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Acute Motor Paralytic Bladder in Renal Transplant Patients with Anogenital Herpes Infection
0022-534 7/80 /1233-0426$02.00 /0
Vol. 123, March Prmted in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
ACUTE MOTOR PARALYTIC BLADDER IN RENAL TRANSPLANT PATIENTS WITH ANOGENITAL HERPES INFECTION STEPHEN C. JACOBS,* LEE A. HEBERT, WALTER F. PIERING
AND
RUSSELL K. LAWSON
From the Departments of Urology and Nephrology, The Medical College of Wisconsin and Milwaukee County Medical Complex, Milwaukee, Wisconsin
ABSTRACT
We report on 2 renal transplant patients in whom acute urinary retention developed after anogenital herpes infections. In 1 case a reversible bladder motor and sensory neuropathy occurred secondary to herpes simplex virus infections. In the other case a motor paralytic bladder developed secondary to an anogenital varicella-zoster infection. Documentation was by carbon dioxide cystometrography and denervation hypersensitivity testing. Both cases were reversible without alteration of the immunosuppressive regimens. Acute urinary retention has been reported previously in patients with anogenital herpes simplex and herpes zoster infections.1-3 The mechanism of the urinary retention has been thought to be owing to an infectious neuritis involving the parasympathetic nerves of the bladder.3 However, the appropriate studies to establish this mechanism have not been done previously. Herein we describe 2 renal transplant patients with anogenital herpes and acute urinary retention in whom cystometric evaluation4 documented that the mechanism of the urinary retention is a reversible motor and sensor neuropathy of the bladder. 5 The management of these patients also is discussed. CASE REPORTS
Case 1. A 58-year-old man had renal failure in 1975 and had received a successful cadaveric renal allograft in 1976. Daily maintenance immunosuppressive regimen consisted of 150 mg. azathioprine and 15 mg. methylprednisolone. In September 1978 the patient presented with a 3-day history of painful rash over the sacrum and perianal area. He also noticed a slow urinary stream and on the day of hospitalization he was unable to void. The patient denied sexual contact of any sort during the last 3 years. Physical examination showed multiple small tender vesicles and shallow ulcers typical of herpes simplex virus bilaterally over the sacrum and perianal area (fig. 1). The perineum was not involved. Neurological examination showed a diminished bulbocavernosus reflex but was otherwise normal. Serum creatinine concentration was 2.3 mg./dl. Urethral catheterization relieved 1,400 cc sterile urine. After 5 days of catheter decompression urodynamic testing and cystoscopy were performed. Cystoscopy revealed mild, non-obstructing benign prosFIG. 1. Multiple confluent tender vesicles and shallow ulcers cover tatic hyperplasia. A cystometrogram showed a 500 cc bladder sacrum, gluteal fold and perianal region in case 1. capacity with a diminished first sensation noted at 440 cc (fig. 2). The patient could not elicit a detrusor response. Denervation despite no change in the immunosuppressive therapy. Case 2. A 37-year-old man had renal failure secondary to hypersensitivity testing6 was performed by repeating the cystometrogram 20 minutes after administration of 2.5 mg. betha- juvenile onset diabetes mellitus. In March 1978 he underwent necol subcutaneously. This was markedly positive with an a successful cadaveric renal transplantation. In November stingincrease of 27 cm. water in intravesicular pressure at 100 cc ing pain developed in the skin over the left sacrum, perineum, bladder filling. Treatment consisted of urethral catheter drain- scrotum and penile shaft. Daily immunosuppressive regimen at age and Burroughs soaks on the skin lesions. A cystometrogram that time was 150 mg. azathioprine and 20 mg. prednisone. The 6 weeks later revealed a decreased bladder capacity to 325 cc vesicles along the left S2, S3 and S4 dermatomes began erupting and denervation hypersensitivity testing was now negative with 2 days after the onset of pain (fig. 3). The patient also noticed an intravesicular pressure increase of only 4 cm. water at 100 cc marked slowing of the urinary stream. On November 6 total bladder filling. The patient was now able to void with only 30 urinary retention occurred and he was hospitalized. The patient cc post-void residual. The herpetic skin lesions also cleared has been impotent secondary to diabetes and denied sexual contact of any type during the last 10 months. Accepted for publication June 8, 1979. Physical examination revealed the skin lesions typical of • Requests for reprints: 8700 W. Wisconsin Ave., Milwaukee, Wisconsin 53226. herpes zoster (fig. 3). Neurological examination showed a sen426
427
ACUTE MOTOR PARALYTIC BLADDER IN RENAL TRANSPLANT PATIENTS
so:ry pe:riphe:ral neuropathy. Catheterization of the bladder :relieved 1,200 cc urine and the bladder was decompressed for 4 before cystoscopy and urodynamic testing. Cystoscopy revealed a completely no:rmal lower urinary tract. A cystometrogTam disclosed diminished sensation with a 500 cc bladder capacity (fig. 4). No detrusor activity could be elicited. Denervation hypersensitivity testing was ma:rkedly positive with an increase in intravesicular pressure of 37 cm. water at 50 cc bladder filling. A cystometrogram 3 weeks later revealed marked improvement in bladder function. Diminished sensation still was present but the patient now had a detrusor contraction and denervation hypersensitivity was no longer present. He was able to void with only a 10 cc residual. The urethral catheter was removed. The skin lesions also cleared without in the immunosuppressive medications.
URODYNAMIC STUDIES IN PATIENT 2 COz CYSTOMETROGRAM
CYSTOMETROGRAM
tr;P,m,co
9-22- 78
A~J
..
I
OEI\JERVATION HYPERSENSITIVITY 9-22-78
cs
40- 0 -~;I 5 30-
20IO -/ L.,,.-,,-~""----', r-
10-
I
I
,
300cc
450cc
100cc
I
150cc
Bladder Filling CO2 CYSTOMETROGRAM
!1-3- 78
DENERVATION HYPERSENSITIVITY 11-3-78
40-
FS
S
30-
¼
*
20- A ~~ 10- ,,.,..
~ ~ } - -..- ~ ~ - 1 I
150cc
F~} JD
40-
30-
I
300cc
CO 2 CYSTOMETROGR AM
40 -
=
first sensation
11-30-78
•
20-
10- " - - - - - - - - - - - - - - - - - - ~ ~
300cc
150cc
40-
600cc
450cc
600cc
11-30-78
•
30-
150cc
300cc
FIG. 4. Note disappearance of positive denervation hypersensitivity test after resolution of varicella-zoster infection involving sacral. dermatomes in case 2.
that anogenital herpes with sacral meningomyelitis and radiculitis was the most common cause of acute urinary retention in young sexually active people. Our 2 patients were not young or sexually active. Case 1 is believed to have had a primary herpes simplex virus infection without a known source of inoculation. 7-' 0 However, 15 per cent of male subjects are known to harbor herpes simplex virus 2 in the urinary tracts. 11 Case 2 is believed to have had reactivation of a varicella-zoster infection. This diagnosis is based on the classic dermatome distribution of the infection and the appearance of the lesions, Presumably, the immunosuppressive therapy led to the reactivation of this latent virus. 10 Treatment of the transplant patient with acute urinary retention secondary to anogenital herpes should include protection of the bladder during the acute paralytic period by catheterization. In our patients a reduction in the immunosuppressive medication was not required to clear the skin lesions or the infectious neuritis. REFERENCES 1. Caplan, L. R., Kleeman, F. J. and Berg, S.: Urinary retention
2. 3. 4. 5.
6.
7. 8.
9.
10.
Fm. 3. Case 2. A, only left side of sacrum and gluteal fold are with painful zosteriform eruption. B, lesions on external genwere primarily on left side but did cross midline.
450cc
FS
2010-
S = abdominal strain D = detrusor contract1on
Fm. 2. Note disappearance of positive denervation hypersensitivity test after resolution of sacral and perianal herpes simplex virus infection in case L
' 50cc
FS
30 -
100cc FS
' 450cc
Bladder Filling
I
300cc
2010-
10-·/..,.~------,-----,---·
DENERVATION HYPERSENSITIVITY
URODYNAMIC STUDIES IN PATIENT
4030-
20-
150cc
r
DENERVATION HYPERSENSITIVITY 11-10- 78
't
4030-
DISCUSSION
This study shows that anogenital infection with either herpes zoster or herpes simplex can result in reversible acute urinary retention causing a motor parasympathetic neuropathy. 5 No study has documented the nature of the nervous system involvement in these infections, although Caplan and associates did report on 2 patients with a "hypotonic bladder" on cystometrography. 1 Oates and Greenhouse thought that their 17 patients (15 female and 2 male subjects) with anogenital herpes virus infections and urinary retention had a "lumbosacral meningomyelitis with involvement of sacral root nerves". 3 Voiding difficulties occurred in 5 per cent of their 311 primary simplex virus 2 anogenital infections. They suggested
CO2
II- 10- 78
Cm HzO Pressllre
11.
probably secondary to herpes genitalis. New Engl. J. Med., 297; 920, 1977. Jellinek, E. H. and Tulloch, W. S.: Herpes zoster with dysfunction of bladder and anus. Lancet, 2: 1219, 1976. Oates, J. K. and Greenhouse, P.R.: Retention of urine in anogenital herpetic infection. Lancet, l: 691, 1978. Wear, J.B., Jr.: Cystometry. Urol. Clin. N. Amer., 1: 45, 1974. Kendall, A. R. and Karafin, L.: Classification ofneurogenic bladder disease. Urol. Clin. N. Amer., l: 37, 1974, Lapides, J., Friend, C.R., Ajemian, E. P. and Reus, W. S.: Denervation supersensitivity as a test for neurogenic bladder. Surg., Gynec. & Obst., 114: 241, 1962. Nahmias, A. J. and Roizman, B.: Infection with herpes-simplex viruses 1 and 2 (first of three parts). New Engl. J. Med., 289: 667, 1973. Nahmias, A. J. and Roizman, B.: Infection with herpes-simplex viruses l and 2 (second of three parts). New Engl. J. Med., 289: 719, 1973. Nahmias, A. J. and Roizman, B.: Infection with herpes-simplex viruses 1 and 2 (third of three parts). New Engl. J. Med., 289: 781, 1973. Naraqi, S., Jackson, G. G., Jonasson, 0. and Yamashiroya, H. M .. Prospective study of prevalence, incidence, and source of herpesvirus infections in patients with renal allografts, J. Infect. Dis., 136: 531, 1977. Centifanto, Y. M., Drylie, D. M., Deardourff, S. L. and Kaufman, H. E.: Herpesvirus type 2 in the male genitourinary tract. Science, 178: 318, 1972.
Vol. 123, March Prmted in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
ACUTE MOTOR PARALYTIC BLADDER IN RENAL TRANSPLANT PATIENTS WITH ANOGENITAL HERPES INFECTION STEPHEN C. JACOBS,* LEE A. HEBERT, WALTER F. PIERING
AND
RUSSELL K. LAWSON
From the Departments of Urology and Nephrology, The Medical College of Wisconsin and Milwaukee County Medical Complex, Milwaukee, Wisconsin
ABSTRACT
We report on 2 renal transplant patients in whom acute urinary retention developed after anogenital herpes infections. In 1 case a reversible bladder motor and sensory neuropathy occurred secondary to herpes simplex virus infections. In the other case a motor paralytic bladder developed secondary to an anogenital varicella-zoster infection. Documentation was by carbon dioxide cystometrography and denervation hypersensitivity testing. Both cases were reversible without alteration of the immunosuppressive regimens. Acute urinary retention has been reported previously in patients with anogenital herpes simplex and herpes zoster infections.1-3 The mechanism of the urinary retention has been thought to be owing to an infectious neuritis involving the parasympathetic nerves of the bladder.3 However, the appropriate studies to establish this mechanism have not been done previously. Herein we describe 2 renal transplant patients with anogenital herpes and acute urinary retention in whom cystometric evaluation4 documented that the mechanism of the urinary retention is a reversible motor and sensor neuropathy of the bladder. 5 The management of these patients also is discussed. CASE REPORTS
Case 1. A 58-year-old man had renal failure in 1975 and had received a successful cadaveric renal allograft in 1976. Daily maintenance immunosuppressive regimen consisted of 150 mg. azathioprine and 15 mg. methylprednisolone. In September 1978 the patient presented with a 3-day history of painful rash over the sacrum and perianal area. He also noticed a slow urinary stream and on the day of hospitalization he was unable to void. The patient denied sexual contact of any sort during the last 3 years. Physical examination showed multiple small tender vesicles and shallow ulcers typical of herpes simplex virus bilaterally over the sacrum and perianal area (fig. 1). The perineum was not involved. Neurological examination showed a diminished bulbocavernosus reflex but was otherwise normal. Serum creatinine concentration was 2.3 mg./dl. Urethral catheterization relieved 1,400 cc sterile urine. After 5 days of catheter decompression urodynamic testing and cystoscopy were performed. Cystoscopy revealed mild, non-obstructing benign prosFIG. 1. Multiple confluent tender vesicles and shallow ulcers cover tatic hyperplasia. A cystometrogram showed a 500 cc bladder sacrum, gluteal fold and perianal region in case 1. capacity with a diminished first sensation noted at 440 cc (fig. 2). The patient could not elicit a detrusor response. Denervation despite no change in the immunosuppressive therapy. Case 2. A 37-year-old man had renal failure secondary to hypersensitivity testing6 was performed by repeating the cystometrogram 20 minutes after administration of 2.5 mg. betha- juvenile onset diabetes mellitus. In March 1978 he underwent necol subcutaneously. This was markedly positive with an a successful cadaveric renal transplantation. In November stingincrease of 27 cm. water in intravesicular pressure at 100 cc ing pain developed in the skin over the left sacrum, perineum, bladder filling. Treatment consisted of urethral catheter drain- scrotum and penile shaft. Daily immunosuppressive regimen at age and Burroughs soaks on the skin lesions. A cystometrogram that time was 150 mg. azathioprine and 20 mg. prednisone. The 6 weeks later revealed a decreased bladder capacity to 325 cc vesicles along the left S2, S3 and S4 dermatomes began erupting and denervation hypersensitivity testing was now negative with 2 days after the onset of pain (fig. 3). The patient also noticed an intravesicular pressure increase of only 4 cm. water at 100 cc marked slowing of the urinary stream. On November 6 total bladder filling. The patient was now able to void with only 30 urinary retention occurred and he was hospitalized. The patient cc post-void residual. The herpetic skin lesions also cleared has been impotent secondary to diabetes and denied sexual contact of any type during the last 10 months. Accepted for publication June 8, 1979. Physical examination revealed the skin lesions typical of • Requests for reprints: 8700 W. Wisconsin Ave., Milwaukee, Wisconsin 53226. herpes zoster (fig. 3). Neurological examination showed a sen426
427
ACUTE MOTOR PARALYTIC BLADDER IN RENAL TRANSPLANT PATIENTS
so:ry pe:riphe:ral neuropathy. Catheterization of the bladder :relieved 1,200 cc urine and the bladder was decompressed for 4 before cystoscopy and urodynamic testing. Cystoscopy revealed a completely no:rmal lower urinary tract. A cystometrogTam disclosed diminished sensation with a 500 cc bladder capacity (fig. 4). No detrusor activity could be elicited. Denervation hypersensitivity testing was ma:rkedly positive with an increase in intravesicular pressure of 37 cm. water at 50 cc bladder filling. A cystometrogram 3 weeks later revealed marked improvement in bladder function. Diminished sensation still was present but the patient now had a detrusor contraction and denervation hypersensitivity was no longer present. He was able to void with only a 10 cc residual. The urethral catheter was removed. The skin lesions also cleared without in the immunosuppressive medications.
URODYNAMIC STUDIES IN PATIENT 2 COz CYSTOMETROGRAM
CYSTOMETROGRAM
tr;P,m,co
9-22- 78
A~J
..
I
OEI\JERVATION HYPERSENSITIVITY 9-22-78
cs
40- 0 -~;I 5 30-
20IO -/ L.,,.-,,-~""----', r-
10-
I
I
,
300cc
450cc
100cc
I
150cc
Bladder Filling CO2 CYSTOMETROGRAM
!1-3- 78
DENERVATION HYPERSENSITIVITY 11-3-78
40-
FS
S
30-
¼
*
20- A ~~ 10- ,,.,..
~ ~ } - -..- ~ ~ - 1 I
150cc
F~} JD
40-
30-
I
300cc
CO 2 CYSTOMETROGR AM
40 -
=
first sensation
11-30-78
•
20-
10- " - - - - - - - - - - - - - - - - - - ~ ~
300cc
150cc
40-
600cc
450cc
600cc
11-30-78
•
30-
150cc
300cc
FIG. 4. Note disappearance of positive denervation hypersensitivity test after resolution of varicella-zoster infection involving sacral. dermatomes in case 2.
that anogenital herpes with sacral meningomyelitis and radiculitis was the most common cause of acute urinary retention in young sexually active people. Our 2 patients were not young or sexually active. Case 1 is believed to have had a primary herpes simplex virus infection without a known source of inoculation. 7-' 0 However, 15 per cent of male subjects are known to harbor herpes simplex virus 2 in the urinary tracts. 11 Case 2 is believed to have had reactivation of a varicella-zoster infection. This diagnosis is based on the classic dermatome distribution of the infection and the appearance of the lesions, Presumably, the immunosuppressive therapy led to the reactivation of this latent virus. 10 Treatment of the transplant patient with acute urinary retention secondary to anogenital herpes should include protection of the bladder during the acute paralytic period by catheterization. In our patients a reduction in the immunosuppressive medication was not required to clear the skin lesions or the infectious neuritis. REFERENCES 1. Caplan, L. R., Kleeman, F. J. and Berg, S.: Urinary retention
2. 3. 4. 5.
6.
7. 8.
9.
10.
Fm. 3. Case 2. A, only left side of sacrum and gluteal fold are with painful zosteriform eruption. B, lesions on external genwere primarily on left side but did cross midline.
450cc
FS
2010-
S = abdominal strain D = detrusor contract1on
Fm. 2. Note disappearance of positive denervation hypersensitivity test after resolution of sacral and perianal herpes simplex virus infection in case L
' 50cc
FS
30 -
100cc FS
' 450cc
Bladder Filling
I
300cc
2010-
10-·/..,.~------,-----,---·
DENERVATION HYPERSENSITIVITY
URODYNAMIC STUDIES IN PATIENT
4030-
20-
150cc
r
DENERVATION HYPERSENSITIVITY 11-10- 78
't
4030-
DISCUSSION
This study shows that anogenital infection with either herpes zoster or herpes simplex can result in reversible acute urinary retention causing a motor parasympathetic neuropathy. 5 No study has documented the nature of the nervous system involvement in these infections, although Caplan and associates did report on 2 patients with a "hypotonic bladder" on cystometrography. 1 Oates and Greenhouse thought that their 17 patients (15 female and 2 male subjects) with anogenital herpes virus infections and urinary retention had a "lumbosacral meningomyelitis with involvement of sacral root nerves". 3 Voiding difficulties occurred in 5 per cent of their 311 primary simplex virus 2 anogenital infections. They suggested
CO2
II- 10- 78
Cm HzO Pressllre
11.
probably secondary to herpes genitalis. New Engl. J. Med., 297; 920, 1977. Jellinek, E. H. and Tulloch, W. S.: Herpes zoster with dysfunction of bladder and anus. Lancet, 2: 1219, 1976. Oates, J. K. and Greenhouse, P.R.: Retention of urine in anogenital herpetic infection. Lancet, l: 691, 1978. Wear, J.B., Jr.: Cystometry. Urol. Clin. N. Amer., 1: 45, 1974. Kendall, A. R. and Karafin, L.: Classification ofneurogenic bladder disease. Urol. Clin. N. Amer., l: 37, 1974, Lapides, J., Friend, C.R., Ajemian, E. P. and Reus, W. S.: Denervation supersensitivity as a test for neurogenic bladder. Surg., Gynec. & Obst., 114: 241, 1962. Nahmias, A. J. and Roizman, B.: Infection with herpes-simplex viruses 1 and 2 (first of three parts). New Engl. J. Med., 289: 667, 1973. Nahmias, A. J. and Roizman, B.: Infection with herpes-simplex viruses l and 2 (second of three parts). New Engl. J. Med., 289: 719, 1973. Nahmias, A. J. and Roizman, B.: Infection with herpes-simplex viruses 1 and 2 (third of three parts). New Engl. J. Med., 289: 781, 1973. Naraqi, S., Jackson, G. G., Jonasson, 0. and Yamashiroya, H. M .. Prospective study of prevalence, incidence, and source of herpesvirus infections in patients with renal allografts, J. Infect. Dis., 136: 531, 1977. Centifanto, Y. M., Drylie, D. M., Deardourff, S. L. and Kaufman, H. E.: Herpesvirus type 2 in the male genitourinary tract. Science, 178: 318, 1972.