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Urinary Retention in Women Caused by Asymptomatic Protruded Lumbar Disk: Report of 5 Cases
VoL 99, May Printed in
THE JOUHNAL OF UROLOGY
Copyright © 1968 by The Williams & Wilkin&' Co.
URINARY RETENTIOK IN WOMEN CAUSED BY ASY~VIPTOlVIATIG PROTRUDED LU1\1BAR DISK: REPORT OF .5 CASES .JOHN L. EMMETT
,L GRAFTON LOVE
AND
From the Sections of Urology and Neurologic Surgery, Mayo Clinfr and Mayo Foundation, Rochester, Minnesola
Unexplained urinary retention in women has been often regarded as psychogenic. 1 Bnt medical history is replete with examples of the discovery of organic lesions to account for many of the so-called functional or psychogenic or hysterical diseases. ·we regard our recent experience with unexplained urinary retention as another example of this type of continuing progress. As the prototype, our first case will be described in detail; the other cases are ~omewhat brief.* I:O,,ITIAL CASJ,
In May 1966 a 20-year-old college girl was referred by a urologist to one of us (.J. L. E.) with the request that a transurethral resection of the vesical neck be perfonned for long-standing complete urinary retention. The patient arrived at this clinic ambulatory and was wearing an indwelling urethral catheter attached to a plastic leg urinal. Her history reveak d that ti years before (at age 14) occasional episodes of intermittent frequency, urgency, and mild dysuria had developed. These episodes recurred every l to 2 months and were of short duration. However, they gradually became more frequent and of greater severity. By November 1965 these episodes were occurring at least every 2 and by late December urgency and frequency had become continuous. Catheterization at that time revealed more than 1,000 ml. urine in tr.e bladder. The patient was sent to a medical center elsewhere for diagnosis and treatment and she remained there for observation for 2 to 3 months. 0
Accepted for publication August 15, 1967. Read at annual meeting of American Association of Genito-Urinary Surgeons, Rye, New York, May 24-26, 1967. 1 Larson, J. W., Swenson, W, JVL, Utz, D. C. and Steinhilber, R. M .. Psychogenic urinary retention in women. J.A.M.A., 184: 697-700, 196:3. *Three of these cases were inchtded in our preliminary report. 2 2 Love, J. G. and Emmett, .J. L.: "Asymptomatic" protruded lumbar disk as a cause of lUinary retention: Preliminary report. Mayo Clin. Proc , 42: 249-257, 1967
Results of neurologic examination at that l.ime were negative. A eystometrogram suggested poor sensory response to filling (up to 600 mL), there was no coordinated continued bladder contraction that resulted in voiding, even after the admiui,;. tration of bethanechol (urecholine). retention was suspected. The patient was cathe terized daily during .January and February she remained unable to void. During this ti,mt· an internal urethrotomy to 45F ,vas performed lmL the patient was still unable to void. She could not tell when the bladder was full except by the Llbdominal distention and some abdominal distre8~ She was finally allowed to return home on intermittent and indwelling catheter drainage. May 1966, when she was sent to the Mayo the situation was essentially unchanged fron1 what it had been at the onset of the c·mnplt'te retention 5 months JJreviously. On examination we noted that the patient was rnoderatcly obese (about 20 pomHi~ An excretory urogram wa,; negative. A cystognun showed no ureteral reflux. Cystoscopy revealed smooth bladder without trabeculation; ~GlW edema and redundancy of the vesicaJ neck a,so ciated with mild chronic cystitis were prPSC'H1. both of which were regarded as having been caused by the indwelling catheter. The patient could barely feel the cystcscope and no pain. The urethra was of nmmal or increased length. Keurologie examination revealed no central nervous system abnormality; the anal reflex was normal. The possibility of hystc'rieal urirnny reten1ion was g,iven serious consideration, 1ml. psychiatric examination disclosed no evidence 01· emotional disturbance. The cnly therapeutic possibilit_,, appeared to be a transurethral resecl ion of the vesical neck 3 , " 3 Emmett, .J. L.: Urinary retention imbalance of detrusor and vesical neck; treal. ment by transurethral resection. J. Urn!., 43: 692-704, 1940. 4 Emmett., J. L., Hutchins, S. P. lL nml McDonald, J. R.: The treatment of urinary reter,, tion in women by transurethral resection. ,I Urn! , 63: 1031-1042, 1950.
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and this was performed in May 1966 by one of us (J.L.E.). Twenty-eight good-sized pieces of tissue were removed from the entire circumference of the vesical neck. l\Iicroscopic examination of this tissue revealed edematous and inflammatory bladder tissue. The result was poor. The patient could void only 2 to 3 ounces at a time, and that only by means of abdominal straining and Crede expression. She still had residual urine of 300 to 500 ml. Ordinarily, this procedure would have been followed with a second-stage transurethral resection, which is neces~ary in approximately 50 per cent of such cases. However, the patient's voiding pat.tern suggested a denervated type of bladder as is seen in a so-called lower motor neuron lesion. 5 • 6 Therefore, we wondered whether a silent neurologic lesion could account for the disorder, in spite of the negative neurologic examination, For this reason neurosurgical consultation was requested. Examination of the roentgenograms of the spinal column revealed unilateral sacralization of the transverse process of the fifth lumbar vertebra on the left, a neural arch defect or spondylolysis of the fifth lumbar vertebra, a wider than normal spinal canal at the fifth lumbar vertebra and a spina bifida of the eleventh thoracic vertebra (but not of the lumbosacral region). An air rnyelogram showed that the cul-de-sac ended at the lumbosacral space (instead of S-2, as normally). This condition could have been explained by either a mass lesion or simply a congenitally short cul-de-sac. 7 , 8 Otherwise the myelogram was interpreted by a neuroradiologist as being negative. Results of spinal fluid examination were normal (total protein, 17 mg. per 100 ml. and 1 lymphocyte per cu. mm.). Although these findings were not strongly 5 Emmett, J. L., Daut, R. V. and Sprague, R. G.: Transurethral resection for neurogenic vesical dysfunction in cases of diabetic nenropathy. J. Urol., 61: 244-257, 1949. 6 Emmett, J. L. and Greene, L. F.: Neurogenic vesical dysfunction (cord bladder) and neuromuscl1lar ureteral dysfunction. In: Urology. Edited by l\f. F. Campbell. Philadelphia: W. B. Saunders Company, 1963, vol. 2, pp. 1406-1504. 7 Love, J. G. and Walsh, M. N.: Intraspinal protrusion of intervertebral disks. Arch. Surg.,
40: 454-484, 1940. 8 Love, J. G.: Intractable low back and sciatic
pain due to protruded intervertebral disks: Diagnosis and treatment. Minnesota Med., 21: 832838, 1938.
suggestive of a lesion, exploration of the spinal column was recommended. Eecause of the short cul-de-sac, the possibility of a tight filum terrninale was considered. 9 • 10 Before accepting exploration, the family requested a second neurosurgical consultation, which was carried out in conjunction with iophendylate (pantopaque) myelography. This was also negative except for the short cul-de-sac. The parents and patient then requested that operative exploration be rerforrned and this was done by one of us (J. G. L.) in June 1966. The cul-de-sac was congenitally short. When the fourth lumbar interspace was explored, the cauda equina was found to be markedly irritable and congested. It was readily apparent that the cauda equina was being compressed by a typical protrusion of the fourth lumbar disk. Removal of the protruded disk freed the cauda equina of pressure. Since the exploration bad been done with the thou!,!:ht that a tight filum terminale might be found, the meninges were opened. The filum terminale was not tight and was in normal position. The urethral catheter was left in place for 72 hours. vVhen it was removed the patient began voiding substantial amounts of urine and within 2 or 3 days had perfectly normal micturition with no residual urine. It is now 1 year since operation and the patient's micturition continues to be normal. Following operation the myelograms were reexamined and a minimal defect in the region of the fourth lumbar disk was definitely preRent (fig. 1). However, the defect is so slight that the neuroradiologists question whether they would call it positive in a routine reading of films. Both before and after operation, neither the patient nor the parents, when questioned, could recall any injury that might have caused this lesion. A few days before dismissal, the mother recalled that about 6 years earlier, just before the urinary symptoms had begun, the patient had fallen hard on her buttocks while playing basketball and had also fractured an ankle. As the patient was being dismissed from the clinic she commented that in addition to being glad that she was able to pass her urine again, 9 Jones, P. H. and Love, J. G,: Tight filum terminale. Arch. Surg., 73: 556-566, 1956. 10 Love, J. G., Daly, D. D. and Harris, L. E.: Tight filum terminale. Report of condition in three siblings. J.A.M.A., 176: 31-33, 1961.
URI>iAHY RETENTIO.'< CAUSED BY PROTRUDED DISK
she was also pleased that her bowel movements were :normal once more . .For many months she had been able to have a bowel movement only once every 4 or 5 Now the movements occurred daily. At this point. we wondered whether this was just an isolated, unusual case or whether it represented a relatively common s:nxlrome which had lleretofo;,e uot been appreciated. After encounter., ing our second case, 6 months later, we began to think that the second postulate was the true one, Three cases, n.11 encountered within Lhe past 5 months, have now cmncincecl us that the lesion 1nust be relatively common and that \Te must learn to recognize it. RE:POR'l' OF OTHER CASES
Case 2. A 2:3-yea.r-olcl woman wa.s referred by a urologist to one of U8 (J. L. E.) because of con-
FIG. l. Case 1. Lateral myelogram with opaque oil (iopheEdylate). Congenitally short cul-de-sac ends at lumbosacral space (lower arrow). Anterior wall of dural sac is indented at fourth lumbar space, where protruded disk was found and removed (upper arrow). (Reprinted with permissiori of Mayo Clinic Proceedings. 2 )
sta.nt leakage of urine, apparently a. rc)su!t, overflow incontinence, The patient was' obese feet 8 inches ta.11, weighing 215 pounds). She wearing diapers a.nd was constantly ,mt. She had a peculiar hostile a.ncl suspicious pernonalit,v and resented questioning. A careful history revealed that she had been bed wetter until the age of H years, hut, sequently had been normal until 2 \ea.rs ago age 21), when, while in nurne's training, she occasional episodes of mild frequency and gency. These symptoms had gradually increased in frequency and severity and 6 months before saw her, severe urgency incontinence had developed which had progressed to precipitate nation with little or no warning. For the past weeks she ha.d been continuously wet and had been unable to tell when the bladder v:a6 There had been no back or leg pain and the patient could recall no injury. An excretory urogram by her home wa.s negative. Cystoscopic examination revealPd 800 ml. residua.I urine with no trabc:culation or the bladder a.nd normal appearing bladder 11cck a.nd urethra. A cystometrogra.m ~uggested poor sensory response with filling up to 1,150 ml. Th(' patient ha.d no appreciation of tcrnperntun, change (from ice water to water heated to 1 A neurologic examination had been refused . Slw had been treated by indwelling catheter without im provemcnt. Results of our examination a.t this clinic were follows. The kidneys were normal on excretory urography. Cystoscopic examination showed /150 ml. residual urine with no tra.becula.tion of the bladder and a normal appearing bladder neck a.nd urethra. The patient experienced no sensation of the cystoscope; it could be moved a.round brusquely and the trigone could be s(·rarwd and probed with the heel of the scope without discomfort or the desire to mid. Exiiulsive force through the c:ptoseope appeared to be normal. When the bladder was distended, this was recognized by the patient only the abdominal distention with some lower abdominal distress. At the conclusion of the examination the bladder ,ms completely empti('d; the patient then remained dry for 9 hours, which time she could not void a,nd there wa.s no leakage. At the end of this period (after 1he bladder had a.gain filled to 800 rnL) overflow dribbling resumed. Results of neurologic examination were essentially negative including sensory a.nd motor components and rrflexl's . The
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anal reflex was normal. Plain roentgenograms of the lumbar region of the spinal column were negative. Our first impression was that psychogenic retention seemed a good possibility. Therefore, psychiatric consultation was requested. The psychiatrist found the patient to be "pan-defensive." She was resistant, evasive and hostile. He concluded that little could be done psychiatrically and urged extreme caution if an operation was to be undertaken. Because of our recent experience with our first case we wondered whether this might represent a similar condition. A plain roentgenogram of the lumbar region of the spinal column showed only a slight anomaly in the lumbosacral region. Air myelography was interpreted by one neuroradiologist as being normal, by another as showing a defect consistent with a protruded lumbar disk. The spinal fluid was normal (total protein of 17 mg. per 100 ml. and l lymphocyte per cu. mm.). Exploration was performed by one of us (J.G.L.) in January 1967. Protrusions of the fourth and fifth lumbar disks were found and removed which freed the cauda equina of pressure. After the catheter came out on the second postoperative day, the patient began to void in substantial amounts and in 2 or 3 days micturition appeared to be normal. A check for residual urine 5 days postoperatively showed only 8 ml. Leakage of urine had ceased. Although she had denied back injury, at dismissal ihe patient recalled that about 2 years before, or just before her irritative bladder symptoms had begun, she had slipped on some icy steps and fallen down hard on her buttocks. Considerable low back pain had been present for several hours afterward. She also admitted that her bowel function had been abnormal for several months and that she had often gone 3 or 4 days without a bowel movement. At the time of dismissal she stated that her bowel function was normal. At this writing (almost 5 months postoperatively), the patient continues to have normal bladder function. There has been an almost complete change in personality, she has lost 35 pounds, is now considered one of the most efficient nurses in her hospital and is active socially. Case 3. A 49-year-old farm wife was referred
by a urologist to one of us (J. L. E.) because of complete urinary retention, 1 month in duration. When she was admitted to the hospital in February 1967, she was wearing an indwelling catheter attached to a leg urinal. The past history revealed that the patient had been at the Mayo Clinic previously (at the age of 35) with multiple complaints which had been regarded as functional. Among the symptoms at that time had been mild frequency and some dribbling with nocturia. The diagnosis had been psychoneurosis. Later, transurethral resection of the vesical neck was performed elsewhere. The patient returned to the Mayo Clinic in February 1956 with acute urinary retention. She stated that she had had a similar episode in 1954. An excretory urogram revealed normal kidneys. Cystoscopic examination revealed no trabeculation of the bladder, but there was a suggestion of some hypertrophy of the vesical neck. The indwelling catheter prevented a check for residual urine. No neurologic examination was made at that time. The 11atient's bladder was stimulated with instillation of gentian violet solution (1: 1,500), and she seemed to resume normal voiding. On her current admittance the patient reported that for many years she had suffered from recurring episodes of cystitis associated with renal and bladder pain and episodes of complete incontinence at which time she passed urine without being aware of it. She had had much treatment with antibiotics. She had been enuretic until the age of 8 years. One month before returning to the 2\ifayo Clinic she had been unable to void and required intermittent catheterization. During one catheterization, 1,400 ml. urine was found. The episodes of retention were associated with pain and spasm across the lower region of the abdomen and the pain radiated along both sides from the back. Two weeks before the patient re-registered at the Mayo Clinic, a urologist had inserted an indwelling catheter, which had been worn since that time. A cystoscopic examination was negative. Cystometrograms suggested some feeling of fullness after 400 ml. but no voiding contractions. No appreciation of temperature could be demonstrated by testing with ice water and water heated to approximately 120F. The patient was obese. An excretory urograrn
URINARY RETENTION CAUSED BY PROTRUDED DISK
1nade elsev,chere was reviewed and called normal. On cystoscopic examination the bladder was described as large but the actual capacity was inadvertently not recorded. The patient experienced no sensation of the presence of the cystoscope and had no feeling when the bladder was distended. There were no trabeculations. She had a good expulsive force through the cystoscope. There was a suggestion of mild hypertrophy of the bladder neck. The catheter was removed for 6 hours but she was still unable to void; she experienced no sensation of fullness of the bladder. On catheterization 500 ml. urine 1rns obtained. A catheter was left in place. Results of a neurologic examination were normal. There was a history of a fall 5 years before, after which the patient had worn a neck brace for 2 years and a back brace for l year. However, no radiculopathy vrns found. X-ray examination of the spinal column revealed anomalous development in the upper thoracic region which was diagnosed as hemivertebrae 1vith spina bifida occulta. On examination there was no evidence of a meningoeele and no history was obtained of an abnormal protrusion at this ]eve!. Because of the congenital anomalies in the high thoracic region and the fact that air myelography in our hands i;e; not satisfactory for that level, an iophendylate myelogram was made. There was no evidence of an intraspinal lesion at the level of the hemivertebrae with spina bificla. The significance of a slight deformity that was found in the nerve sleeves in the lower lumbar region was in doubt. The conus medullaris appeared to be at the first lumbar vertebra, which is considered normal. The spinal fluid contained a total protein of 27 mg. per 100 mL (normal). On exploration of the lumbar canal in February 1967, a protruded fourth lumbar cfok was encountered which was compressing the cauda equina; it wa.~ removed. Seventy-two hours after the laminectomy and ren10val of the protruded fourth lumbar disk, the urethral catheter was removed and approximately 4 hours after that the patient began to void in quantities varying between 350 and 550 ml. At dismissal, 9 days postoperatively, micturition was normal. Examination for residual urine revealed only 2 ml. A recent recheck (4 months after operation) showed the patient to be experiencing normal voiding; there was 75 mL dear residual urine pre,eut.
f\01
Remarks. Cases 4 and 5, observed within thr, past 2 months, are somewbat different. In rnse 4, both a protruded third lumbar disk and tumor (epenclyrn.oma) of the cauda equina were present. In both cases some pain was also present, so that the lesions cannot be called asymptomatic. However, both are excellent examples of the early, irritative bladder symptoms which may be present for months or year, before either actual complete retention supervenes or typical symptoms of disk appear. These 2 cases provide some insight into the genesis and the neuropbysiologic mechanisms involved. Case 4. A 38-year-old housewife had been treated at this clinic intermittently since November 1963 for urinary infection that had caused episodes of frequency, urgency, burning and suprapubic distress. She had also complained of difficulty in passing urine and many check, for residual urine revealed amounts from 150 to 600 ml. Chemotherap:r, urethra.l dilatation, administration of bethanechol and local treatment had been ineffective. An excretory urogram gave essentially negative results. In October 1966 some low sacral pain had developed. Roentgen examination of the lumbat region of the spinal column had been Orthopedic consultation in January 1967 had been non-contributory. In :.\!Iarch cystoscopil' examination re,-caled residual urine of 600 ml., no trabecuJation of the bladder, diffuse cystitis cystica and good C'X· pulsive force through the cysto~cope but with definite reduction in sensation. Internal Ull' .. throtomy to 43F gave little if any relief. :\ partial neurologic examination revealed normal achilles and patellar reflexes. There wa,s some evidence of radiculopathy, namely mild pain on forward bending and straight-leg raising 1\.11 air myelogram revealed a protruded third lumbar disk and a filling defect from an intradural tumor which extended from the lower border of L-1 to the upper 111.argin of L-3 (fig. 2). was performed exploration by one of us (.J. G. in April. A protruded third lumbar disk waE; present. vVhen the dura was opened there was a large ependymorna of the filum terminale ancl lower portion of the eonus medullaris.1' Because the tumor was too large to be delivered i11 l piece, it was removed in fragments. H was 11 Whisnant, .J. :P. and Love, J. G. Pitfall in diagnosis of diabetic "cord bladder". Intra.spurn\ ependymoma ..J.A.. M.A., 174: 147--1.50, 1960.
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densely adherent to filaments of cauda. It seemed quite likely that the caudal tumor was sufficient to produce the vesical dysfunction. Therefore, the third lumbar disk was not removed since this would have appreciably increased the risk of the operation. Microscopic examination of the tumor revealed a grade 2 ependymoma in multiple pieces aggregating 1.5 cm. in diameter. As might be expected, edema of the cauda equina from the operative trauma resulted in postoperative neurologic deficits consisting cf patchy perianal hypalgesia (left greater than right) with some weakness of the lower part of the left leg, some reduction in the left ankle jerk and absent anal reflex. There was also some
Frn. 2. Case 4. Air myelogram lateral view. There is negative filling defect from intramedullary tumor of terminal conus and filum terminale. Upper and lower margins of tumor are indicated by upper and lower vertical arrows. Erosion of second lumbar vertebra from tumor with widening of vertebral canal is indicated by upper horizontal arrow. Defect from protruded L-3 disk is indicated by lower horizontal arrow.
pain in the posterior region of the thighs. The patient complained of the numbness. We consider this situation to be temporary and a repeat examination 6 weeks postoperatively revealed that the neurologic deficits are diminishing. The catheter was removed 1 week postoperatively but the patient was unable to void. It was removed again 2 weeks postoperatively and she has been voiding fairly well since, tbe first check for residual urine showing 100 ml. The last residual check (6 weeks postoperatively) showed 60 ml. We expect that it will be some time yet before optimum results can he realized. Whether the protruded disk at L-3 will require removal at a later date is not known. The malignancy of the tumor also clouds the prognosis. Decision regarding postoperative irradiation has not yet been made. Case 5. Our most recent case is that of a 41year-old woman who for about 2 or 3 years had complained of recurring episodes of low back pain. A protruded lumbar disk had been suspected as the cause but conservative treatment had been advised. In April 1965 the patient began to complain of recurring episodes of bladder irritability consisting of frequency and urgency. At times the frequency was as often as every 15 to 30 minutes, associated with nocturia of 3 to 4 time8. No infection could be demonstrated in the urine and cystoscopy bad been reported as revealing chronic urethritis. Treatment, consisting of urethral dilatation, urethral suppositories, sitz baths and so on, was not effective. The episodes continued to be bothersome during the ensuing year. In March 1966 the patient had an episode of acute low back pain accompanied by some signs of radiculopathy which suggested protruded disk. By September, in addition to the frequency and urgency of urination, symptoms cf urinary obstruction developed consisting of difficulty in initiating the stream, straining to void, interruption of the stream, dribbling and a feeling cf incomplete voiding. Intermittent pain developed in the right lower region of the abdomen. (It was suggested that a moderate right renal ptosis might be responsible for the pain.) By May 1967 the urinary symptoms bad become so troublesome that urologic re-evaluation was requested. Excretory urography was negative except for a moderate right renal ptosis. Cystoscopy shmved
URINARY RETENTION CAUSED BY PROTRUDED DISK
no residual mine and no 1rabeculation but did demonstrate markedly reduced sensation; the patient was hardly aware that the cystoscope was in place and the trigone could be roughly scraped with the heel of the scope without discomfort to the patient. The capacity of the bladder was 500 ml., and when it was distended to this degree the patient had no desire to void and recognized it only hy abdominal distention and supra.pubic distress, which was most marked in the lower abdominal region on the right side (the same location as the long-standing pain). :\Jeurologic examination revealed some questionable hypalgesia in the left perianal area. The anal reflex was normal, ankle and knee were normal and no muscular weakness could be demonstrated. There were some mildly positive signs of radiculopathy consisting of painful straight-leg rai.,ing and some limitation of forward and lateral bending. An air myelogram showed a midline Jirotruded
Fm. 3. Case 5. Air myelogram, lateral view. Defect from protruded L-4 disk (arrow).
fourth lumbar disk (fig. 3). tion \Vas advised. At operation performed by one of us G. in May, a compressed and hyper-irritable eauds equina was found caused protrusion ol the fourth lumbar disk. The disk was rcmoncl and the lumbar spinal column was fused with g bilateral bone graft. At this writing, the urinar~· syrn.ptoms have almost disapriearecl. She now sleeps through tlw without voiding. The day frequency and urgency have disappeared and she voids free]:1·. Thn right lower abdominal clistrC'ss bas abo peared. Dic,CUSSJON
The term asymptomatic disk require~ ,,umc, clarification. It has always been taught thal pain is an absolute prerequisite to the of protruded lumbar disk. The pain is considered to be the result of radiculopathy (nerve j'OOt irritation) from pressure from the disk on 1he nerve root. The radiculopathy i,; manife~ted spasm of the erector spinae muscles, limited or painful motions of the trunk, positive sign (painful straight-leg raising), listing of t be trunk and a limp. A history of injury may or may not be obtained. 7 • 8 :;'IJeurologic deficits (sensory, motor or may or may not be present, such as loss oi kiw(, and ankle jerks, numbness in the perinea! weakness of the leg muscles and so on. The presence of numbness and masclc weakrn'.~" ha~ been considered to indicate involvement of the cauda equina. Urinary and bowel dysfunction have been noted with symptomatic protruded disk,, bm these findings have been reported only infrrquently and have almost always been a,sociatrd with demonstrable neurologic defieits. The demonstration that vesical progressing to urinary retention can be caused by an asymptomatic protruded disk is a hope to the patient suffering from this condition, but it also places heavy on the physician. The fact that in 3 of our Fi nr cases the myelograms were either equivocal means that often diagnrn,is will be made only at operative exploration. Thus there will no doubt be negative explorations, whcli tor obvious reasons must be kept at a minimum. Certainly operative exploration of the Ju.ml.Jo
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sacral spinal region should not be performed in all cases of unexplained urinary retention in women. In an effort to pinpoint signs, symptoms and diagnostic procedures which may be helpful in selecting cases for exploration, we have critically analyzed the data from our 5 cases. As experience and the number of cases increase we hope that selection of cases may be more accurate. Sex and weight. All of our patients have been women. We do not know if this is significant or just a chance occurrence. Three of the 5 women were obese. Enuresis in childhood. Three of the 5 women had a history of enuresis in childhood. vVe have speculated whether this might indicate some abnormality in bladder innervation or an unusually vulnerable cauda equina. Ifistory of infury. There was a definite history of injury in 3 of the 5 cases, although in 2 cases it was not recalled, in spite of careful questioning, until after operation. In case 5, the patient had had a severe back injury while in college 20 years previously; the significance of this injury is in doubt. In cases 1 and 2, injury immediately preceded the onset of irritative bladder symptoms. Associated bowel dysfunction. In 2 cases (cases 1 and 2) bowel dysfunction was present consisting of inability to have a bowel movement more often than once every 3 to 5 days. After operation, bowel function returned to normal. Vesical dysfunction associated with typical symptoms of protruded disk. In the first 3 cases no typical symptoms of disk were present (such as pain, neurologic deficits and evidence of radiculopathy). In case 4, pain in the sacral region developed almost 3 years after the onset of the urinary symptoms. In case 5, mild episodes of typical disk pain had been associated with and preceded the onset of vesical dysfunction. Irritative vesical symptoms preceding retention. One of the most illuminating observations to come out of this study is that women with complete urinary retention were found (on close questioning) to have had intermittent vesical dysfunction and irritability since an injury which had apparently caused the protruded disk. In case 1, this had gone on for almost 5 years, culminating in complete retention. In case 2, it had been present for about 2 years, culminating in retention and overflow incontinence. In case 3,
it had been present off and on for many years, periodically resulting in complete retention. These prodromal symptoms often are forgotten by the patient and are brought out only by careful questioning. Urologic examination. The urologic examination has been definitely helpful in selecting these cases and we may learn more from it as experience increases. In none of the cases has the upper urinary tract been compromised from the urinary retention, as demonstrated by excretory uroggraphy. This is somewhat reminiscent of the time when tabes dorsalis was common. 12 It was not unusual then to see patients with greatly distended bladders of long standing (distended with 2 to 5 liters of urine) with normal upper urinary tracts. The most characteristic urologic findings appear to be a result of a defect in the sensory perception of the bladder, which was demonstrated in all 5 cases. (It was demonstrated by cystoscopy in all 5 and by cystometry in the 3 cases in which this examination was performed.) Cystoscopically, there has been diminished or absent sensation with almost complete absence of pain when the cystoscope is in place. Even brusque movements of the instrument and scraping and prodding of the trigone are recognized poorly or not at all by the patient. An important finding has been the absence of normal awareness of bladder distention. The patient does not eJqJerience the typical desire to void but simply feels lower abdominal distention and distress when the bladder is overdistended. It is of interest in case 5 that this discomfort was localized over the lower abdominal region on the right side, the site of the pain of which she had been complaining. Another important finding we believe is the total absence of trabeculation of the bladder despite large quantities of residual urine. There appeared to be reasonably normal expulsive force through the cystoscope in all cases. The bladder neck and the urethra have been essentially normal in appearance. Although we have not made cystometrograms at this clinic on these cases, this test was done elsewhere in the first 3 cases and poor sensory response to filling was noted in all cases. At 1 2 Emmett, J. L. and Beare, J.B.: Transurethral resection for vesical dysfunction in cases of tabes dorsalis. J.A.M.A., 136: 1093-1096, 1948.
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present we believe that we get as much information (or even more) from careful cystoscopy as we would from a cystometrogram. Roentgenographic examination of the spinal column. In all cases the roentgenograms of the spinal column showed mini1nal to pronounced congenital abnormalities, such as spina bifida occulta, hemivertebrae, spondylolysis and widening of the lumbar region of the spinal canal. Myelography. We are concerned that the myelograms in the first 3 cases were either negative or equivocal because the defects were so small as to seem of questionable importance. The reason for this appears to be the increased anteroposterior depth of the spinal canal in the lower lumbar region, where the cauda equina and dural canal tend to drift away from the posterior surface of the spinal column; apparently this permits relatively large protruded disks to be present without producing the typical negative defect in the myelogram. Possibly some improvement in technique can be worked out to yield a higher percentage of positive films. Physiopathologic mechanism involved. It is difficult to explain the mechanism in these cases. That none of the patients had appreciable bladder sensation or trabeculation, and yet all retained normal expulsive force, suggests a sensory neurologic deficit produced by pressure of the protruded disk on the cauda equina. Removal of the lesions compressing the cauda equina was sufficient to re-establish normal bladder micturition. Psychiatn:c aspect. The findings in these cases seriously weaken the concept of psychogenic retention. This is an example of the experience that, as knowledge increases, the incidence of organic diagnoses increases and that of functional diagnoses declines. Psychogenic retention could easily have been diagnosed in the first 3 cases, especially cases l and 2. Although it would be unwise at this point to condemn the diagnosis of psychogenic retention, it does seem increasingly clear that organic lesions must be carefully searched for. SDllHIARY
Five cases of vcsical dysfunction in women have been reported that were caused by protruded lumbar disks (with an assoriated tumor of the cauda equina in l). In 4 cases the dysfunction consisted of urinary retention, which was
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total in 3 and incomplete in L In the fifth case, the dysfunction was urgency, and difficulty in voiding which had not yet reached the retention stage. The 3 patients with complete retention had all experienced episodes of frequency, urgency and bladder irritability for long periods before complete retention occurred. The 2 other pn· tients had not yet rea,ched the point of total retention. Urologic examination in all cases, absence of trabeculation, great reduction in sensation, absence of the norrual desire to void and apparently normal expulsivf, force through the cystoscope Distention of the bladder was recognized the jlatient chiefly lower abdominal distention and distrcst::. In 1 case of complete retention, overflow incontinencr had developed, In the first 3 cases the protruded disks vrnre entirely asymptcmatic and the result,, of physical and neurologic examinations wrre negative. Myelography was negative or cal. In all patients a protruded lumbar disk Wfl..', found. In 1 case there was al.so an cpendymorna of the cauda equina. Three of the patients liad 11 history of a. definite low back injury sustained before the initial urinary symptoms had developed. The 4 patients v;ith protrnded diHks were completely relieved of their symptoms and retention imrnediately after operative removal of the disk In the riaticnt with the a,sociatecl large tumor, the tumm was removed , t.o avoid increasing the risk of the operation, the disk was not removed. This patient has experienced some transient neurologic deficits, which are diminishing. She is still under observation. The mechanism of this form cf urinary re tention is believed to be a sensory ncurolog1c defect produced by pressure of a protruded disk on the cauda equina. ADDENDUM*
In the 4 months that have since thi~ paper was read, 6 a.dditional patients have been encountered and operated on, a total of 11 eases. Excellent results have been achieved in all cept one. In the one exception, micturition has returned to normal for the fir8t time in rnany years, but a residual urine of 200 mL (preoperative residual was 600 ml.). We suspect that a mild postoperative contracture of the *Written September 15, 1967.
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vesical neck from previous transurethral resections may explain this. Also, preoperative abnormal bowel function has returned to normal. A brief summary and analysis of these six additional cases follow. The ages of these women varied from 18 to 67 years. The level of the disk was L-4 in all except one (L-3). The myelogram was positive in four and negative or equivocal in two. The neurologic examination was negative in all. The typical cystoscopic findings (described above) were present in all. The amount of residual urine in each was 3,000, 200-600, 200-500, 150, 75 and 50 ml. Associated bowel dysfunction was present in two of the 6 cases; it was relieved after operation. Irritative vesical symptoms either preceding retention or as the presenting complaint were present in all except one case, that of a woman, age 67, who had sought medical help because of an enlarging abdomen. There had been no urinary symptoms, the only discomfort having been the lower abdominal fullness. A diagnosis had been made elsewhere of a pelvic tumor and operation had been advised. While the patient was being anesthetized for abdominal exploration, urine began passing through the urethra. Catheterization removed 3,000 ml. of urine; the abdominal mass disappeared, so that the operation was not performed. An indwelling urethral catheter for 4 months had not restored normal voiding. Our air myelogram was positive, and removal of the asymptomatic fourth lumbar disk restored normal micturition. Whereas in the original 5 cases (herein described) typical disk-type back and leg pain with signs of radiculopathy was present in only one (case 5), it was a prominent feature in two of the six additional cases. In one of these, the patient stated that during periods of most severe pain her bowels would not move well. It
should be pointed out that in 3 of the 11 cases, some degree of typical disk-type back and leg pain was present and therefore the term "asymptomatic" disk used in the title of this paper is no longer entirely accurate. We expect to encounter more and more patients who have varying degrees of typical or atypical disk symptoms. We continue to be impressed with patients who complain of pain in the abdomen, flank or ingui'.nal region associated with irritative vesical symptoms, somewhat similar to the situation in case 5 in this paper. Typical was a woman, age 41, who was sent to our clinic for a right nephrectomy because of "pyelonephritL~" and ureteral obstruction. For 4 months she had "been sitting on the toilet trying to void" and suffering with pain in the right lower abdomen which radiated to the right flank. There had been one or two episodes of fever. U rographically, mild right pyeloureterectasis could be demonstrated; the ureter was dilated to the level of S-1, a picture suggesting "right ovarian vein syndrome". Cystoscopy demonstrated the typical findings herein described. There was a residual urine of 75 ml. Distension of the bladder reproduced the right abdominal and right flank pain whereas a retrograde pyelogram would not (even with overfilling). An air myelogram revealed an L-4 protruded disk, and all of the symptoms were completely relieved when it was removed. Although she could recall no previous injury, she did remember that 12 years previously she had been hospitalized for 12 days with a severe back pain which had been successfully treated with traction. It seems significant to point out here that 10 of the total of 11 patients have been cared for since January 1967, a period of only 9}-i months. This would seem to indicate that the condition is more common than we ha.ve suspected.
THE JOUHNAL OF UROLOGY
Copyright © 1968 by The Williams & Wilkin&' Co.
URINARY RETENTIOK IN WOMEN CAUSED BY ASY~VIPTOlVIATIG PROTRUDED LU1\1BAR DISK: REPORT OF .5 CASES .JOHN L. EMMETT
,L GRAFTON LOVE
AND
From the Sections of Urology and Neurologic Surgery, Mayo Clinfr and Mayo Foundation, Rochester, Minnesola
Unexplained urinary retention in women has been often regarded as psychogenic. 1 Bnt medical history is replete with examples of the discovery of organic lesions to account for many of the so-called functional or psychogenic or hysterical diseases. ·we regard our recent experience with unexplained urinary retention as another example of this type of continuing progress. As the prototype, our first case will be described in detail; the other cases are ~omewhat brief.* I:O,,ITIAL CASJ,
In May 1966 a 20-year-old college girl was referred by a urologist to one of us (.J. L. E.) with the request that a transurethral resection of the vesical neck be perfonned for long-standing complete urinary retention. The patient arrived at this clinic ambulatory and was wearing an indwelling urethral catheter attached to a plastic leg urinal. Her history reveak d that ti years before (at age 14) occasional episodes of intermittent frequency, urgency, and mild dysuria had developed. These episodes recurred every l to 2 months and were of short duration. However, they gradually became more frequent and of greater severity. By November 1965 these episodes were occurring at least every 2 and by late December urgency and frequency had become continuous. Catheterization at that time revealed more than 1,000 ml. urine in tr.e bladder. The patient was sent to a medical center elsewhere for diagnosis and treatment and she remained there for observation for 2 to 3 months. 0
Accepted for publication August 15, 1967. Read at annual meeting of American Association of Genito-Urinary Surgeons, Rye, New York, May 24-26, 1967. 1 Larson, J. W., Swenson, W, JVL, Utz, D. C. and Steinhilber, R. M .. Psychogenic urinary retention in women. J.A.M.A., 184: 697-700, 196:3. *Three of these cases were inchtded in our preliminary report. 2 2 Love, J. G. and Emmett, .J. L.: "Asymptomatic" protruded lumbar disk as a cause of lUinary retention: Preliminary report. Mayo Clin. Proc , 42: 249-257, 1967
Results of neurologic examination at that l.ime were negative. A eystometrogram suggested poor sensory response to filling (up to 600 mL), there was no coordinated continued bladder contraction that resulted in voiding, even after the admiui,;. tration of bethanechol (urecholine). retention was suspected. The patient was cathe terized daily during .January and February she remained unable to void. During this ti,mt· an internal urethrotomy to 45F ,vas performed lmL the patient was still unable to void. She could not tell when the bladder was full except by the Llbdominal distention and some abdominal distre8~ She was finally allowed to return home on intermittent and indwelling catheter drainage. May 1966, when she was sent to the Mayo the situation was essentially unchanged fron1 what it had been at the onset of the c·mnplt'te retention 5 months JJreviously. On examination we noted that the patient was rnoderatcly obese (about 20 pomHi~ An excretory urogram wa,; negative. A cystognun showed no ureteral reflux. Cystoscopy revealed smooth bladder without trabeculation; ~GlW edema and redundancy of the vesicaJ neck a,so ciated with mild chronic cystitis were prPSC'H1. both of which were regarded as having been caused by the indwelling catheter. The patient could barely feel the cystcscope and no pain. The urethra was of nmmal or increased length. Keurologie examination revealed no central nervous system abnormality; the anal reflex was normal. The possibility of hystc'rieal urirnny reten1ion was g,iven serious consideration, 1ml. psychiatric examination disclosed no evidence 01· emotional disturbance. The cnly therapeutic possibilit_,, appeared to be a transurethral resecl ion of the vesical neck 3 , " 3 Emmett, .J. L.: Urinary retention imbalance of detrusor and vesical neck; treal. ment by transurethral resection. J. Urn!., 43: 692-704, 1940. 4 Emmett., J. L., Hutchins, S. P. lL nml McDonald, J. R.: The treatment of urinary reter,, tion in women by transurethral resection. ,I Urn! , 63: 1031-1042, 1950.
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and this was performed in May 1966 by one of us (J.L.E.). Twenty-eight good-sized pieces of tissue were removed from the entire circumference of the vesical neck. l\Iicroscopic examination of this tissue revealed edematous and inflammatory bladder tissue. The result was poor. The patient could void only 2 to 3 ounces at a time, and that only by means of abdominal straining and Crede expression. She still had residual urine of 300 to 500 ml. Ordinarily, this procedure would have been followed with a second-stage transurethral resection, which is neces~ary in approximately 50 per cent of such cases. However, the patient's voiding pat.tern suggested a denervated type of bladder as is seen in a so-called lower motor neuron lesion. 5 • 6 Therefore, we wondered whether a silent neurologic lesion could account for the disorder, in spite of the negative neurologic examination, For this reason neurosurgical consultation was requested. Examination of the roentgenograms of the spinal column revealed unilateral sacralization of the transverse process of the fifth lumbar vertebra on the left, a neural arch defect or spondylolysis of the fifth lumbar vertebra, a wider than normal spinal canal at the fifth lumbar vertebra and a spina bifida of the eleventh thoracic vertebra (but not of the lumbosacral region). An air rnyelogram showed that the cul-de-sac ended at the lumbosacral space (instead of S-2, as normally). This condition could have been explained by either a mass lesion or simply a congenitally short cul-de-sac. 7 , 8 Otherwise the myelogram was interpreted by a neuroradiologist as being negative. Results of spinal fluid examination were normal (total protein, 17 mg. per 100 ml. and 1 lymphocyte per cu. mm.). Although these findings were not strongly 5 Emmett, J. L., Daut, R. V. and Sprague, R. G.: Transurethral resection for neurogenic vesical dysfunction in cases of diabetic nenropathy. J. Urol., 61: 244-257, 1949. 6 Emmett, J. L. and Greene, L. F.: Neurogenic vesical dysfunction (cord bladder) and neuromuscl1lar ureteral dysfunction. In: Urology. Edited by l\f. F. Campbell. Philadelphia: W. B. Saunders Company, 1963, vol. 2, pp. 1406-1504. 7 Love, J. G. and Walsh, M. N.: Intraspinal protrusion of intervertebral disks. Arch. Surg.,
40: 454-484, 1940. 8 Love, J. G.: Intractable low back and sciatic
pain due to protruded intervertebral disks: Diagnosis and treatment. Minnesota Med., 21: 832838, 1938.
suggestive of a lesion, exploration of the spinal column was recommended. Eecause of the short cul-de-sac, the possibility of a tight filum terrninale was considered. 9 • 10 Before accepting exploration, the family requested a second neurosurgical consultation, which was carried out in conjunction with iophendylate (pantopaque) myelography. This was also negative except for the short cul-de-sac. The parents and patient then requested that operative exploration be rerforrned and this was done by one of us (J. G. L.) in June 1966. The cul-de-sac was congenitally short. When the fourth lumbar interspace was explored, the cauda equina was found to be markedly irritable and congested. It was readily apparent that the cauda equina was being compressed by a typical protrusion of the fourth lumbar disk. Removal of the protruded disk freed the cauda equina of pressure. Since the exploration bad been done with the thou!,!:ht that a tight filum terminale might be found, the meninges were opened. The filum terminale was not tight and was in normal position. The urethral catheter was left in place for 72 hours. vVhen it was removed the patient began voiding substantial amounts of urine and within 2 or 3 days had perfectly normal micturition with no residual urine. It is now 1 year since operation and the patient's micturition continues to be normal. Following operation the myelograms were reexamined and a minimal defect in the region of the fourth lumbar disk was definitely preRent (fig. 1). However, the defect is so slight that the neuroradiologists question whether they would call it positive in a routine reading of films. Both before and after operation, neither the patient nor the parents, when questioned, could recall any injury that might have caused this lesion. A few days before dismissal, the mother recalled that about 6 years earlier, just before the urinary symptoms had begun, the patient had fallen hard on her buttocks while playing basketball and had also fractured an ankle. As the patient was being dismissed from the clinic she commented that in addition to being glad that she was able to pass her urine again, 9 Jones, P. H. and Love, J. G,: Tight filum terminale. Arch. Surg., 73: 556-566, 1956. 10 Love, J. G., Daly, D. D. and Harris, L. E.: Tight filum terminale. Report of condition in three siblings. J.A.M.A., 176: 31-33, 1961.
URI>iAHY RETENTIO.'< CAUSED BY PROTRUDED DISK
she was also pleased that her bowel movements were :normal once more . .For many months she had been able to have a bowel movement only once every 4 or 5 Now the movements occurred daily. At this point. we wondered whether this was just an isolated, unusual case or whether it represented a relatively common s:nxlrome which had lleretofo;,e uot been appreciated. After encounter., ing our second case, 6 months later, we began to think that the second postulate was the true one, Three cases, n.11 encountered within Lhe past 5 months, have now cmncincecl us that the lesion 1nust be relatively common and that \Te must learn to recognize it. RE:POR'l' OF OTHER CASES
Case 2. A 2:3-yea.r-olcl woman wa.s referred by a urologist to one of U8 (J. L. E.) because of con-
FIG. l. Case 1. Lateral myelogram with opaque oil (iopheEdylate). Congenitally short cul-de-sac ends at lumbosacral space (lower arrow). Anterior wall of dural sac is indented at fourth lumbar space, where protruded disk was found and removed (upper arrow). (Reprinted with permissiori of Mayo Clinic Proceedings. 2 )
sta.nt leakage of urine, apparently a. rc)su!t, overflow incontinence, The patient was' obese feet 8 inches ta.11, weighing 215 pounds). She wearing diapers a.nd was constantly ,mt. She had a peculiar hostile a.ncl suspicious pernonalit,v and resented questioning. A careful history revealed that she had been bed wetter until the age of H years, hut, sequently had been normal until 2 \ea.rs ago age 21), when, while in nurne's training, she occasional episodes of mild frequency and gency. These symptoms had gradually increased in frequency and severity and 6 months before saw her, severe urgency incontinence had developed which had progressed to precipitate nation with little or no warning. For the past weeks she ha.d been continuously wet and had been unable to tell when the bladder v:a6 There had been no back or leg pain and the patient could recall no injury. An excretory urogram by her home wa.s negative. Cystoscopic examination revealPd 800 ml. residua.I urine with no trabc:culation or the bladder a.nd normal appearing bladder 11cck a.nd urethra. A cystometrogra.m ~uggested poor sensory response with filling up to 1,150 ml. Th(' patient ha.d no appreciation of tcrnperntun, change (from ice water to water heated to 1 A neurologic examination had been refused . Slw had been treated by indwelling catheter without im provemcnt. Results of our examination a.t this clinic were follows. The kidneys were normal on excretory urography. Cystoscopic examination showed /150 ml. residual urine with no tra.becula.tion of the bladder and a normal appearing bladder neck a.nd urethra. The patient experienced no sensation of the cystoscope; it could be moved a.round brusquely and the trigone could be s(·rarwd and probed with the heel of the scope without discomfort or the desire to mid. Exiiulsive force through the c:ptoseope appeared to be normal. When the bladder was distended, this was recognized by the patient only the abdominal distention with some lower abdominal distress. At the conclusion of the examination the bladder ,ms completely empti('d; the patient then remained dry for 9 hours, which time she could not void a,nd there wa.s no leakage. At the end of this period (after 1he bladder had a.gain filled to 800 rnL) overflow dribbling resumed. Results of neurologic examination were essentially negative including sensory a.nd motor components and rrflexl's . The
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anal reflex was normal. Plain roentgenograms of the lumbar region of the spinal column were negative. Our first impression was that psychogenic retention seemed a good possibility. Therefore, psychiatric consultation was requested. The psychiatrist found the patient to be "pan-defensive." She was resistant, evasive and hostile. He concluded that little could be done psychiatrically and urged extreme caution if an operation was to be undertaken. Because of our recent experience with our first case we wondered whether this might represent a similar condition. A plain roentgenogram of the lumbar region of the spinal column showed only a slight anomaly in the lumbosacral region. Air myelography was interpreted by one neuroradiologist as being normal, by another as showing a defect consistent with a protruded lumbar disk. The spinal fluid was normal (total protein of 17 mg. per 100 ml. and l lymphocyte per cu. mm.). Exploration was performed by one of us (J.G.L.) in January 1967. Protrusions of the fourth and fifth lumbar disks were found and removed which freed the cauda equina of pressure. After the catheter came out on the second postoperative day, the patient began to void in substantial amounts and in 2 or 3 days micturition appeared to be normal. A check for residual urine 5 days postoperatively showed only 8 ml. Leakage of urine had ceased. Although she had denied back injury, at dismissal ihe patient recalled that about 2 years before, or just before her irritative bladder symptoms had begun, she had slipped on some icy steps and fallen down hard on her buttocks. Considerable low back pain had been present for several hours afterward. She also admitted that her bowel function had been abnormal for several months and that she had often gone 3 or 4 days without a bowel movement. At the time of dismissal she stated that her bowel function was normal. At this writing (almost 5 months postoperatively), the patient continues to have normal bladder function. There has been an almost complete change in personality, she has lost 35 pounds, is now considered one of the most efficient nurses in her hospital and is active socially. Case 3. A 49-year-old farm wife was referred
by a urologist to one of us (J. L. E.) because of complete urinary retention, 1 month in duration. When she was admitted to the hospital in February 1967, she was wearing an indwelling catheter attached to a leg urinal. The past history revealed that the patient had been at the Mayo Clinic previously (at the age of 35) with multiple complaints which had been regarded as functional. Among the symptoms at that time had been mild frequency and some dribbling with nocturia. The diagnosis had been psychoneurosis. Later, transurethral resection of the vesical neck was performed elsewhere. The patient returned to the Mayo Clinic in February 1956 with acute urinary retention. She stated that she had had a similar episode in 1954. An excretory urogram revealed normal kidneys. Cystoscopic examination revealed no trabeculation of the bladder, but there was a suggestion of some hypertrophy of the vesical neck. The indwelling catheter prevented a check for residual urine. No neurologic examination was made at that time. The 11atient's bladder was stimulated with instillation of gentian violet solution (1: 1,500), and she seemed to resume normal voiding. On her current admittance the patient reported that for many years she had suffered from recurring episodes of cystitis associated with renal and bladder pain and episodes of complete incontinence at which time she passed urine without being aware of it. She had had much treatment with antibiotics. She had been enuretic until the age of 8 years. One month before returning to the 2\ifayo Clinic she had been unable to void and required intermittent catheterization. During one catheterization, 1,400 ml. urine was found. The episodes of retention were associated with pain and spasm across the lower region of the abdomen and the pain radiated along both sides from the back. Two weeks before the patient re-registered at the Mayo Clinic, a urologist had inserted an indwelling catheter, which had been worn since that time. A cystoscopic examination was negative. Cystometrograms suggested some feeling of fullness after 400 ml. but no voiding contractions. No appreciation of temperature could be demonstrated by testing with ice water and water heated to approximately 120F. The patient was obese. An excretory urograrn
URINARY RETENTION CAUSED BY PROTRUDED DISK
1nade elsev,chere was reviewed and called normal. On cystoscopic examination the bladder was described as large but the actual capacity was inadvertently not recorded. The patient experienced no sensation of the presence of the cystoscope and had no feeling when the bladder was distended. There were no trabeculations. She had a good expulsive force through the cystoscope. There was a suggestion of mild hypertrophy of the bladder neck. The catheter was removed for 6 hours but she was still unable to void; she experienced no sensation of fullness of the bladder. On catheterization 500 ml. urine 1rns obtained. A catheter was left in place. Results of a neurologic examination were normal. There was a history of a fall 5 years before, after which the patient had worn a neck brace for 2 years and a back brace for l year. However, no radiculopathy vrns found. X-ray examination of the spinal column revealed anomalous development in the upper thoracic region which was diagnosed as hemivertebrae 1vith spina bifida occulta. On examination there was no evidence of a meningoeele and no history was obtained of an abnormal protrusion at this ]eve!. Because of the congenital anomalies in the high thoracic region and the fact that air myelography in our hands i;e; not satisfactory for that level, an iophendylate myelogram was made. There was no evidence of an intraspinal lesion at the level of the hemivertebrae with spina bificla. The significance of a slight deformity that was found in the nerve sleeves in the lower lumbar region was in doubt. The conus medullaris appeared to be at the first lumbar vertebra, which is considered normal. The spinal fluid contained a total protein of 27 mg. per 100 mL (normal). On exploration of the lumbar canal in February 1967, a protruded fourth lumbar cfok was encountered which was compressing the cauda equina; it wa.~ removed. Seventy-two hours after the laminectomy and ren10val of the protruded fourth lumbar disk, the urethral catheter was removed and approximately 4 hours after that the patient began to void in quantities varying between 350 and 550 ml. At dismissal, 9 days postoperatively, micturition was normal. Examination for residual urine revealed only 2 ml. A recent recheck (4 months after operation) showed the patient to be experiencing normal voiding; there was 75 mL dear residual urine pre,eut.
f\01
Remarks. Cases 4 and 5, observed within thr, past 2 months, are somewbat different. In rnse 4, both a protruded third lumbar disk and tumor (epenclyrn.oma) of the cauda equina were present. In both cases some pain was also present, so that the lesions cannot be called asymptomatic. However, both are excellent examples of the early, irritative bladder symptoms which may be present for months or year, before either actual complete retention supervenes or typical symptoms of disk appear. These 2 cases provide some insight into the genesis and the neuropbysiologic mechanisms involved. Case 4. A 38-year-old housewife had been treated at this clinic intermittently since November 1963 for urinary infection that had caused episodes of frequency, urgency, burning and suprapubic distress. She had also complained of difficulty in passing urine and many check, for residual urine revealed amounts from 150 to 600 ml. Chemotherap:r, urethra.l dilatation, administration of bethanechol and local treatment had been ineffective. An excretory urogram gave essentially negative results. In October 1966 some low sacral pain had developed. Roentgen examination of the lumbat region of the spinal column had been Orthopedic consultation in January 1967 had been non-contributory. In :.\!Iarch cystoscopil' examination re,-caled residual urine of 600 ml., no trabecuJation of the bladder, diffuse cystitis cystica and good C'X· pulsive force through the cysto~cope but with definite reduction in sensation. Internal Ull' .. throtomy to 43F gave little if any relief. :\ partial neurologic examination revealed normal achilles and patellar reflexes. There wa,s some evidence of radiculopathy, namely mild pain on forward bending and straight-leg raising 1\.11 air myelogram revealed a protruded third lumbar disk and a filling defect from an intradural tumor which extended from the lower border of L-1 to the upper 111.argin of L-3 (fig. 2). was performed exploration by one of us (.J. G. in April. A protruded third lumbar disk waE; present. vVhen the dura was opened there was a large ependymorna of the filum terminale ancl lower portion of the eonus medullaris.1' Because the tumor was too large to be delivered i11 l piece, it was removed in fragments. H was 11 Whisnant, .J. :P. and Love, J. G. Pitfall in diagnosis of diabetic "cord bladder". Intra.spurn\ ependymoma ..J.A.. M.A., 174: 147--1.50, 1960.
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densely adherent to filaments of cauda. It seemed quite likely that the caudal tumor was sufficient to produce the vesical dysfunction. Therefore, the third lumbar disk was not removed since this would have appreciably increased the risk of the operation. Microscopic examination of the tumor revealed a grade 2 ependymoma in multiple pieces aggregating 1.5 cm. in diameter. As might be expected, edema of the cauda equina from the operative trauma resulted in postoperative neurologic deficits consisting cf patchy perianal hypalgesia (left greater than right) with some weakness of the lower part of the left leg, some reduction in the left ankle jerk and absent anal reflex. There was also some
Frn. 2. Case 4. Air myelogram lateral view. There is negative filling defect from intramedullary tumor of terminal conus and filum terminale. Upper and lower margins of tumor are indicated by upper and lower vertical arrows. Erosion of second lumbar vertebra from tumor with widening of vertebral canal is indicated by upper horizontal arrow. Defect from protruded L-3 disk is indicated by lower horizontal arrow.
pain in the posterior region of the thighs. The patient complained of the numbness. We consider this situation to be temporary and a repeat examination 6 weeks postoperatively revealed that the neurologic deficits are diminishing. The catheter was removed 1 week postoperatively but the patient was unable to void. It was removed again 2 weeks postoperatively and she has been voiding fairly well since, tbe first check for residual urine showing 100 ml. The last residual check (6 weeks postoperatively) showed 60 ml. We expect that it will be some time yet before optimum results can he realized. Whether the protruded disk at L-3 will require removal at a later date is not known. The malignancy of the tumor also clouds the prognosis. Decision regarding postoperative irradiation has not yet been made. Case 5. Our most recent case is that of a 41year-old woman who for about 2 or 3 years had complained of recurring episodes of low back pain. A protruded lumbar disk had been suspected as the cause but conservative treatment had been advised. In April 1965 the patient began to complain of recurring episodes of bladder irritability consisting of frequency and urgency. At times the frequency was as often as every 15 to 30 minutes, associated with nocturia of 3 to 4 time8. No infection could be demonstrated in the urine and cystoscopy bad been reported as revealing chronic urethritis. Treatment, consisting of urethral dilatation, urethral suppositories, sitz baths and so on, was not effective. The episodes continued to be bothersome during the ensuing year. In March 1966 the patient had an episode of acute low back pain accompanied by some signs of radiculopathy which suggested protruded disk. By September, in addition to the frequency and urgency of urination, symptoms cf urinary obstruction developed consisting of difficulty in initiating the stream, straining to void, interruption of the stream, dribbling and a feeling cf incomplete voiding. Intermittent pain developed in the right lower region of the abdomen. (It was suggested that a moderate right renal ptosis might be responsible for the pain.) By May 1967 the urinary symptoms bad become so troublesome that urologic re-evaluation was requested. Excretory urography was negative except for a moderate right renal ptosis. Cystoscopy shmved
URINARY RETENTION CAUSED BY PROTRUDED DISK
no residual mine and no 1rabeculation but did demonstrate markedly reduced sensation; the patient was hardly aware that the cystoscope was in place and the trigone could be roughly scraped with the heel of the scope without discomfort to the patient. The capacity of the bladder was 500 ml., and when it was distended to this degree the patient had no desire to void and recognized it only hy abdominal distention and supra.pubic distress, which was most marked in the lower abdominal region on the right side (the same location as the long-standing pain). :\Jeurologic examination revealed some questionable hypalgesia in the left perianal area. The anal reflex was normal, ankle and knee were normal and no muscular weakness could be demonstrated. There were some mildly positive signs of radiculopathy consisting of painful straight-leg rai.,ing and some limitation of forward and lateral bending. An air myelogram showed a midline Jirotruded
Fm. 3. Case 5. Air myelogram, lateral view. Defect from protruded L-4 disk (arrow).
fourth lumbar disk (fig. 3). tion \Vas advised. At operation performed by one of us G. in May, a compressed and hyper-irritable eauds equina was found caused protrusion ol the fourth lumbar disk. The disk was rcmoncl and the lumbar spinal column was fused with g bilateral bone graft. At this writing, the urinar~· syrn.ptoms have almost disapriearecl. She now sleeps through tlw without voiding. The day frequency and urgency have disappeared and she voids free]:1·. Thn right lower abdominal clistrC'ss bas abo peared. Dic,CUSSJON
The term asymptomatic disk require~ ,,umc, clarification. It has always been taught thal pain is an absolute prerequisite to the of protruded lumbar disk. The pain is considered to be the result of radiculopathy (nerve j'OOt irritation) from pressure from the disk on 1he nerve root. The radiculopathy i,; manife~ted spasm of the erector spinae muscles, limited or painful motions of the trunk, positive sign (painful straight-leg raising), listing of t be trunk and a limp. A history of injury may or may not be obtained. 7 • 8 :;'IJeurologic deficits (sensory, motor or may or may not be present, such as loss oi kiw(, and ankle jerks, numbness in the perinea! weakness of the leg muscles and so on. The presence of numbness and masclc weakrn'.~" ha~ been considered to indicate involvement of the cauda equina. Urinary and bowel dysfunction have been noted with symptomatic protruded disk,, bm these findings have been reported only infrrquently and have almost always been a,sociatrd with demonstrable neurologic defieits. The demonstration that vesical progressing to urinary retention can be caused by an asymptomatic protruded disk is a hope to the patient suffering from this condition, but it also places heavy on the physician. The fact that in 3 of our Fi nr cases the myelograms were either equivocal means that often diagnrn,is will be made only at operative exploration. Thus there will no doubt be negative explorations, whcli tor obvious reasons must be kept at a minimum. Certainly operative exploration of the Ju.ml.Jo
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sacral spinal region should not be performed in all cases of unexplained urinary retention in women. In an effort to pinpoint signs, symptoms and diagnostic procedures which may be helpful in selecting cases for exploration, we have critically analyzed the data from our 5 cases. As experience and the number of cases increase we hope that selection of cases may be more accurate. Sex and weight. All of our patients have been women. We do not know if this is significant or just a chance occurrence. Three of the 5 women were obese. Enuresis in childhood. Three of the 5 women had a history of enuresis in childhood. vVe have speculated whether this might indicate some abnormality in bladder innervation or an unusually vulnerable cauda equina. Ifistory of infury. There was a definite history of injury in 3 of the 5 cases, although in 2 cases it was not recalled, in spite of careful questioning, until after operation. In case 5, the patient had had a severe back injury while in college 20 years previously; the significance of this injury is in doubt. In cases 1 and 2, injury immediately preceded the onset of irritative bladder symptoms. Associated bowel dysfunction. In 2 cases (cases 1 and 2) bowel dysfunction was present consisting of inability to have a bowel movement more often than once every 3 to 5 days. After operation, bowel function returned to normal. Vesical dysfunction associated with typical symptoms of protruded disk. In the first 3 cases no typical symptoms of disk were present (such as pain, neurologic deficits and evidence of radiculopathy). In case 4, pain in the sacral region developed almost 3 years after the onset of the urinary symptoms. In case 5, mild episodes of typical disk pain had been associated with and preceded the onset of vesical dysfunction. Irritative vesical symptoms preceding retention. One of the most illuminating observations to come out of this study is that women with complete urinary retention were found (on close questioning) to have had intermittent vesical dysfunction and irritability since an injury which had apparently caused the protruded disk. In case 1, this had gone on for almost 5 years, culminating in complete retention. In case 2, it had been present for about 2 years, culminating in retention and overflow incontinence. In case 3,
it had been present off and on for many years, periodically resulting in complete retention. These prodromal symptoms often are forgotten by the patient and are brought out only by careful questioning. Urologic examination. The urologic examination has been definitely helpful in selecting these cases and we may learn more from it as experience increases. In none of the cases has the upper urinary tract been compromised from the urinary retention, as demonstrated by excretory uroggraphy. This is somewhat reminiscent of the time when tabes dorsalis was common. 12 It was not unusual then to see patients with greatly distended bladders of long standing (distended with 2 to 5 liters of urine) with normal upper urinary tracts. The most characteristic urologic findings appear to be a result of a defect in the sensory perception of the bladder, which was demonstrated in all 5 cases. (It was demonstrated by cystoscopy in all 5 and by cystometry in the 3 cases in which this examination was performed.) Cystoscopically, there has been diminished or absent sensation with almost complete absence of pain when the cystoscope is in place. Even brusque movements of the instrument and scraping and prodding of the trigone are recognized poorly or not at all by the patient. An important finding has been the absence of normal awareness of bladder distention. The patient does not eJqJerience the typical desire to void but simply feels lower abdominal distention and distress when the bladder is overdistended. It is of interest in case 5 that this discomfort was localized over the lower abdominal region on the right side, the site of the pain of which she had been complaining. Another important finding we believe is the total absence of trabeculation of the bladder despite large quantities of residual urine. There appeared to be reasonably normal expulsive force through the cystoscope in all cases. The bladder neck and the urethra have been essentially normal in appearance. Although we have not made cystometrograms at this clinic on these cases, this test was done elsewhere in the first 3 cases and poor sensory response to filling was noted in all cases. At 1 2 Emmett, J. L. and Beare, J.B.: Transurethral resection for vesical dysfunction in cases of tabes dorsalis. J.A.M.A., 136: 1093-1096, 1948.
URINARY RETENTION CAUSED BY PROTRUDED DISK
present we believe that we get as much information (or even more) from careful cystoscopy as we would from a cystometrogram. Roentgenographic examination of the spinal column. In all cases the roentgenograms of the spinal column showed mini1nal to pronounced congenital abnormalities, such as spina bifida occulta, hemivertebrae, spondylolysis and widening of the lumbar region of the spinal canal. Myelography. We are concerned that the myelograms in the first 3 cases were either negative or equivocal because the defects were so small as to seem of questionable importance. The reason for this appears to be the increased anteroposterior depth of the spinal canal in the lower lumbar region, where the cauda equina and dural canal tend to drift away from the posterior surface of the spinal column; apparently this permits relatively large protruded disks to be present without producing the typical negative defect in the myelogram. Possibly some improvement in technique can be worked out to yield a higher percentage of positive films. Physiopathologic mechanism involved. It is difficult to explain the mechanism in these cases. That none of the patients had appreciable bladder sensation or trabeculation, and yet all retained normal expulsive force, suggests a sensory neurologic deficit produced by pressure of the protruded disk on the cauda equina. Removal of the lesions compressing the cauda equina was sufficient to re-establish normal bladder micturition. Psychiatn:c aspect. The findings in these cases seriously weaken the concept of psychogenic retention. This is an example of the experience that, as knowledge increases, the incidence of organic diagnoses increases and that of functional diagnoses declines. Psychogenic retention could easily have been diagnosed in the first 3 cases, especially cases l and 2. Although it would be unwise at this point to condemn the diagnosis of psychogenic retention, it does seem increasingly clear that organic lesions must be carefully searched for. SDllHIARY
Five cases of vcsical dysfunction in women have been reported that were caused by protruded lumbar disks (with an assoriated tumor of the cauda equina in l). In 4 cases the dysfunction consisted of urinary retention, which was
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total in 3 and incomplete in L In the fifth case, the dysfunction was urgency, and difficulty in voiding which had not yet reached the retention stage. The 3 patients with complete retention had all experienced episodes of frequency, urgency and bladder irritability for long periods before complete retention occurred. The 2 other pn· tients had not yet rea,ched the point of total retention. Urologic examination in all cases, absence of trabeculation, great reduction in sensation, absence of the norrual desire to void and apparently normal expulsivf, force through the cystoscope Distention of the bladder was recognized the jlatient chiefly lower abdominal distention and distrcst::. In 1 case of complete retention, overflow incontinencr had developed, In the first 3 cases the protruded disks vrnre entirely asymptcmatic and the result,, of physical and neurologic examinations wrre negative. Myelography was negative or cal. In all patients a protruded lumbar disk Wfl..', found. In 1 case there was al.so an cpendymorna of the cauda equina. Three of the patients liad 11 history of a. definite low back injury sustained before the initial urinary symptoms had developed. The 4 patients v;ith protrnded diHks were completely relieved of their symptoms and retention imrnediately after operative removal of the disk In the riaticnt with the a,sociatecl large tumor, the tumm was removed , t.o avoid increasing the risk of the operation, the disk was not removed. This patient has experienced some transient neurologic deficits, which are diminishing. She is still under observation. The mechanism of this form cf urinary re tention is believed to be a sensory ncurolog1c defect produced by pressure of a protruded disk on the cauda equina. ADDENDUM*
In the 4 months that have since thi~ paper was read, 6 a.dditional patients have been encountered and operated on, a total of 11 eases. Excellent results have been achieved in all cept one. In the one exception, micturition has returned to normal for the fir8t time in rnany years, but a residual urine of 200 mL (preoperative residual was 600 ml.). We suspect that a mild postoperative contracture of the *Written September 15, 1967.
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vesical neck from previous transurethral resections may explain this. Also, preoperative abnormal bowel function has returned to normal. A brief summary and analysis of these six additional cases follow. The ages of these women varied from 18 to 67 years. The level of the disk was L-4 in all except one (L-3). The myelogram was positive in four and negative or equivocal in two. The neurologic examination was negative in all. The typical cystoscopic findings (described above) were present in all. The amount of residual urine in each was 3,000, 200-600, 200-500, 150, 75 and 50 ml. Associated bowel dysfunction was present in two of the 6 cases; it was relieved after operation. Irritative vesical symptoms either preceding retention or as the presenting complaint were present in all except one case, that of a woman, age 67, who had sought medical help because of an enlarging abdomen. There had been no urinary symptoms, the only discomfort having been the lower abdominal fullness. A diagnosis had been made elsewhere of a pelvic tumor and operation had been advised. While the patient was being anesthetized for abdominal exploration, urine began passing through the urethra. Catheterization removed 3,000 ml. of urine; the abdominal mass disappeared, so that the operation was not performed. An indwelling urethral catheter for 4 months had not restored normal voiding. Our air myelogram was positive, and removal of the asymptomatic fourth lumbar disk restored normal micturition. Whereas in the original 5 cases (herein described) typical disk-type back and leg pain with signs of radiculopathy was present in only one (case 5), it was a prominent feature in two of the six additional cases. In one of these, the patient stated that during periods of most severe pain her bowels would not move well. It
should be pointed out that in 3 of the 11 cases, some degree of typical disk-type back and leg pain was present and therefore the term "asymptomatic" disk used in the title of this paper is no longer entirely accurate. We expect to encounter more and more patients who have varying degrees of typical or atypical disk symptoms. We continue to be impressed with patients who complain of pain in the abdomen, flank or ingui'.nal region associated with irritative vesical symptoms, somewhat similar to the situation in case 5 in this paper. Typical was a woman, age 41, who was sent to our clinic for a right nephrectomy because of "pyelonephritL~" and ureteral obstruction. For 4 months she had "been sitting on the toilet trying to void" and suffering with pain in the right lower abdomen which radiated to the right flank. There had been one or two episodes of fever. U rographically, mild right pyeloureterectasis could be demonstrated; the ureter was dilated to the level of S-1, a picture suggesting "right ovarian vein syndrome". Cystoscopy demonstrated the typical findings herein described. There was a residual urine of 75 ml. Distension of the bladder reproduced the right abdominal and right flank pain whereas a retrograde pyelogram would not (even with overfilling). An air myelogram revealed an L-4 protruded disk, and all of the symptoms were completely relieved when it was removed. Although she could recall no previous injury, she did remember that 12 years previously she had been hospitalized for 12 days with a severe back pain which had been successfully treated with traction. It seems significant to point out here that 10 of the total of 11 patients have been cared for since January 1967, a period of only 9}-i months. This would seem to indicate that the condition is more common than we ha.ve suspected.