Date post: | 07-May-2015 |
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Health & Medicine |
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The Vanishing Bladder Mass
History • Mr ASK• 60yrs old male• Was referred from BARC hospital at midnight with
h/o-1) Acute retention of urine since one day2) Gross hematuria 4-6 hours post foleys
catheterisation (this was after draining initial 300-400 ml of clear urine)3) Disorientation
No history of –• Traumatic catheterisation• Bleeding diasthesis • Lump in abdomen
Relatives on enquiry revealed 1 week history of • Dysuria• Oliguria • Mod grade fever with chills• Poor oral intake
• Past history- - H/o recurrent urinary tract infection
- Features of LUTS
- Had retention of urine twice in 6 months requiring catheterisation.
- Coronary artery disease, systemic hypertension, old stoke
- No h/o of past kidney disease
- Was on dual antiplatelets , antihypertensives and statins
On examination• Tachycardia- 120/min• BP- 100/70• Gross pallor, dehydrationCNS- Disoriented, irrelevant talks No focal neurological deficit No s/o meningeal irritationPer Abdomen- Bladder palpable upto umbillicus. No separate mass felt.
Investigation
• Hb- 7.1 gm% PT- 13• TLC- 13,240/mm3 INR- 1.2• Platelets- 2.3 lacs/mm3 aPTT- 30• BUN- 84• Creatinine- 6.4 mg%• Na- 136 meq/dl• K- 4.8 meq/dl• Ca- 8.1 mg%• PO4- 3.8 mg%• UA- 7.8 mg%• LFT- WNL
Provisional diagnosis
Acute retention of urine ? Bladder outlet obstruction
Hematuria - UTI? Cystitis ? Bladder mass
Acute kidney injury with Uremic Encephalopathy? Obstructive uropathy
Course post admission• Due to poor general condition, he was shifted
to Neuro ICU, where he had one episode of GTC.
• He was dialysed with 2 units of packed red cells transfusion.
• Continous bladder irrigation with NS started, inj Meropenem given suspecting ESBL
Portable ultrasound – Day 1• RK- 10 * 5.5• LK- 9.8 * 4.9• Dilatation of bilateral pelvicalyceal system with
bilateral hydroureters throughout its course.• Distended bladder (420 ml) with thickened wall
with deep trabeculations.• Heterogenous predominantly hyperechoic
vascular mass of size 170 cc arising from post. and right lateral wall of bladder. Internal echoes noted in bladder
• Prostrate volume- 25 gm
Non contrast CT- KUB – Day 2
• Similar findings as ultrasound noted.• Air densities in bladder and the mentioned
mass• Impression of a bladder mass with associated
hematoma, would be worthwhile to obtain a contrast study.
Urology consult
• Large bladder mass with BOO leading to bilateral hydroureteronephrosis.
• Continued bladder irrigation• Bladder mass would require cystoscopic
biopsy and excision (simple/radical cystectomy) on later date.
Course in wards• Hematuria stopped on day 4, urine output 1.5 - 2 lit/day
• Required additional 2 units PRC transfusion
• Sensorium improved , not dialysed further.
• Renal function normalised.
• Shifted to floor on day -5
• Urine Culture- E. Coli – Meropenem sensitive, contd.
• Wait continued for the credit note from BARC for cystoscopy and bladder mass biopsy
Cystoscopy findings – Day 14
NODULAR HEMORRHAGIC CYSTITIS
NO BLADDER MASS VISUALISED
Repeat Contrast CT KUB
• Thickened enhancing bladder wall , bilateral Vesicoureteric junction and entire course of ureter suggestive of cystitis and urethritis
• Bilateral kidneys normal
Trial of catheter removal• Failed predischarge.• Hence started on Urimax, Urispas
• Urodynamic studies-Optimal capacity bladder with good complianceHypocontractile DetrusorSignificant post void residue (390 cc)
Discharged with silicone foleys in situ.
REVIEW OF LITERATURE
“ HEMORRHAGIC CYSTITIS ”
Hemorrhagic cystitisDiffuse inflammatory condition of the urinary bladder due to an infectious or noninfectious etiology resulting inbleeding from the bladder mucosa.
a) Infections –
Bacterial (MC)- E.coli, Klebsiella, Proteus, Staph Viral - BK, Adeno, CMV, JC, HerpesFungal - Candida, Aspergillus, CryptococcusParasites – Schistosomia, Ecchinococus
b) Drugs – Cyclophosphamide, Iphosphamide (due to metabolite - Acrolein ) Busulphan, Thiotepa.Penicillin and its synthetic derivatives.Danazol, Allopurinol.Intravesical instillation of drugs.
c) Occupation hazards –Dyes – Aniline, toulidinePesticides- Chlorodimeform
c) Radiation - for pelvic malignancies, atleast 90 day lag
Early - obliterative endarteritis causing ischemia f/b neovascularisation and bleeding Late – may be beyond 10 yrs, progressive disease associated with fibrosis, reduced capacity bladder
d) Systemic disease- Rheumatoid arthritisAmyloidosisCrohn’s diseaseBoon’s disease – prolonged high altitude air travel