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Abacterial Cystitis: Treatment with Sodium Oxychlorosene
Vol. 116, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
ABACTERIAL CYSTITIS: TREATMENT WITH SODIUM OXYCHLOROSENE JOHN N. WETTLAUFER From the Urology Service, Department of Surgery, Madigan Army Medical Center, Tacoma, Washington
ABSTRACT
The effectiveness of intravenous arsenicals (neoarsphenamine and oxophenarsine hydrochloride) for abacterial cystitis is well established but these agents currently are not available. A complete response to intravesical sodium oxychlorosene in 2 patients with well documented abacterial cystitis is detailed. Abacterial cystitis (pyuria) was first described by Reiter in 1916. 1 Subsequently; several reports have detailed its clinical manifestations and therapy .... This unusual urologic disorder of unknown etiology characteristically afflicts young men between 20 and 30 years old, producing variable local (non-systemic) lower urinary tract infectious-like symptoms with sterile pyuria and often hematuria. Physical examination usually is non-specific, with suprapubic tenderness being the most common finding. Patients with severe bladder symptoms may show dilated terminal ureters with contracted deformed bladders on excretory urography (IVP). Endoscopic findings in severe cases may be unique, that is diffuse velvety red edematous mucosa frequently with an exudate and ulcerations, occasionally confused with tumor. 5 Biopsy reveals acute and/or chronic non-specific inflammation. Treatment with anti-infective agents and bladder sedatives is classically unsuccessful. Intravenous arsenicals (neoarsphenamine and oxophenarsine hydrochloride) are the treatment of choice and are curative with rare exception. However, the manufacture of these agents has been discontinued in this country and, thus, they are not readily available. We, as well as others, have had variable but definite success in treating patients with other types of cystitis (interstitial 6 • 7 and tuberculous 8) with sodium oxychlorosene. * Because of the aforementioned experience and the non-availability of the arsenical preparations we have treated our last 2 patients with unequivocal abacterial cystitis with intravesical instillations of sodium oxychlorosene. Both patients had a rapid complete response to this agent.
bladder findings as noted previously. Review of the transfer slides and tissue obtained at the second biopsy revealed severe acute and chronic cystitis with areas of mucosal necrosis, granulation tissue and pleomorphic, inflammatory cellular infiltrate of neutrophils, eosinophils, plasma cells, lymphocytes and histiocytes. No micro-organisms were identified with fungal, acid-fast and tissue Gram stains. The patient received the first intravesical instillation of 0.1 per cent solution of sodium oxychlorosene 2 weeks after the biopsy. Within 3 days the symptoms were improved markedly. He received a second treatment 7 days later and was discharged from the hospital essentially free of symptoms and has had no recurrence to date. Case 2. D. E., a 19-year-old white man, presented with progressive urgency, frequency, dysuria, stranguria and terminal gross hematuria 2 weeks in duration. Physical examination was normal. Urinalysis revealed white and red blood cells, and epithelial cells too numerous to count. Multiple urine cultures for the usual organisms and acid-fast bacillus revealed no growth. On IVP there was segmental terminal ureterectasis with a small deformed bladder (part A of figure). At endoscopy under anesthesia the bladder capacity was 50 to 75 cc, with diffuse mucosal hyperemia and edema of the entire wall. Multiple bladder biopsies revealed acute and chronic cystitis. Three days later the patient was treated with intravesical sodium oxychlorosene. Within 6 days voided volumes were 400 cc and the patient was virtually without symptoms (part B of figure). He had 2 additional bladder instillations of sodium oxychlorosene 7 and 30 days later and has remained free of symptoms.
CASE REPORTS
DISCUSSION
Case 1. C. M., a 17-year-old white man, had terminal gross The chemical composition and reaction of sodium oxychlorohematuria with severe dysuria and marked frequency of sene have been well defined. 9 • 10 It has potent bactericidal, urination 8 weeks in duration. Urinalysis revealed red and fungicidal, virulicidal and anti-inflammatory action. The techwhite blood cells too numerous to count with negative multiple nique of treatment in interstitial cystitis has been outlined by urine cultures for aerobic and anaerobic organisms, acid-fast O'Conor 6 and, subsequently, by Wishard and associates. 7 In bacillus and gonococcic infection. Physical examination was our cases we prepared a 0.1 per cent solution by dissolving the unremarkable and an IVP was normal. Endoscopy under a standard 2 gm. soluble powdered aliquot in 2,000 cc warm local anesthetic was unsuccessful because of severe bladder sterile water. After the bladder is emptied with a catheter it is spasms. At cystoscopy under anesthesia there was diffuse filled to gravity tolerance by elevating the Kelly flask to 30 cm. mucosal hyperemia and edema with an area of white exudate After 30 to 60 seconds the solution is withdrawn and the bladder on the mid posterior wall. Multiple bladder biopsies were again is filled to gravity tolerance. This procedure is repeated interpreted as grade II transitional cell carcinoma of the 3 to 5 times with the total bladder exposure time not to exceed bladder and the patient was transferred to our institution with 5 minutes. Before the catheter is removed the bladder is rinsed continued severe lower urinary tract infectious-irritative symp- thoroughly with warm sterile water. Intravenous diazepam was toms with mucoid-appearing urine. Repeat panendoscopy and adequate in managing the discomfort in the 2 patients. The bladder biopsy were done under anesthesia with the same treatment can be repeated at weekly intervals. To our knowledge this is the first report detailing the use of Accepted for publication March 26, 1976. * Clorpactin WCS-90, Guardian Chemical Corp. Hauppauge, Long sodium oxychlorosene in the treatment of abacterial cystitis. The complete response in our 2 patients is gratifying and sugIsland, New York. 434
ABACTERIAL CYSTITIS: TREATMENT WITH SODIUM OXYCHLOROSENE
I I
Case 2. A, pre-treatment IVP with terminal ureterectasis and small irregular bladder. B, cystogram 6 days after first treatment shows normal bladder.
gests that this agent needs further evaluation in treating this condition, especially in view of the non-availability of the intravenous arsenicals. REFERENCES
1. Reiter, H.: Uber eine bisher unerkannate Spirochateninfektion.
Deutsch. med. Wohnschr., 42: 1535, 1916. 2. Wildbolz, H.: On amicrobic pyuria. J. Urol., 37: 605, 1937. 3. Landes, R. R. and Ransom, C. L.: Abacterial pyuria: possible relationship to Reiter's syndrome. J. Urol., 60: 666, 1948. 4. Sillar, S. R.: Abacterial cystitis. Urol. Digest, 9: 12, 1970.
5. Hewitt, C. B., Stewart, B. H. and Kiser, W. S.: Abacterial pyuria. J. Urol., 109: 86, 1973. 6. O'Conor, V. J.: Clorpactin WCS 90 in the treatment of interstitial cystitis. Quart. Bull. N.W. Univ. Med. School., 29: 392, 1955. 7. Wishard, W. N., Jr., Nourse, M. H. and Mertz, J. H. 0.: Use of clorpactin WCS 90 for relief of symptoms due to interstitial cystitis. J. Urol., 77: 420, 1957. 8. Lattimer, J. K. and Spirito, A. L.: Clorpactin for tuberculous cystitis. J. Urol., 73: 1015, 1955. 9. Swanker, W. A.: Use of clorpactin WCS 90 as an antiseptic in surgery. Amer. J. Surg., 90: 44, 1955. 10. Zwerling, M.: Clorpactin WCS 90: a new antiseptic. Arch. Otolar., 62: 157, 1955.
THE JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
ABACTERIAL CYSTITIS: TREATMENT WITH SODIUM OXYCHLOROSENE JOHN N. WETTLAUFER From the Urology Service, Department of Surgery, Madigan Army Medical Center, Tacoma, Washington
ABSTRACT
The effectiveness of intravenous arsenicals (neoarsphenamine and oxophenarsine hydrochloride) for abacterial cystitis is well established but these agents currently are not available. A complete response to intravesical sodium oxychlorosene in 2 patients with well documented abacterial cystitis is detailed. Abacterial cystitis (pyuria) was first described by Reiter in 1916. 1 Subsequently; several reports have detailed its clinical manifestations and therapy .... This unusual urologic disorder of unknown etiology characteristically afflicts young men between 20 and 30 years old, producing variable local (non-systemic) lower urinary tract infectious-like symptoms with sterile pyuria and often hematuria. Physical examination usually is non-specific, with suprapubic tenderness being the most common finding. Patients with severe bladder symptoms may show dilated terminal ureters with contracted deformed bladders on excretory urography (IVP). Endoscopic findings in severe cases may be unique, that is diffuse velvety red edematous mucosa frequently with an exudate and ulcerations, occasionally confused with tumor. 5 Biopsy reveals acute and/or chronic non-specific inflammation. Treatment with anti-infective agents and bladder sedatives is classically unsuccessful. Intravenous arsenicals (neoarsphenamine and oxophenarsine hydrochloride) are the treatment of choice and are curative with rare exception. However, the manufacture of these agents has been discontinued in this country and, thus, they are not readily available. We, as well as others, have had variable but definite success in treating patients with other types of cystitis (interstitial 6 • 7 and tuberculous 8) with sodium oxychlorosene. * Because of the aforementioned experience and the non-availability of the arsenical preparations we have treated our last 2 patients with unequivocal abacterial cystitis with intravesical instillations of sodium oxychlorosene. Both patients had a rapid complete response to this agent.
bladder findings as noted previously. Review of the transfer slides and tissue obtained at the second biopsy revealed severe acute and chronic cystitis with areas of mucosal necrosis, granulation tissue and pleomorphic, inflammatory cellular infiltrate of neutrophils, eosinophils, plasma cells, lymphocytes and histiocytes. No micro-organisms were identified with fungal, acid-fast and tissue Gram stains. The patient received the first intravesical instillation of 0.1 per cent solution of sodium oxychlorosene 2 weeks after the biopsy. Within 3 days the symptoms were improved markedly. He received a second treatment 7 days later and was discharged from the hospital essentially free of symptoms and has had no recurrence to date. Case 2. D. E., a 19-year-old white man, presented with progressive urgency, frequency, dysuria, stranguria and terminal gross hematuria 2 weeks in duration. Physical examination was normal. Urinalysis revealed white and red blood cells, and epithelial cells too numerous to count. Multiple urine cultures for the usual organisms and acid-fast bacillus revealed no growth. On IVP there was segmental terminal ureterectasis with a small deformed bladder (part A of figure). At endoscopy under anesthesia the bladder capacity was 50 to 75 cc, with diffuse mucosal hyperemia and edema of the entire wall. Multiple bladder biopsies revealed acute and chronic cystitis. Three days later the patient was treated with intravesical sodium oxychlorosene. Within 6 days voided volumes were 400 cc and the patient was virtually without symptoms (part B of figure). He had 2 additional bladder instillations of sodium oxychlorosene 7 and 30 days later and has remained free of symptoms.
CASE REPORTS
DISCUSSION
Case 1. C. M., a 17-year-old white man, had terminal gross The chemical composition and reaction of sodium oxychlorohematuria with severe dysuria and marked frequency of sene have been well defined. 9 • 10 It has potent bactericidal, urination 8 weeks in duration. Urinalysis revealed red and fungicidal, virulicidal and anti-inflammatory action. The techwhite blood cells too numerous to count with negative multiple nique of treatment in interstitial cystitis has been outlined by urine cultures for aerobic and anaerobic organisms, acid-fast O'Conor 6 and, subsequently, by Wishard and associates. 7 In bacillus and gonococcic infection. Physical examination was our cases we prepared a 0.1 per cent solution by dissolving the unremarkable and an IVP was normal. Endoscopy under a standard 2 gm. soluble powdered aliquot in 2,000 cc warm local anesthetic was unsuccessful because of severe bladder sterile water. After the bladder is emptied with a catheter it is spasms. At cystoscopy under anesthesia there was diffuse filled to gravity tolerance by elevating the Kelly flask to 30 cm. mucosal hyperemia and edema with an area of white exudate After 30 to 60 seconds the solution is withdrawn and the bladder on the mid posterior wall. Multiple bladder biopsies were again is filled to gravity tolerance. This procedure is repeated interpreted as grade II transitional cell carcinoma of the 3 to 5 times with the total bladder exposure time not to exceed bladder and the patient was transferred to our institution with 5 minutes. Before the catheter is removed the bladder is rinsed continued severe lower urinary tract infectious-irritative symp- thoroughly with warm sterile water. Intravenous diazepam was toms with mucoid-appearing urine. Repeat panendoscopy and adequate in managing the discomfort in the 2 patients. The bladder biopsy were done under anesthesia with the same treatment can be repeated at weekly intervals. To our knowledge this is the first report detailing the use of Accepted for publication March 26, 1976. * Clorpactin WCS-90, Guardian Chemical Corp. Hauppauge, Long sodium oxychlorosene in the treatment of abacterial cystitis. The complete response in our 2 patients is gratifying and sugIsland, New York. 434
ABACTERIAL CYSTITIS: TREATMENT WITH SODIUM OXYCHLOROSENE
I I
Case 2. A, pre-treatment IVP with terminal ureterectasis and small irregular bladder. B, cystogram 6 days after first treatment shows normal bladder.
gests that this agent needs further evaluation in treating this condition, especially in view of the non-availability of the intravenous arsenicals. REFERENCES
1. Reiter, H.: Uber eine bisher unerkannate Spirochateninfektion.
Deutsch. med. Wohnschr., 42: 1535, 1916. 2. Wildbolz, H.: On amicrobic pyuria. J. Urol., 37: 605, 1937. 3. Landes, R. R. and Ransom, C. L.: Abacterial pyuria: possible relationship to Reiter's syndrome. J. Urol., 60: 666, 1948. 4. Sillar, S. R.: Abacterial cystitis. Urol. Digest, 9: 12, 1970.
5. Hewitt, C. B., Stewart, B. H. and Kiser, W. S.: Abacterial pyuria. J. Urol., 109: 86, 1973. 6. O'Conor, V. J.: Clorpactin WCS 90 in the treatment of interstitial cystitis. Quart. Bull. N.W. Univ. Med. School., 29: 392, 1955. 7. Wishard, W. N., Jr., Nourse, M. H. and Mertz, J. H. 0.: Use of clorpactin WCS 90 for relief of symptoms due to interstitial cystitis. J. Urol., 77: 420, 1957. 8. Lattimer, J. K. and Spirito, A. L.: Clorpactin for tuberculous cystitis. J. Urol., 73: 1015, 1955. 9. Swanker, W. A.: Use of clorpactin WCS 90 as an antiseptic in surgery. Amer. J. Surg., 90: 44, 1955. 10. Zwerling, M.: Clorpactin WCS 90: a new antiseptic. Arch. Otolar., 62: 157, 1955.