and storage irritative: anticholinergics. His obstructive symptoms (hesitancy and weak urinary
weak urinary stream and urge incontinence. The patient endorsed stream) resolved on tamsulosin, but his storage symptoms of frequency
symptoms developed after an episode of meningoencephalitis seven and urge incontinence persisted. He failed trials of oxybutynin, tolter­
years prior. Given this prior history and the subject’s young age; deci­ odine and trospium and first line of treatments for OAB.
sion was made to perform a complete evaluation of bladder function Patient denies any exposure to medications, drugs, laxatives or
including a urodynamic study (UDS), and a cystoscopy. Cystoscopy chemotherapy. He endorses no other systemic symptoms. Uptodate he is
showed no evidence of obstruction, but the encountered mucosa had an pending further management treatment upon follow up.
unusual diffuse black, velvety appearance (Fig. 1). Bladder wall biopsies
were taken from the area. UDS demonstrated detrusor overactivity, Discussion
equivocal parameters for bladder outlet obstruction and normal bladder
detrusor contractility. Melanosis is defined as an “excessive pigmentation” of any part of the
Initial pathology report of the bladder biopsy described a 5 x 3 � 3 body due to altered melanin production, usually in reference to skin
mm fragment of tan tissue that consisted of urothelium, lamina propia hyperpigmentation in a variety of conditions. In the bladder, melanin

Abbreviations: urodynamic study, UDS; overactive bladder, OAB.

* Corresponding author. 4302 Alton Road suite 540, Miami Beach, FL, 33137, USA.
E-mail addresses: dlopategui@gmail.com (D.M. Lopategui), rcgriffith@lifespan.org (R.C. Griffith), janice.santoscortes@msmc.com (J. Santos Cortes).

https://doi.org/10.1016/j.eucr.2020.101283
Received 21 April 2020; Received in revised form 27 April 2020; Accepted 29 April 2020
Available online 27 May 2020
2214-4420/© 2020 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
D.M. Lopategui et al. Urology Case Reports 33 (2020) 101283

Fig. 1. Left ureteral orifice on cystoscopy (panel A) and bladder mucosa (panel B).

Fig. 2. Bladder biopsy H&E, 200X (panel A):

golden brown granular pigment is present mostly
in the superficial urothelial but also in deeper cells
and in macrophages in the lamina propria, which is
congested with focal hemorrhage. Bladder biopsy
Fontana-Masson, 200X, (panel B): the pigment is
stained black by the Fontana-Mason stain in the
urothelial and the lamina propria, consistent with
melanin. (For interpretation of the references to
colour in this figure legend, the reader is referred
to the Web version of this article.)

deposition is named bladder melanosis or, alternatively, melanosis characterized by melanin deposits that give the bladder mucosa a dark,
vesicae. It constitutes an extremely rare entity, only described in less velvety appearance. With less than 25 cases reported in the literature, its
than 25 reports in the literature currently available. Bladder melanosis is pathophysiology, as well as clinical significance, are uncertain to this
considered a benign, incidental finding with no known connection to date. It has been documented in a wide range of patients’ age, as well as
malignancy or benign bladder conditions.1 However, clinical signifi­ with a variety of symptoms including dysuria, urinary frequency and
cance cannot be fully determined given the paucity of cases reported and incontinence. We present the first report of UDS-proven detrusor over­
their lack of follow up. Melanosis is otherwise found more often in re­ activity in conjunction with bladder melanosis, in a young man studied
ports from colonoscopies. Melanosis coli has been associated with for neurogenic OAB. Although one case is far from enough to establish
chronic laxative use.2 an association between these entities, it may represent the first evidence
Bladder melanosis has been documented in patients of ages between of an inflammatory mechanism leading to bladder melanosis.
43 and 90 with no gender preference, and in association with a number
of different symptoms including dysuria, urinary frequency, hematuria, Funding
incontinence and retention. It has also been reported preceding or syn­
chronous with urothelial carcinoma and with bladder melanoma; this This research did not receive any specific grant from funding
last condition constituting the most important differential diagnosis agencies in the public, commercial, or not-for profit sectors.
from the pathological analysis standpoint to determine treatment.1 This
present case constitutes the first report, to our knowledge, of bladder Declaration of competing interest
melanosis in conjunction with UDS-demonstrated diagnosis of detrusor
overactivity. Characteristic histology findings of neurogenic OAB such We declare no conflict of interest.
as congestion and chronic inflammation3 were present in this patient’s
bladder biopsy in addition to the golden brown granular deposits of References
melanin, present mostly in the superficial urothelium but also in deeper
cells and in macrophages in the lamina propria (Fig. 2). Needless to say, 1. Yau SE, Singer EJ, Sun Y, Johnson ME. Bladder melanosis with concurrent urothelial
carcinoma. Urol Case Rep. 2017 Nov;15:30–32.
one case report is insufficient to show any association between mela­ 2. Liu ZH, Foo DCC, Law WL, Chan FSY, Fan JKM, Peng JS. Melanosis coli: harmless
nosis and OAB. But it certainly does make it a possibility, and may pigmentation? A case-control retrospective study of 657 cases. PloS One. 2017. Oct
potentially constitute the first evidence towards the elucidation of the 31;(10):12.
3. Comp� erat E, Reitz A, Delcourt A, Capron F, Denys P, Chartier-Kastler E. Histologic
pathogenic pathway leading to bladder melanosis, perhaps entailing features in the urinary bladder wall affected from neurogenic overactivity–a
inflammatory and immunologic mechanisms certainly involved in the comparison of inflammation, oedema and fibrosis with and without injection of
changes seen in OAB. botulinum toxin type A. Eur Urol. 2006 Nov;50(5):1058–1064.

Conclusion

Bladder melanosis is a benign, extremely rare condition,