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Fluid and electrolyte Changes Following the Relief of Urinary Obstruction
THE JOURNAL OF UROLOGY
Vol. 74, No. 2, August 1955
Printed in U.S.A.
FLUID AND ELECTROLYTE CHANGES FOLLOWING THE RELIEF OF URINARY OBSTRUCTION B. EISEMAN, C. VIVION
AND
J. VIVIAN
From the Department of Surgery, University of Colorado School of Medicine and the Denver Veterans Administration Hospital, Colorado
It has long been known that varying degrees of diuresis may follow the relief of chronic urinary obstruction. In 1951 'Wilson, Riseman and Moyer1 made preliminary observations concerning the nature of this diuresis and emphasized the marked degree of sodium and water loss that may result. The purpose of this paper is to analyze the pattern of fluid and electrolyte changes occurring in a series of patients following the relief of chronic lower urinary tract obstruction. Preliminary data regarding possible etiologic factors contributing to such electrolyte abnormalities are also presented. MATERIALS AND METHODS
Twenty-four patients admitted during the past 3 years to the Barnes Hospital, the St. Louis City Hospital, and the three University Hospitals in Denver (the Colorado General Hospital, the Denver General Hospital and the Veterans Administration Hospital) form the basis of the present study. Patients from the Denver hospitals represent consecutive admissions of obstructed patients to the urological services. Upon hospital admission each patient was catheterized, and the urine of this and each successive 12-hour period was measured as to volume and to sodium content. Water and sodium intake was carefully recorded during the 3 days of the balance study. In most cases all fluid and electrolyte intake was limited to the parenteral route. Each patient was weighed daily. Blood chemistries, including nonprotein nitrogen, chloride, carbon dioxide combining power, hemoglobin, hematocrit and proteins were examined as indicated. Daily physical examinations were performed on these patients emphasizing the occurrence of edema, cardiac irregularities, signs of cardiac failure, abnormalities of blood pressure, or signs of abnormal hydration or sodium deficit. Fluid balance was determined by standard methods, allowing an estimated daily loss of 1000 ml. including insensible loss and water loss through perspiration. None of the balance studies happened to be performed during periods of extreme heat. RESULTS
Of the 24 patients studied, all had acute urinary obstruction superimposed upon long standing chronic obstruction. All cases in this series were in some degree of negative water balance during the Read at the Forum on Fundamental Surgical Problems at the annual meeting of the American College of Surgeons in November 1954. Accepted for publication February 1, 1955. 1 Wilson, B., Riseman, D. D. and Moyer, C. A.: Fluid balance in the urological patient. Disturbances in the renal regulation of the excretion of water and sodium salts following decompression of the urinary bladder. J. Urol., 66: 812, 1951. 222
FLUID AND ELECTROLYTE CHANGES AFTER RELIEF OF OBSTRUCTION TABLE
223
1. Water diuresis following relief of acute and chronic prostatic obstruction
No. of Patients-24 1st day 1st day 3 day period TABLE
Negative balance exceeding 1000 ml. Negative balance exceeding 2000 ml. Negative balance exceeding 4000 ml.
18 pts. (75%) 12 pts. (50%) 8 pts. (33%)
2. Sodium diuresis following relief of acute and chronic prostatic obstruction
No. of Patients-24 1st day 1st day 3 day period 3 day period
Negative Negative Negative Negative
balance balance balance balance
exceeding exceeding exceeding exceeding
100 150 250 400
m/Eq. m/Eq. m/Eq. m/Eq.
12 7 11 4
pts. pts. pts. pts.
(50%) (29%) (46%) (16%)
3-day period of study. Sixteen of the 24 patients had during at least one 24-hour period a negative balance of 1500 cc or more (table 1). One case had a 24-hour negative balance of well over 8 liters, or approximately % of his normal extracellular fluid volume. The body weight of these patients mirrored the negative balance and in each case a definite weight loss was recorded. Four of the 24 patients lost 9 pounds or more during the 3 days following relief of urinary obstruction. The maximum diuresis and weight loss occurred during the first 24 hours following decompression in 21 of the 24 patients. SODIUM DIURESIS
Sodium loss via the urine followed a pattern similar to that of the water diuresis (table 2). In all but 2 cases the maximum urinary sodium loss occurred during the first 24 hours following relief of obstruction. In 21 of the 24 cases the urine consistently was hypotonic (less than 150 mEq/L) in regard to sodium excretion. The greatest daily negative sodium balance consisted of a loss of 524 m/Eq. In this patient the marked sodium diuresis disappeared 48 hours after relief of obstruction. In 1 case only was there a prolonged sodium and water diuresis. Case 14 (J. P.) following the relief of acute prostatic obstruction, 1961 m/Eq. of sodium were excreted in the urine during one 24-hour period, an amount greater than that normally contained in the extracellular fluid compartment. For a period of 3 months he continued to lose massive amounts of sodium in the urine and presented the clinical picture of an advanced and uncontrolled salt losing nephritis. His inability to withhold sodium necessitated a daily intake of 40 gm. of sodium chloride or more in order to preserve the integrity of his extracellular fluid volume. The volume of his urinary output approached that of the patient with diabetes insipidus, totaling 15 liters daily. Neither the sodium nor the water diuresis was affected appreciably either by DOCA, ACTH, or by antidiuretic hormone. Urinary specific gravity and daily urinary volume gradually returned to normal during a 6-month period. CLINICAL PICTURE
The change of certain clinical abnormalities possibly related to electrolyte and fluid imbalance was observed following urinary tract decompression. Three
224
B. EISEMAN, C. VIVION AND C. VIVIAN
patients had obvious disappearance of their peripheral edema accompanying their sodium and water diuresis. Four other patients had a disappearance of cardiac irregularities. One patient, who prior to decompression had pulmonary edema on a cardiac basis, responded promptly to the sodium and water diuresis following urinary tract decompression, and no longer showed signs of failure. Hypertension disappeared in 6 patients following such decompression. DISCUSSION OF CLINICAL STUDY
Although all of the patients under study showed some degree of negative water and sodium balance, only two of the 24 individuals demonstrated an excessive diuresis. One patient lost sodium and water at an alarming rate for 24 hours during which time his peripheral edema disappeared, but was thereafter essentially in a normal balance of water and sodium. The other one demonstrated the clinical picture of an intractable salt losing nephritis which continued for 3 months following the relief of his urinary tract obstruction. Most of these signs of clinical improvement following urinary tract decompression can be accounted for by a negative sodium and water balance with its accompanying diminution of extracellular fluid volume. The re-establishment of normotensive blood pressures following the relief of such urinary tract obstruction could be ascribed either to an increase in renal blood flow or to the diminution of the hypervolemia consequent to the sodium diuresis. We have as yet no evidence to indicate which of these mechanisms are in fact operative.
D Water
SODIUM AND WATER BALANCE FOLLOWING Intake
RELIEF QE PROSTATIC OBSTRUCTION Pt. J. U.
~ Sod(um
D. V.A. No. 18495
II Insensible Loss
3000
~
"'
0 0 0
g
."'"'
a
n n
n n
2000
.
a
1000
Output
"'
i
t----,--,-,----+-"'h--.,-,,c-r-----l-+-,----,--,-,,---j--+,--.,-,=---lm~:f
§n
n
1000
150
2000
3000
4000
+---------~--~--~--------'
Adm.
12 hrs.
24hrs.
36 hrs.
FIG. 1
48 hrs.
60 hrs.
72 hrs.
22/5
FLUID AND ELmCTROLYTE CHANGES AFTE}R RELIEF OF OBSTRUCTION CUMULATIVE SODIUM AND WATER BALANCE FOLLOWING RELIEF Q.!: PROSTATIC OBSTRUCTION
Pt JU. D. VA. No. 18495 ,----,--,-,,,,---r,-c,r---,-r,,-r--,--,-,----,~,..,---,--,-,-----,r,-c,----,mEot
.
No
a,
75
0
0
150
IOOO
225 230
278
2000
300
3000
4000
5000
Owater 6000
CJ Sodium 7 hc-rs-.- - ~ ··--l'-m---,-2-hr-,.---24_h_,s__---3-6-hr-,.---4--,-8-hr-,.---6.,,0_h_rs_.---::-72
FIG. 2 SODIUM ~ ABSORPTION FROM CHRONICALLY INFECTED BLADDER
Peripheral
i
Jnsiillol1on of 150micro curies Na 24 in Bladder
j
Blood
"
Cts./min
..
I
:J
l
Minutes
O
15
30
45
60
75
120
080
FIG. 3 lNVESTJGATION OF FACTORS PRODUCING SODIUM AND WATER RETENTIOT\ DURING
ACU'rE AND CHRONIC URINARY TRACT OBSTRUCTIOX
Sodium absorption from the urinary bladder. The patient with r:hronic lower urinary tract obstruction continually carries a residual of urine in his bladder. Should sodium he absorbed from the bladder this might contribute to the quantities of sodium that are excreted following the relief of urinary obstruction. Crinary bladder absorption studies of :'-Ja24 have been carried out in both auimals and in man. In :3 normal patients installation of a 0.85 per cent sodium ehloride solution containing approximately 1 millicmie of N a 24 resulted in no appreciable disappearance of the bladder sodium or appearance of radioactive
226
B. EISEMAN, C. VIVION AND C. VIVIAN
material in the peripheral blood. No sodium absorption was noted in 2 patients in whom the pH of the urine was regulated to alkalinity (pH 7.4) by the oral administration of sodium bicarbonate, or to acidity (pH 5.0) by the ingestion of ammonium chloride. These findings are in variance from those of Nelson, Hlad and Holmes 2 who found that appreciable quantities of sodium were absorbed from the intact dog bladder when the pH of the instilled material deviated in either direction from neutrality. Studies on one patient with a chronically infected bladder demonstrated a 2 per cent uptake of sodium within a 3-hour period (fig. 1). If these findings are corroborated, it is possible that the effect of pH change on bladder absorption is merely one of causing an inflammation of the bladder mucosa. See also figures 2 and 3. Ejfects of bladder distention on renal function. Should bladder distention depress renal function and diminish the ability to excrete a sodium load, this might conceivably be a factor in producing sodium and water retention during chronic lower urinary tract obstruction. "\Ve have studied the effects on renal function* of bladder distention by measuring the PAH and inulin clearance and the sodium excretory capacity in a patient before and after distending the bladder with 300 ml of a glucose in water solution via an indwelling urethral catheter. Urine collections were made via bilateral ureteral catheters. The values for renal clearance and sodium excretory capacity were depressed by as much as 17 per cent and remained diminished for 60 minutes after the bladder was emptied. It is our feeling that this is probably a nonspecific antidiuretic hormone response to a painful stimulus,3 a theory as yet unproven. SUMMARY
Water and sodium balance studies have been carried out on a series of 24 patients following the relief of chronic and acute lower urinary tract obstruction. A negative water and sodium balance has occurred in every case, usually maximal in the 24 hours immediately following decompression. Only occasionally does this require heroic replacement therapy. The exact incidence of such a change requires a more extensive study. One of our cases present a clinical picture of severe resistant salt-losing nephritis which persisted for 3 months following urinary decompression. In an effort to explain the pathogenesis of this condition, we have performed sodium absorption studies from the bladder of both dogs and man. Our preliminary data indicate that urinary bladder distention, such as may exist in the chronically obstructed patient, will diminish the excretory capacity of the kidney for sodium, and will appreciably diminish the rates of PAH and inulin clearance. 2 Nelson, R. E., Hlad, C. F. and Holmes, J. H., Jr.: Transfer of electrolytes across the normal urinary bladder. Am. J. Med., 12: 611, 1951. 3 Theobald, G. W. and Verney, E. B.: An anti-diuretic substance extracted from the liver. J. Physiol., 83: 277, 1935. * With the kind help of Dr. Neal Bricker and Dr. C. J. Hlad.
Vol. 74, No. 2, August 1955
Printed in U.S.A.
FLUID AND ELECTROLYTE CHANGES FOLLOWING THE RELIEF OF URINARY OBSTRUCTION B. EISEMAN, C. VIVION
AND
J. VIVIAN
From the Department of Surgery, University of Colorado School of Medicine and the Denver Veterans Administration Hospital, Colorado
It has long been known that varying degrees of diuresis may follow the relief of chronic urinary obstruction. In 1951 'Wilson, Riseman and Moyer1 made preliminary observations concerning the nature of this diuresis and emphasized the marked degree of sodium and water loss that may result. The purpose of this paper is to analyze the pattern of fluid and electrolyte changes occurring in a series of patients following the relief of chronic lower urinary tract obstruction. Preliminary data regarding possible etiologic factors contributing to such electrolyte abnormalities are also presented. MATERIALS AND METHODS
Twenty-four patients admitted during the past 3 years to the Barnes Hospital, the St. Louis City Hospital, and the three University Hospitals in Denver (the Colorado General Hospital, the Denver General Hospital and the Veterans Administration Hospital) form the basis of the present study. Patients from the Denver hospitals represent consecutive admissions of obstructed patients to the urological services. Upon hospital admission each patient was catheterized, and the urine of this and each successive 12-hour period was measured as to volume and to sodium content. Water and sodium intake was carefully recorded during the 3 days of the balance study. In most cases all fluid and electrolyte intake was limited to the parenteral route. Each patient was weighed daily. Blood chemistries, including nonprotein nitrogen, chloride, carbon dioxide combining power, hemoglobin, hematocrit and proteins were examined as indicated. Daily physical examinations were performed on these patients emphasizing the occurrence of edema, cardiac irregularities, signs of cardiac failure, abnormalities of blood pressure, or signs of abnormal hydration or sodium deficit. Fluid balance was determined by standard methods, allowing an estimated daily loss of 1000 ml. including insensible loss and water loss through perspiration. None of the balance studies happened to be performed during periods of extreme heat. RESULTS
Of the 24 patients studied, all had acute urinary obstruction superimposed upon long standing chronic obstruction. All cases in this series were in some degree of negative water balance during the Read at the Forum on Fundamental Surgical Problems at the annual meeting of the American College of Surgeons in November 1954. Accepted for publication February 1, 1955. 1 Wilson, B., Riseman, D. D. and Moyer, C. A.: Fluid balance in the urological patient. Disturbances in the renal regulation of the excretion of water and sodium salts following decompression of the urinary bladder. J. Urol., 66: 812, 1951. 222
FLUID AND ELECTROLYTE CHANGES AFTER RELIEF OF OBSTRUCTION TABLE
223
1. Water diuresis following relief of acute and chronic prostatic obstruction
No. of Patients-24 1st day 1st day 3 day period TABLE
Negative balance exceeding 1000 ml. Negative balance exceeding 2000 ml. Negative balance exceeding 4000 ml.
18 pts. (75%) 12 pts. (50%) 8 pts. (33%)
2. Sodium diuresis following relief of acute and chronic prostatic obstruction
No. of Patients-24 1st day 1st day 3 day period 3 day period
Negative Negative Negative Negative
balance balance balance balance
exceeding exceeding exceeding exceeding
100 150 250 400
m/Eq. m/Eq. m/Eq. m/Eq.
12 7 11 4
pts. pts. pts. pts.
(50%) (29%) (46%) (16%)
3-day period of study. Sixteen of the 24 patients had during at least one 24-hour period a negative balance of 1500 cc or more (table 1). One case had a 24-hour negative balance of well over 8 liters, or approximately % of his normal extracellular fluid volume. The body weight of these patients mirrored the negative balance and in each case a definite weight loss was recorded. Four of the 24 patients lost 9 pounds or more during the 3 days following relief of urinary obstruction. The maximum diuresis and weight loss occurred during the first 24 hours following decompression in 21 of the 24 patients. SODIUM DIURESIS
Sodium loss via the urine followed a pattern similar to that of the water diuresis (table 2). In all but 2 cases the maximum urinary sodium loss occurred during the first 24 hours following relief of obstruction. In 21 of the 24 cases the urine consistently was hypotonic (less than 150 mEq/L) in regard to sodium excretion. The greatest daily negative sodium balance consisted of a loss of 524 m/Eq. In this patient the marked sodium diuresis disappeared 48 hours after relief of obstruction. In 1 case only was there a prolonged sodium and water diuresis. Case 14 (J. P.) following the relief of acute prostatic obstruction, 1961 m/Eq. of sodium were excreted in the urine during one 24-hour period, an amount greater than that normally contained in the extracellular fluid compartment. For a period of 3 months he continued to lose massive amounts of sodium in the urine and presented the clinical picture of an advanced and uncontrolled salt losing nephritis. His inability to withhold sodium necessitated a daily intake of 40 gm. of sodium chloride or more in order to preserve the integrity of his extracellular fluid volume. The volume of his urinary output approached that of the patient with diabetes insipidus, totaling 15 liters daily. Neither the sodium nor the water diuresis was affected appreciably either by DOCA, ACTH, or by antidiuretic hormone. Urinary specific gravity and daily urinary volume gradually returned to normal during a 6-month period. CLINICAL PICTURE
The change of certain clinical abnormalities possibly related to electrolyte and fluid imbalance was observed following urinary tract decompression. Three
224
B. EISEMAN, C. VIVION AND C. VIVIAN
patients had obvious disappearance of their peripheral edema accompanying their sodium and water diuresis. Four other patients had a disappearance of cardiac irregularities. One patient, who prior to decompression had pulmonary edema on a cardiac basis, responded promptly to the sodium and water diuresis following urinary tract decompression, and no longer showed signs of failure. Hypertension disappeared in 6 patients following such decompression. DISCUSSION OF CLINICAL STUDY
Although all of the patients under study showed some degree of negative water and sodium balance, only two of the 24 individuals demonstrated an excessive diuresis. One patient lost sodium and water at an alarming rate for 24 hours during which time his peripheral edema disappeared, but was thereafter essentially in a normal balance of water and sodium. The other one demonstrated the clinical picture of an intractable salt losing nephritis which continued for 3 months following the relief of his urinary tract obstruction. Most of these signs of clinical improvement following urinary tract decompression can be accounted for by a negative sodium and water balance with its accompanying diminution of extracellular fluid volume. The re-establishment of normotensive blood pressures following the relief of such urinary tract obstruction could be ascribed either to an increase in renal blood flow or to the diminution of the hypervolemia consequent to the sodium diuresis. We have as yet no evidence to indicate which of these mechanisms are in fact operative.
D Water
SODIUM AND WATER BALANCE FOLLOWING Intake
RELIEF QE PROSTATIC OBSTRUCTION Pt. J. U.
~ Sod(um
D. V.A. No. 18495
II Insensible Loss
3000
~
"'
0 0 0
g
."'"'
a
n n
n n
2000
.
a
1000
Output
"'
i
t----,--,-,----+-"'h--.,-,,c-r-----l-+-,----,--,-,,---j--+,--.,-,=---lm~:f
§n
n
1000
150
2000
3000
4000
+---------~--~--~--------'
Adm.
12 hrs.
24hrs.
36 hrs.
FIG. 1
48 hrs.
60 hrs.
72 hrs.
22/5
FLUID AND ELmCTROLYTE CHANGES AFTE}R RELIEF OF OBSTRUCTION CUMULATIVE SODIUM AND WATER BALANCE FOLLOWING RELIEF Q.!: PROSTATIC OBSTRUCTION
Pt JU. D. VA. No. 18495 ,----,--,-,,,,---r,-c,r---,-r,,-r--,--,-,----,~,..,---,--,-,-----,r,-c,----,mEot
.
No
a,
75
0
0
150
IOOO
225 230
278
2000
300
3000
4000
5000
Owater 6000
CJ Sodium 7 hc-rs-.- - ~ ··--l'-m---,-2-hr-,.---24_h_,s__---3-6-hr-,.---4--,-8-hr-,.---6.,,0_h_rs_.---::-72
FIG. 2 SODIUM ~ ABSORPTION FROM CHRONICALLY INFECTED BLADDER
Peripheral
i
Jnsiillol1on of 150micro curies Na 24 in Bladder
j
Blood
"
Cts./min
..
I
:J
l
Minutes
O
15
30
45
60
75
120
080
FIG. 3 lNVESTJGATION OF FACTORS PRODUCING SODIUM AND WATER RETENTIOT\ DURING
ACU'rE AND CHRONIC URINARY TRACT OBSTRUCTIOX
Sodium absorption from the urinary bladder. The patient with r:hronic lower urinary tract obstruction continually carries a residual of urine in his bladder. Should sodium he absorbed from the bladder this might contribute to the quantities of sodium that are excreted following the relief of urinary obstruction. Crinary bladder absorption studies of :'-Ja24 have been carried out in both auimals and in man. In :3 normal patients installation of a 0.85 per cent sodium ehloride solution containing approximately 1 millicmie of N a 24 resulted in no appreciable disappearance of the bladder sodium or appearance of radioactive
226
B. EISEMAN, C. VIVION AND C. VIVIAN
material in the peripheral blood. No sodium absorption was noted in 2 patients in whom the pH of the urine was regulated to alkalinity (pH 7.4) by the oral administration of sodium bicarbonate, or to acidity (pH 5.0) by the ingestion of ammonium chloride. These findings are in variance from those of Nelson, Hlad and Holmes 2 who found that appreciable quantities of sodium were absorbed from the intact dog bladder when the pH of the instilled material deviated in either direction from neutrality. Studies on one patient with a chronically infected bladder demonstrated a 2 per cent uptake of sodium within a 3-hour period (fig. 1). If these findings are corroborated, it is possible that the effect of pH change on bladder absorption is merely one of causing an inflammation of the bladder mucosa. See also figures 2 and 3. Ejfects of bladder distention on renal function. Should bladder distention depress renal function and diminish the ability to excrete a sodium load, this might conceivably be a factor in producing sodium and water retention during chronic lower urinary tract obstruction. "\Ve have studied the effects on renal function* of bladder distention by measuring the PAH and inulin clearance and the sodium excretory capacity in a patient before and after distending the bladder with 300 ml of a glucose in water solution via an indwelling urethral catheter. Urine collections were made via bilateral ureteral catheters. The values for renal clearance and sodium excretory capacity were depressed by as much as 17 per cent and remained diminished for 60 minutes after the bladder was emptied. It is our feeling that this is probably a nonspecific antidiuretic hormone response to a painful stimulus,3 a theory as yet unproven. SUMMARY
Water and sodium balance studies have been carried out on a series of 24 patients following the relief of chronic and acute lower urinary tract obstruction. A negative water and sodium balance has occurred in every case, usually maximal in the 24 hours immediately following decompression. Only occasionally does this require heroic replacement therapy. The exact incidence of such a change requires a more extensive study. One of our cases present a clinical picture of severe resistant salt-losing nephritis which persisted for 3 months following urinary decompression. In an effort to explain the pathogenesis of this condition, we have performed sodium absorption studies from the bladder of both dogs and man. Our preliminary data indicate that urinary bladder distention, such as may exist in the chronically obstructed patient, will diminish the excretory capacity of the kidney for sodium, and will appreciably diminish the rates of PAH and inulin clearance. 2 Nelson, R. E., Hlad, C. F. and Holmes, J. H., Jr.: Transfer of electrolytes across the normal urinary bladder. Am. J. Med., 12: 611, 1951. 3 Theobald, G. W. and Verney, E. B.: An anti-diuretic substance extracted from the liver. J. Physiol., 83: 277, 1935. * With the kind help of Dr. Neal Bricker and Dr. C. J. Hlad.