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Another aspect of acute urinary retention in young patients
ORIGINAL CONTRIBUTION acute urinary retention, anal intercourse and; urologic emergencies, acute urinary retention
Another Aspect of Acute ,Urinary Retention in Young Patients Four homosexual men and one heterosexual woman presented with acute urinary retention secondary to intense anal intercourse. All had normal urologic histories. Their residual urine volumes ranged from 475 ml to 1,400 ml. Urinalyses and urine cultures were negative. All were treated with an indwelling Foley catheter and then with bethanechol and dibenzyline. Normal micturition was restored. To evaluate the influence of anal dilatation on detrusor function, five control patients with urge incontinence were studied. A cystometrograrn (CMG) displayed a hyperreflexic bladder pattern in all five patients. Average bladder capacity was 86 m]. Calibrated anal dilatation increased bladder capacity to the average value of 406 mI on CMG. The diameter of anal dilatation ranged from 3.5 cm to 5 cm. Intense anal intercourse producing severe anal dilatation triggers reflex bladder inhibition leading to acute urinary retention. The sensory input travels from the dilated anus to the sacral spinal micturition center, which sends inhibitory stimuli to the urinary bladder. [Godec CJ, Cass AS, Ruiz E: Another aspect of acute urinary retention in young patients. Ann Emerg Med 11:471474, September i982.]
Ciril J. Godec, MD* Alexander S. Cass, MDt Ernest Ruiz, MD ~ Minneapolis, Minnesota St. Paul, Minnesota From the Department of Surgery, Division of Urology,* and the Department of Emergency Medicine, ~ Hennepin County Medical Center, Minneapolis; and the Department of Urology, St. PauI-Ramsey Medical Center? St. Paul, Minnesota. Address for reprints: Ciril J. Godec, MD, Co-head, Department of Urology, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, Minnesota 55415.
INTRODUCTION Acute urinary retention in otherwise healthy young men, and especially in women, is an unusual finding in urologic practice. When it occurs, the usual cause is prostatic or perineal inflammation, urethral stones, or severely inflamed hemorrhoids. A new group of young patients presenting with acute urinary retention has emerged: those with retention resulting from anal intercourse. These patients should be tactfully questioned about their sexual habits. There usually is no history of previous micturition disorders. The likely explanation for acute urinary retention in these patients involves the reflex inhibition of the micturition center in the sacral spinal cord. To document the possible mechanism of action, we performed anal dilatation in a control group of patients after seeing the syndrome in five otherwise healthy patients.
MATERIALS A N D METHODS Five young, otherwise healthy patients (four male homosexuals and one female heterosexual) came to the emergency department of Hennepin County Medical Center with symptoms of acute urinary retention. Four patients underwent cystometric evaluation of the detrusor. The cystometry was performed in the supine position with a 16-Fr Foley catheter and instillation of COz at a rate of fill of 150 cc/min. Foley catheterization was used as the initial form of treatment. After removal, treatment with Duvoid ® (bethanechol chloride) and phenoxybenzamine was started. Informed consent was obtained from all control patients, and the study was approved by the hospital's investigations committee. The control group of five patients was studied with cystometry as well; they all had hyperreflexic bladders. A specially designed, cone-shaped anal dilator with calibration in centimeters (Minnesota Mining and Manufacturing Co, St. Paul) was used for anal dilatation (Figure 1). The diameter of dilatation at the anocutaneous line represented the degree of anal dilatation. 11:9 September 1982
Annals of Emergency Medicine
471/29
ACUTE URINARY RETENTION Godec, Cass & Ruiz
Fig. 1. Cone-shaped anal dilator, diameter calibrated in centimeters.
ANAL DILATOR
With copious use of K-Y jelly, the device was inserted into the anus as deeply as the patient would tolerate. The device was manually retained in this position and a second cystometrogram (CMG) was performed. Anal sphincter electromyography {EMG), using DISA coaxial needles, was performed at the resting condition in all patients before anal dilatation and was displayed on a storage oscilloscope (Tetronics, Beaverton, OR).
RESULTS From May 1977 to December 1980 five patients ranging in age from 18 to 30 years were seen with acute urinary retention. Each had a history of intense anal intercourse prior to the onset of acute urinary retention. Their residual urines ranged from 475 ml to 1,400 ml, and findings on urinalysis and urine cultures were within normal limits. Two had anal warts, two had an anal fissure, and one had had a hemorrhoidectomy one year previously. None had a history of lower urinary tract disease. They were treated initially with an indwelling Foley catheter and then with Duvoid ® (50 mg PO qid) and phenoxybenzamine (10 mg PO qid) until residual urine decreased to less than 50 ml (Table 1). Normal voiding returned within a week in all five patients. For the control group, five patients (three men and two women ranging from 15 to 47 years) were selected with cystometrically documented severe hyperreflexic bladder dysfunction (Table 2}. None of the control group had other pathology demonstrated in their urinary tract on urologic workup. The EMG displayed no reduction in firing of motor units in the anal sphincter. The average bladder capacity in the standing position was 86 ml, with a range of 40 ml to 130 ml. When the second CMG was performed with anal dilatation, the bladder capacity increased to an average value of 406 ml, with a range of 210 ml to 730 ml. The c y s t o m e t r i c profiles b e c a m e either normal or less hyperreflexic (Figure 2).
DISCUSSION Due to the common embryology of the lower urinary and fecal pathways, sensory stimulation in the anal area produces changes in the urethra and 30/472
6
5
4
5
I I
i t
i
I
2
I/2
Diameters measured in Centimeters
1
TABLE 1. Findings and management in patients with acute urinary reter]tion
Sex Age
Residual Urine
Urinalysis/ Urine Culture
Assoc. Disease
Treatment
F
18
475 cc
Negative
Anal fissure
Catheter, bethanechol, dibenzyline
M
30
1,000 cc
Negative
Anal warts
Catheter, bethanechol, dibenzyline
M
30
1,400 cc
Negative
Hemorrhoidectomy one year ago
Catheter, bethanechol, dibenzyline
M
30
1,200 cc
Negative
Anal fissure
Catheter, bethanechol, dibenzyline
M
24
600 cc
Negative
Anal warts
Catheter, bethanechol, dibenzyline
bladder as well as in the anal canal and rectal ampulla. 1 The mechanism involved is reflexive in nature. Severe mechanical or electrical stimulation of the anal area produces massive sensory input to the micturition center in the $2-$4 level of the spinal cord. The efferent response is double: contraction of the anal and urethral sphincter, and inhibition of the bladder and rectal ampulla (Figure 3). The clinical pattern of increased anorectal and colon diseases in homosexual patients is termed the "gay bowel syndrome."2 The clinical observation of acute urinary retention seen Annals of Emergency Medicine
in homosexual patients was paralleled in laboratory studies in patients with hyperreflexic bladders. The intensity of stimulation was gauged with the diameter of the dilatation device. Kiviat et al 3 stressed the importance of precise s t r e t c h i n g of the anal sphincter. If the rectal ampulla were stretched, a bowel movement could be triggered. Rodriguez and Awad 4 found that anal dilatation inhibited ongoing bladder contractions and decreased bladder tone in seven of 12 patients. Rossier and Bors s found that in spinal cord injury patients, introducing or withdrawing a rectal catheter or in11:9 September 1982
TABLE 2. Control group with anal dilatation producing bladder inhibition
Sex Age
CMG Curve Capacity (standing)
Diagnosis
M
27
Nocturnal enuresis
H*
M
34
Urge incontinence
Dilatation (cm)
CMG with Anal Dilatation Curve Capacity (standing)
60
5
N
430
H
80
4.5
N
310
120
4.5
N
350
3.5
LH*
210
N
730
F
37
Stress, urge and urge incontinence
H
M
15
Nocturnal enuresis
H
40
F
47
Urge, frequency, urge incontinence
H
130
4
(Average 86 cc)
(Average 406 cc)
*Hyperreflexic. tNormal. *Less hyperreflexic.
Stondinq_
60r 40
o
/
20
T
E
(D
0
r-
60
Volume
Standing with Anal Dilation ¢.D (D
60r
Fig. 2. Cystometrogram with patient in standing position with anal dilatation 5 cm diameter; cystometric curve before and during anal dilatation. flating or deflating a rectal balloon resulted in i n c o n s i s t e n t bladder response. Among 19 patients, 12 responded with detrusor facilitation, four with inhibition, and two showed facilitation in one examination and inhibition in another. One patient had short-lived inhibition followed by facilitation. It is likely the rectal balloon produced different degrees of anal dilatation in different patients, thus explaining their inconsistent results. In our study, dilatation was precisely performed and recorded, resulting in consistent responses in bladder tone. The anal area represents one of the most receptive areas for sensory input for bladder inhibition. The inhibitory s t i m u l a t i o n from the dilated anal sphincter is carried to the sacral mict u r i t i o n center through pudendal nerves. From the system of polysynaptic reflex transmissions in the $2-$4 sacral spinal cord, the motor inhibitory impulses to the bladder are carried through parasympathetic pelvic nerves. In the study group, bladder function was clinically normal before the acute urinary retention occurred. We postulate that the massive sensory input from severe anal dilatation paralyzed the normal bladders. In the control group, hyperreflexic bladders were converted to normal in four, and to less hyperreflexic in one patient with different degrees of anal dilatation. The c o m m o n embryologic development of the lower urinary and fecal pathways could explain the involvement of sacral spinal reflexes in the mechanism of micturition and defecation.
EL.
40 20 0 11:9 September 1982
Volume
430
Annals of Emergency Medicine
CONCLUSION It is likely that urinary retention is triggered when the intensity of anal stimulation reaches the threshold for bladder inhibition. Emergency physicians should be aware of the close correlation between bladder dyshanction and unusual sexual practices. The absence of previous urological diseases and a history of anal intercourse may provide a clue to the diagnosis. Sophisticated urodynamic investigation is not necessary. In the emergency department, the patient should get ade473/31
ACUTE URINARY RETENTION Godec, Cass & Ruiz
F i g . 3. T h e m e c h a n i s m
of a n a l dilatation triggering simultaneously bladder inhibition and contraction of the pelvic floor.
SPINAL CORD
quate treatment, including Foley catheter, b e t h a n e c h o l chloride, and p h e n o x y b e n z a m i n e . If this approach does not improve the condition, the patient should be referred to a urologist.
f /
REFERENCES 1. Godec CJ, Ayala G, Cass AS: Electrical stimulation of the rectal ampulla causing reflex voiding. J UroI 117:772, 1977. 2. Sohn N, Robilotti JG: The "Gay Bowel Syndrome." Am J Gastroenterol 67:478, 1977. 3. Kiviat MD, Zimmerman TA, Donovan WH; Sphincter stretch: A new technique resulting in continence and complete voiding in paraplegics. J Urol 114:895, 1975. 4. Rodriguez AA, Awad E: Detrusor muscle and sphincter response to anorectal stimulation in spinal cord injury. Arch Phys Med Rehabil 60:269, 1979. 5. Rossier A, Bors E: Detrusor responses to perianal and rectal stimulation in patients with spinal cord injuries. Urol Int 18:181, 1964.
32/474
RECTAL AMPULLA
i
) PELV,O P,OO
3
Annals of Emergency Medicine
11:9 September 1982
Another Aspect of Acute ,Urinary Retention in Young Patients Four homosexual men and one heterosexual woman presented with acute urinary retention secondary to intense anal intercourse. All had normal urologic histories. Their residual urine volumes ranged from 475 ml to 1,400 ml. Urinalyses and urine cultures were negative. All were treated with an indwelling Foley catheter and then with bethanechol and dibenzyline. Normal micturition was restored. To evaluate the influence of anal dilatation on detrusor function, five control patients with urge incontinence were studied. A cystometrograrn (CMG) displayed a hyperreflexic bladder pattern in all five patients. Average bladder capacity was 86 m]. Calibrated anal dilatation increased bladder capacity to the average value of 406 mI on CMG. The diameter of anal dilatation ranged from 3.5 cm to 5 cm. Intense anal intercourse producing severe anal dilatation triggers reflex bladder inhibition leading to acute urinary retention. The sensory input travels from the dilated anus to the sacral spinal micturition center, which sends inhibitory stimuli to the urinary bladder. [Godec CJ, Cass AS, Ruiz E: Another aspect of acute urinary retention in young patients. Ann Emerg Med 11:471474, September i982.]
Ciril J. Godec, MD* Alexander S. Cass, MDt Ernest Ruiz, MD ~ Minneapolis, Minnesota St. Paul, Minnesota From the Department of Surgery, Division of Urology,* and the Department of Emergency Medicine, ~ Hennepin County Medical Center, Minneapolis; and the Department of Urology, St. PauI-Ramsey Medical Center? St. Paul, Minnesota. Address for reprints: Ciril J. Godec, MD, Co-head, Department of Urology, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, Minnesota 55415.
INTRODUCTION Acute urinary retention in otherwise healthy young men, and especially in women, is an unusual finding in urologic practice. When it occurs, the usual cause is prostatic or perineal inflammation, urethral stones, or severely inflamed hemorrhoids. A new group of young patients presenting with acute urinary retention has emerged: those with retention resulting from anal intercourse. These patients should be tactfully questioned about their sexual habits. There usually is no history of previous micturition disorders. The likely explanation for acute urinary retention in these patients involves the reflex inhibition of the micturition center in the sacral spinal cord. To document the possible mechanism of action, we performed anal dilatation in a control group of patients after seeing the syndrome in five otherwise healthy patients.
MATERIALS A N D METHODS Five young, otherwise healthy patients (four male homosexuals and one female heterosexual) came to the emergency department of Hennepin County Medical Center with symptoms of acute urinary retention. Four patients underwent cystometric evaluation of the detrusor. The cystometry was performed in the supine position with a 16-Fr Foley catheter and instillation of COz at a rate of fill of 150 cc/min. Foley catheterization was used as the initial form of treatment. After removal, treatment with Duvoid ® (bethanechol chloride) and phenoxybenzamine was started. Informed consent was obtained from all control patients, and the study was approved by the hospital's investigations committee. The control group of five patients was studied with cystometry as well; they all had hyperreflexic bladders. A specially designed, cone-shaped anal dilator with calibration in centimeters (Minnesota Mining and Manufacturing Co, St. Paul) was used for anal dilatation (Figure 1). The diameter of dilatation at the anocutaneous line represented the degree of anal dilatation. 11:9 September 1982
Annals of Emergency Medicine
471/29
ACUTE URINARY RETENTION Godec, Cass & Ruiz
Fig. 1. Cone-shaped anal dilator, diameter calibrated in centimeters.
ANAL DILATOR
With copious use of K-Y jelly, the device was inserted into the anus as deeply as the patient would tolerate. The device was manually retained in this position and a second cystometrogram (CMG) was performed. Anal sphincter electromyography {EMG), using DISA coaxial needles, was performed at the resting condition in all patients before anal dilatation and was displayed on a storage oscilloscope (Tetronics, Beaverton, OR).
RESULTS From May 1977 to December 1980 five patients ranging in age from 18 to 30 years were seen with acute urinary retention. Each had a history of intense anal intercourse prior to the onset of acute urinary retention. Their residual urines ranged from 475 ml to 1,400 ml, and findings on urinalysis and urine cultures were within normal limits. Two had anal warts, two had an anal fissure, and one had had a hemorrhoidectomy one year previously. None had a history of lower urinary tract disease. They were treated initially with an indwelling Foley catheter and then with Duvoid ® (50 mg PO qid) and phenoxybenzamine (10 mg PO qid) until residual urine decreased to less than 50 ml (Table 1). Normal voiding returned within a week in all five patients. For the control group, five patients (three men and two women ranging from 15 to 47 years) were selected with cystometrically documented severe hyperreflexic bladder dysfunction (Table 2}. None of the control group had other pathology demonstrated in their urinary tract on urologic workup. The EMG displayed no reduction in firing of motor units in the anal sphincter. The average bladder capacity in the standing position was 86 ml, with a range of 40 ml to 130 ml. When the second CMG was performed with anal dilatation, the bladder capacity increased to an average value of 406 ml, with a range of 210 ml to 730 ml. The c y s t o m e t r i c profiles b e c a m e either normal or less hyperreflexic (Figure 2).
DISCUSSION Due to the common embryology of the lower urinary and fecal pathways, sensory stimulation in the anal area produces changes in the urethra and 30/472
6
5
4
5
I I
i t
i
I
2
I/2
Diameters measured in Centimeters
1
TABLE 1. Findings and management in patients with acute urinary reter]tion
Sex Age
Residual Urine
Urinalysis/ Urine Culture
Assoc. Disease
Treatment
F
18
475 cc
Negative
Anal fissure
Catheter, bethanechol, dibenzyline
M
30
1,000 cc
Negative
Anal warts
Catheter, bethanechol, dibenzyline
M
30
1,400 cc
Negative
Hemorrhoidectomy one year ago
Catheter, bethanechol, dibenzyline
M
30
1,200 cc
Negative
Anal fissure
Catheter, bethanechol, dibenzyline
M
24
600 cc
Negative
Anal warts
Catheter, bethanechol, dibenzyline
bladder as well as in the anal canal and rectal ampulla. 1 The mechanism involved is reflexive in nature. Severe mechanical or electrical stimulation of the anal area produces massive sensory input to the micturition center in the $2-$4 level of the spinal cord. The efferent response is double: contraction of the anal and urethral sphincter, and inhibition of the bladder and rectal ampulla (Figure 3). The clinical pattern of increased anorectal and colon diseases in homosexual patients is termed the "gay bowel syndrome."2 The clinical observation of acute urinary retention seen Annals of Emergency Medicine
in homosexual patients was paralleled in laboratory studies in patients with hyperreflexic bladders. The intensity of stimulation was gauged with the diameter of the dilatation device. Kiviat et al 3 stressed the importance of precise s t r e t c h i n g of the anal sphincter. If the rectal ampulla were stretched, a bowel movement could be triggered. Rodriguez and Awad 4 found that anal dilatation inhibited ongoing bladder contractions and decreased bladder tone in seven of 12 patients. Rossier and Bors s found that in spinal cord injury patients, introducing or withdrawing a rectal catheter or in11:9 September 1982
TABLE 2. Control group with anal dilatation producing bladder inhibition
Sex Age
CMG Curve Capacity (standing)
Diagnosis
M
27
Nocturnal enuresis
H*
M
34
Urge incontinence
Dilatation (cm)
CMG with Anal Dilatation Curve Capacity (standing)
60
5
N
430
H
80
4.5
N
310
120
4.5
N
350
3.5
LH*
210
N
730
F
37
Stress, urge and urge incontinence
H
M
15
Nocturnal enuresis
H
40
F
47
Urge, frequency, urge incontinence
H
130
4
(Average 86 cc)
(Average 406 cc)
*Hyperreflexic. tNormal. *Less hyperreflexic.
Stondinq_
60r 40
o
/
20
T
E
(D
0
r-
60
Volume
Standing with Anal Dilation ¢.D (D
60r
Fig. 2. Cystometrogram with patient in standing position with anal dilatation 5 cm diameter; cystometric curve before and during anal dilatation. flating or deflating a rectal balloon resulted in i n c o n s i s t e n t bladder response. Among 19 patients, 12 responded with detrusor facilitation, four with inhibition, and two showed facilitation in one examination and inhibition in another. One patient had short-lived inhibition followed by facilitation. It is likely the rectal balloon produced different degrees of anal dilatation in different patients, thus explaining their inconsistent results. In our study, dilatation was precisely performed and recorded, resulting in consistent responses in bladder tone. The anal area represents one of the most receptive areas for sensory input for bladder inhibition. The inhibitory s t i m u l a t i o n from the dilated anal sphincter is carried to the sacral mict u r i t i o n center through pudendal nerves. From the system of polysynaptic reflex transmissions in the $2-$4 sacral spinal cord, the motor inhibitory impulses to the bladder are carried through parasympathetic pelvic nerves. In the study group, bladder function was clinically normal before the acute urinary retention occurred. We postulate that the massive sensory input from severe anal dilatation paralyzed the normal bladders. In the control group, hyperreflexic bladders were converted to normal in four, and to less hyperreflexic in one patient with different degrees of anal dilatation. The c o m m o n embryologic development of the lower urinary and fecal pathways could explain the involvement of sacral spinal reflexes in the mechanism of micturition and defecation.
EL.
40 20 0 11:9 September 1982
Volume
430
Annals of Emergency Medicine
CONCLUSION It is likely that urinary retention is triggered when the intensity of anal stimulation reaches the threshold for bladder inhibition. Emergency physicians should be aware of the close correlation between bladder dyshanction and unusual sexual practices. The absence of previous urological diseases and a history of anal intercourse may provide a clue to the diagnosis. Sophisticated urodynamic investigation is not necessary. In the emergency department, the patient should get ade473/31
ACUTE URINARY RETENTION Godec, Cass & Ruiz
F i g . 3. T h e m e c h a n i s m
of a n a l dilatation triggering simultaneously bladder inhibition and contraction of the pelvic floor.
SPINAL CORD
quate treatment, including Foley catheter, b e t h a n e c h o l chloride, and p h e n o x y b e n z a m i n e . If this approach does not improve the condition, the patient should be referred to a urologist.
f /
REFERENCES 1. Godec CJ, Ayala G, Cass AS: Electrical stimulation of the rectal ampulla causing reflex voiding. J UroI 117:772, 1977. 2. Sohn N, Robilotti JG: The "Gay Bowel Syndrome." Am J Gastroenterol 67:478, 1977. 3. Kiviat MD, Zimmerman TA, Donovan WH; Sphincter stretch: A new technique resulting in continence and complete voiding in paraplegics. J Urol 114:895, 1975. 4. Rodriguez AA, Awad E: Detrusor muscle and sphincter response to anorectal stimulation in spinal cord injury. Arch Phys Med Rehabil 60:269, 1979. 5. Rossier A, Bors E: Detrusor responses to perianal and rectal stimulation in patients with spinal cord injuries. Urol Int 18:181, 1964.
32/474
RECTAL AMPULLA
i
) PELV,O P,OO
3
Annals of Emergency Medicine
11:9 September 1982