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Gangrene of the Bladder. Review of two Hundred Seven Cases; Report of two Personal Cases1
GANGRENE OF THE BLADDER REVIEW OF TWO HUNDRED SEVEN CASES; REPORT OF TWO ' PERSONAL CASES1 W. CALHOUN STIRLING
AND
G. A. HOPKINS
Washington, D. C. HISTORICAL
Gangrene of the bladder was first described in 1650 by Willis, who reported a case of exfoliatiori of the bladder. Later, in 1829, Lever reported a case in which bladder tissue was found microscopically. In 1887 Guyon described two types, false or pseudo-membraneous and true necrosis of the bladder. Fronstein says that vesical gangrene is so rare that we should describe each separate case. This also is the opinion of several other authors. O'Neil in 1910 reviewed 2 personal cases occurring as a complication of labor. Carson found 6 cases at necr,opsy, 3 following suprapubic prostatectomy, the fourth following a suprapubic cystotomy, the others occurring in females. Randall in 1932 cited a case of generalized hemorrhagic gangrenous cystitis, involving the entire bladder wall to the peritoneum probably of syphilitic origin. Aschner in 1924 reported a case of gangrene of the bladder and suprapubic wound following prostatectomy. Judd and Meeker in the same year had a similar case. Miller and W olferth also at this time collected 134 cases, reporting 2 personal cases occurring as a complication of typhoid fever. Patch in 1928 added 2 cases of gangrene of the bladder, both of infectious origin. Giesecke reviewed the literature in 1931, finding 197 cases. He added a personal case in a prostatic with acute distention. This paper includes approximately 207 cases reviewed, including 2 personal cases. The condition is not as rare as was formerly thought, though the subject has received little attention in text books. 1 Read at the thirtieth annual meeting of the American Urological Association, Chicago, Ill., June, 1933.
517 THE JOURNAL OF UROLO GY, VOL. XXXI 1 N O .
4
518
W. C. STIRLING AND G. A. HOPKINS
ETIOLOGY
The causative factors may be roughly divided into four groups in the order of their frequency: (1) Traumatic, including (a) pressure from without, such as uterine displacement in pregnancy, ovarian tumors, etc., (b) distention of the bladder, internal or external, (c) circulatory obstruction, ligation of adjacent arterials, venous obstruction from pressure, emboli and (d) operative proTABLE 1 Summary of cases of gangrene of the bladder from etiological standpoint NUMBER OF CASES
1. Pressure on the bladder from without, i.e ., malposition of
pregnant uterus ......... ·. . . . . . . . . . . . . . . . . . . . . . . . . . . . . As a complication of labor . .. .. . .......... . . . . ... . ....... . Pressure on bladder from other causes .... . ..... . . . ..... . . . Obstruction from urethral stricture ... . .... . . . .. . .. .... . .. . Obstruction from prostatic enlargement ....... . . . . . .. . . . . . Chronic Cystitis ... ........... . ..... . . . .... . .. . . . ..... . .. . General infections, i.e., typhoid, diphtheria, etc . . . ... . . .. . Chemical injected into bladder .. . .. . ......... . ....... . ... . X -ray and thermic . .... . . . .. . . . . .. .. . . . ... . . ... . .... ... . . . Stone in the bladder ... ... ...... . ... . . .... .. ... . . .... . . . . . Lesions of central nervous system ... . .... . . . .. .. .. . .... .. . Following prostatic resection . ..... . ...... . ... . .. . ........ . Miscellaneous (operative procedures on uterus, carcinoma of cervix uteri, chronic urinary retention of unknown origin) .
31
Total number of cases .. .. . . . .... . ...... . ..... . ...... . ..... .
207
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
44 23 11
17 7 19 15 11 3 7 12 4
cedures on the bladder, i.e., prostatic resect ion or incisional prostatectomy; (2) infectious, local or general; (3) nerve lesions of the cord; (4) chemical, i.e., various substances injected into the bladder to induce abortion, etc., (5) thermal or following x-ray or radium treatment. W olferth and Miller believe that infection and interference with the circulation are responsible for the greatest number of cases. Antonopoulos reports 2 cases in females in which ligation of the hypogastric arteries during a Wertheim operation were followed by necrosis of the bladder. Hisgen in doing the same operation
GANGRENE OF BLADDER
519
without ligation of the hypogastrics, reported a case of necrosis the bladder. Gangrene of the bladder was produced experimentally in animals by Heubner and also by May. Haultain believes that retention causes venous obstruction at the base and neck the bladder, and thus produces congestion later followed by necrosis. Ouglev reports 4 cases of vesical gangrene, one following the injection of corrosive sublimate solution, the second due to pregnancy, the third in a boy four years old with a vesical stone and the fourth in a three-year-old girl with chronic cystitis. A new etiological factor not previously stressed in the literature is gangrene of the bladder following transurethal prostatic resection. Alcock cites 2 cases, Cowen 1 case and a fourth ,vas seen by the writer. I have heard of several similar cases which remain unreported. Alcock ascribes the necrosis to resecting too far up in the bladder and to excessive coagulation. In the case reported Cowen, the bladder muscle was gangrenous and pelvic peritonitis was noted. Any or all the layers of the bladder may be involved, several cases showing extension through the bladder wall ing the peritoneum. Geisicke reports a case of necrosis following the sixth application of x-rays to the bladder area. The mucosa and submucosa are most often affected, due to their loose attachment and delicate blood supply. INCIDENCE
Gangrene of the bladder has been found more frequently females, due to complications of labor, occurring in 67 of 207 cases reviewed by me. Retention of urine was present in over one-·half of the cases. Among the more recent reports the majority have occurred in males in which retention and infection were the most prominent Of the 207 cases in this revievv, 120 died, recovered, and in the others the outcome was indefinite. PATHOLOGICAL FINDINGS
The mucosa of bladder, being loosely attached except at the base, may exfoliate en masse or be cast off in small particles as the degenerative process progresses. The term diphtheritic or croupous arises from the fact numerous cases
520
W. C. STIRLING AND G. A. HOPKINS
been found in which the mucosa and the submucosa were passed as a cast of the bladder. Various German writers describe this condition as a dissecting gangrenous cystitis. The mucosa is often covered with a layer of fibrin, containing pus, degenerating epithelium and microorganisms. This so-called pseudomembranous cystitis, may occur in typhoid fever, measles, diphtheria and puerperal fever. I found this condition present in a case of rupture of the bladder with perivesical suppuration, though actual necrosis of the bladder mucosa was not present. The offending organisms usually present are Streptococcus pyogenes, viridans, Staphylococcus pyogenes, Bacillus coli, Bacillus typhosis and proteus. CYSTOSCOPIC FINDINGS
The cystoscopic picture varies with the duration and severity of the necrosis. In the early cases the trigone is intensely congested, the interior of the bladder is covered by dirty, grayishlooking areas of necrosis, often involving the muscularis with isolated hemorrhagic areas often seen. In other cases a purulent fibrinous exudate predominates with deposits of urinary salts. After separation of the slough, the bladder wall is very pale and trabeculated if distention was present. The ureteral orifices are usually patent, if visible at all. O'Neil describes a peculiar whitish appearance of the bladder wall, with tortuous vessels. After regeneration and fibrosis take place, the bladder shows marked contracture. It is difficult to distend and regurgitation to the kidney pelvis is a common finding, pyelonephritis being the rule rather than the exception. SYMPTOMS-DIAGNOSIS
The clinical picture is that of urosepsis, depending on the severity and extension of the process. Extension to the kidneys is characterized by a profound constitutional reaction. Involvement of the peritonium gives the characteristic board-like rigidity of the abdomen. The urine is very fetid, contains much pus, and is usually alkaline in reaction. The passage of exfoliated debris containing gangrenous portions of the bladder epithelium is
GANGRENE OF BLADDER
521
diagnostic. Inability to evacuate the bladder with interruption the stream during catheterization, suggests gangrene of the bladder. Cystoscopy should be done after degenerative exfoliation occurs to determine the extent of the renal involvement. A cystogram made after the infection subsides, will reveal the degree of contracture of the bladder and also determine the presence of ureteral reflux. Geisicke points out that an early diagnosis is of great prognostic significance. Stoeckel quoted by Patch reported 3 cases in which the ureters were widely dilated. Intravenous urography is valuable these cases where the ureteral orifices are obscured.
in
TREATMENT
The treatment of vesical gangrene is free and adequate drainage. Catheterization with frequent irrigations of 0.5 to l per cent phosphoric acid, are beneficial in the early cases to combat the alkaline cystitis. A spontaneous cure may be effected in females, as the caliber of the urethra is ample to permit the passage of the necrotic material. In males, early suprapubic drainage is indicated, with supportive measures, i.e., transfusion, urinary antiseptics, subcutaneous perfusion, to combat the renal infection. The necrotic membrane should be removed if possible when the bladder is opened. In injuries of the spinal cord, frequent catheterization should be done to prevent overdistention of the bladder, pyelonephritis and later death. I saw a case in which the spinal cord was severed by a rifle bullet, the patient dying six weeks later from urinary sepsis. The bladder mucosa in this case was evidently undergoing degenerative changes as the urine was very foul and containing necrotic material. If recovery takes place, any obstruction in the urethra or neck of the bladder should corrected by dilatation. REPORT OF CASES
I wish to summarize briefly 2 personal cases of vesical gangrene, the first one a complication of labor; the second following prostatic resection. Miss W. B., primipara, white, aged seventeen, seen in consultation on May 25, 1924. Patient gave a history of having been in labor for thirty-six hours without medical attention, in an attempt to conceal
522
W. C. STIRLING AND G. A. HOPKINS
an illegitimate pregnancy. Following a difficult forceps delivery, she was unable to void normally. Catheterization was done until she was admitted to the hospital, four days later. The family and previous history was negative. On physical examination a severe cystitis with foul ammoniacal urine was noted. The patient was very toxic. Intermittent catheterization was unsatisfactory, due to plugging of the catheter, as was cystoscopy due to the cloudy medium, therefore a cystotomy was done on June 3, 1924. The bladder was markedly distended and contained a grayish membrane involving the mucosa and submucosa. This membrane was quite necrotic and was removed with difficulty. Involvement of the kidneys was undoubtedly the cause of the septic type of fever. After drainage was established, a marked improvement was noted in her general condition. A culture showed Bacillus coli and Streptococcus hemolyticus and viridins. The tube was removed two weeks later, an indwelling catheter being placed in the urethra to insure drainage. The urine continued very cloudy and contained much pus. The lacerated perineum was repaired after t he cystotomy wound had healed. The patient left the hospital six weeks following the cystotomy. There was 30 cc. of residual urine present. The bladder capacity was limited to 200 cc. Comment. A prolonged pelvic presentation with circulatory inhibition and overdistention of the bladder, were the outstanding findings, and undoubtedly brought on the necrosis in this case.
Case II. Mr. F. B., male, aged sixty-six, was admitted to Georgetown Hospital on January 24, 1932, with acute retention of urine. Patient had been unable to void for the past four years, catheterizing himself at regular intervals. Rectal examination revealed a very large, symmetrical, type 4 prostatic enlargement. Physical examination was otherwise negative. Cystoscopic examination showed an elongated, tortuous urethra, with large lateral and median lobes introvesical in type. The bladder capacity was 360 cc. The blood findings were as follows: hemoglobin, 75 per cent; red cells, 3,390,000; 91 per cent polymorphonuclears; 8 per cent lymphocytes; blood pressure, 105/65. The phthalein output was 65 per cent for two hours; blood urea, 18 mgm.; blood sugar, 120 mgm.; clotting time, 1 minute. Because of the enormous size of the gland a suprapubic prostatectomy was suggested but the patient refused so a two-stage resection was decided upon. On January 25, 1932, prostatic resection was done, 15 grams of adenomatous tissue
GANGRENE OF BLADDER
523
being removed. There was very little bleeding during the resection which was controlled by light coagulation. A microscopic study of the resected tissue showed no evidence of malignancy. There were, however, marked inflammatory changes present. An indwelling catheter was placed in the urethra. However, on February 3, 1932 (nine days later), the catheter drainage was insufficient, blockage of the catheter occurring several times daily. Therefore a suprapubic cystotomy was done under ethylene anaesthesia, a No. 40 mushroom catheter being placed in the bladder suprapubically. The patient improved very rapidly, the phthalein and blood urea tests again becoming normal after several days forced fluids and drainage. Ten days after the suprapubic operation, the incision was healthy and had healed about the tube, a second resection was done at this time, 18 grams of tissue were removed from the right and left lateral lobes, very little bleeding being observed. No cuts were made high in the bladder. The patient was returned to his room with the bladder irrigation clear, pulse full and regular with no shock being seem. However, on February 15, on the fourth postoperative day, a low grade urosepsis was noted with an elevation in temperature. The thermal curve became steeple-like in character, ranging between 99° and 104°F. The urinary output which had been 3500 to 4000 cc. daily, rapidly diminished. Intravenous glucose was given twice daily, in an attempt to increase the urinary output. Urotropin was given intravenously for the suspected pyelonephritis. A transfusion of 500 cc. of citrated blood was also administered on February 19. The patient gradually became uremic, very restless and hiccoughed constantly. The day preceding death, February 22, the blood urea was 160 mgm. and the urinary output had decreased to 100 cc. for twenty-four hours. Necropsy report (Dr. W. M. Yater): Anatomical diagnosis: (1) Recent suprapubic cystotomy wound, which is necrotic; (2) gangrenous cystitis; (3) nephrosis with pyelonephritis; (4) chronic cholecystitis; (5) acute ulceration of the colon. The bladder wall was markedly thickened and edematous, the mucosa purplish in color, necrotic and covered by a yellowish-green exudate. The bladder wall was intact; no evidence of rupture was seen. Comment. Gangrene of the bladder and cystotomy incision in this case was undoubtedly due to interference with the blood supply probably thrombotic in origin. The necropsy findings showed no evidence of injury to the bladder wall from instrumentation.
524
W. C. STIRLING AND G. A. HOPKINS CONCLUSIONS
1.
In any severe chronic cystitis, gangrene should be kept in
mind and drainage instituted as early as possible. 2. Gangrene of the bladder is probably much more common than we have suspected due to failure in diagnosis and obtaining autopsies. 3. Retention of urine and the presence of infection are the chief predisposing factors. 4. Treatment if instituted early, may result favorably even in the presence of severe necrosis. 5. Palliative treatment may be tried in the female, but early drainage by cystotomy offers the best prognosis in the male.
1621 Connecticut Ave., N.W. Washington, D. C. REFERENCES ANTONOUPOLUS ET DOUAY: Gangrene Entendue de la Paroi Vesicale. Quinec. et Obstet., Paris, January, 1931, xxiii, 196- 207. AscHNER, PAUL: Suprapubic prostate. Jour. Urol., 1924, xii, 252- 266. CARSON, W. J.: Gangrene of bladder. Ann. surg., 1927, lxxxv, 269- 274. CARSON, W. J.: Gangrene of bladder. Jour. Urol., February, 1925, xiii, 205. CowEN, L . B., AND CowEN, ROBT.: A fatality following electromic prostatic resection. Report of a case with autopsy findings. Urol. and Cut. Review, February, 1933, 105-107. DucHANOFF, A.: Cystitis Gangraenosa Dessecans. Zeits. fur Urolog. Chir., 1930, xxix, 516-530, Berlin. DuNET ET CREYSSELL: Cystite Gangreneuse Totale Survenue a la Suite d'une Retention Oign. Z. Urol. Chir., 1926. ELIASON, E. H .: Gangrene of the bladder. An,n. Surg., 1925, lxxxvi, 546. FRONSTEIN, R.: Uber Cystitis Gangraenosa. Zeitschrift fur Urol. Chir., 1926, Xl X.
GEISICKE, HELLMUTH VoN: Cystitis Dissecans Gangraenescens. Zeitsch. fur Urologie, 1931, xxv, 561-572, Leipzig. GuYON: Quoted by Patch, 1927, loc. cit. HAULTAIN, F . W. : Laboratory Reports Royal College Phys. Edinburgh, 1890, ii, 216. HEIDLER, HANS: Cystitis Dissecans Gangraenosa Actinogenetica. Z. Geburtsh., 1927, xcii, 1- 13. HEUBNER: Die Experimentelle Diphth. Leipsig, 1883. HrsGEN: Cited by Antonoupolus Munchen. Mediz. Wochenschrift, 1919, 1292. JUDD, E. S., AND MEEKER, W.R.: Jour. Urol., 1924, xi, 411. LEUGUE: Fraite Chir. a Urol., 614, Paris, 1921.
GANGRENE OF BLADDER LEMPERG, FRITZ: Cystitis Gangraenosa Dissecans.
525
Zbl. Quinak., 1926, xviii,
1203.
KARLIN, MAX: Ein. Fall von Cystitis Gangrae. Miro. Wochenbett. Zbl. Gynak., 1926, xviii, 1205-50. LEVER: Guys Hosp. Rep., 1852, no. 51, 49. O'NEIL, R. F.: Necrosis of the bladder with exfoliation. Surg., Gynecol., and Obstet., May, 1910, 503-518. OuGLEV, RouMAN: La Gangrene Vesicale. Jour. d'urol. Medic. et Chir. Paris, 1931, xxxii, 120-132. PATCH, F . S. Gangrenous cystitis. Jour. Urol., June, 1928, xix, 713. PETERS, W.: Uber Cystitis Gangraenosa. Dtsch. Z. Chir., 1924, clxxxvii. PRUDDEN, T . M., AND DELAFIELD, F . : Pathology, 1914. RANDALL, ALEX: Two unusual bladder lesions. Trans. Amer. Assoc. GenitoUrin. Surg., 1923, xvi, 215. STOECKEL: Berliner Klinische Wochen., 1905, 20. WILLIS: Diss. de Urinis, 1650. WoLFERTH, C. C., AND MILLER, T. G.: Necrosis and gangrene of urinary bladder. Review of 153 cases, etc. Amer. Jour. Med. Sci., 1924, clxvii, 339-367.
AND
G. A. HOPKINS
Washington, D. C. HISTORICAL
Gangrene of the bladder was first described in 1650 by Willis, who reported a case of exfoliatiori of the bladder. Later, in 1829, Lever reported a case in which bladder tissue was found microscopically. In 1887 Guyon described two types, false or pseudo-membraneous and true necrosis of the bladder. Fronstein says that vesical gangrene is so rare that we should describe each separate case. This also is the opinion of several other authors. O'Neil in 1910 reviewed 2 personal cases occurring as a complication of labor. Carson found 6 cases at necr,opsy, 3 following suprapubic prostatectomy, the fourth following a suprapubic cystotomy, the others occurring in females. Randall in 1932 cited a case of generalized hemorrhagic gangrenous cystitis, involving the entire bladder wall to the peritoneum probably of syphilitic origin. Aschner in 1924 reported a case of gangrene of the bladder and suprapubic wound following prostatectomy. Judd and Meeker in the same year had a similar case. Miller and W olferth also at this time collected 134 cases, reporting 2 personal cases occurring as a complication of typhoid fever. Patch in 1928 added 2 cases of gangrene of the bladder, both of infectious origin. Giesecke reviewed the literature in 1931, finding 197 cases. He added a personal case in a prostatic with acute distention. This paper includes approximately 207 cases reviewed, including 2 personal cases. The condition is not as rare as was formerly thought, though the subject has received little attention in text books. 1 Read at the thirtieth annual meeting of the American Urological Association, Chicago, Ill., June, 1933.
517 THE JOURNAL OF UROLO GY, VOL. XXXI 1 N O .
4
518
W. C. STIRLING AND G. A. HOPKINS
ETIOLOGY
The causative factors may be roughly divided into four groups in the order of their frequency: (1) Traumatic, including (a) pressure from without, such as uterine displacement in pregnancy, ovarian tumors, etc., (b) distention of the bladder, internal or external, (c) circulatory obstruction, ligation of adjacent arterials, venous obstruction from pressure, emboli and (d) operative proTABLE 1 Summary of cases of gangrene of the bladder from etiological standpoint NUMBER OF CASES
1. Pressure on the bladder from without, i.e ., malposition of
pregnant uterus ......... ·. . . . . . . . . . . . . . . . . . . . . . . . . . . . . As a complication of labor . .. .. . .......... . . . . ... . ....... . Pressure on bladder from other causes .... . ..... . . . ..... . . . Obstruction from urethral stricture ... . .... . . . .. . .. .... . .. . Obstruction from prostatic enlargement ....... . . . . . .. . . . . . Chronic Cystitis ... ........... . ..... . . . .... . .. . . . ..... . .. . General infections, i.e., typhoid, diphtheria, etc . . . ... . . .. . Chemical injected into bladder .. . .. . ......... . ....... . ... . X -ray and thermic . .... . . . .. . . . . .. .. . . . ... . . ... . .... ... . . . Stone in the bladder ... ... ...... . ... . . .... .. ... . . .... . . . . . Lesions of central nervous system ... . .... . . . .. .. .. . .... .. . Following prostatic resection . ..... . ...... . ... . .. . ........ . Miscellaneous (operative procedures on uterus, carcinoma of cervix uteri, chronic urinary retention of unknown origin) .
31
Total number of cases .. .. . . . .... . ...... . ..... . ...... . ..... .
207
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
44 23 11
17 7 19 15 11 3 7 12 4
cedures on the bladder, i.e., prostatic resect ion or incisional prostatectomy; (2) infectious, local or general; (3) nerve lesions of the cord; (4) chemical, i.e., various substances injected into the bladder to induce abortion, etc., (5) thermal or following x-ray or radium treatment. W olferth and Miller believe that infection and interference with the circulation are responsible for the greatest number of cases. Antonopoulos reports 2 cases in females in which ligation of the hypogastric arteries during a Wertheim operation were followed by necrosis of the bladder. Hisgen in doing the same operation
GANGRENE OF BLADDER
519
without ligation of the hypogastrics, reported a case of necrosis the bladder. Gangrene of the bladder was produced experimentally in animals by Heubner and also by May. Haultain believes that retention causes venous obstruction at the base and neck the bladder, and thus produces congestion later followed by necrosis. Ouglev reports 4 cases of vesical gangrene, one following the injection of corrosive sublimate solution, the second due to pregnancy, the third in a boy four years old with a vesical stone and the fourth in a three-year-old girl with chronic cystitis. A new etiological factor not previously stressed in the literature is gangrene of the bladder following transurethal prostatic resection. Alcock cites 2 cases, Cowen 1 case and a fourth ,vas seen by the writer. I have heard of several similar cases which remain unreported. Alcock ascribes the necrosis to resecting too far up in the bladder and to excessive coagulation. In the case reported Cowen, the bladder muscle was gangrenous and pelvic peritonitis was noted. Any or all the layers of the bladder may be involved, several cases showing extension through the bladder wall ing the peritoneum. Geisicke reports a case of necrosis following the sixth application of x-rays to the bladder area. The mucosa and submucosa are most often affected, due to their loose attachment and delicate blood supply. INCIDENCE
Gangrene of the bladder has been found more frequently females, due to complications of labor, occurring in 67 of 207 cases reviewed by me. Retention of urine was present in over one-·half of the cases. Among the more recent reports the majority have occurred in males in which retention and infection were the most prominent Of the 207 cases in this revievv, 120 died, recovered, and in the others the outcome was indefinite. PATHOLOGICAL FINDINGS
The mucosa of bladder, being loosely attached except at the base, may exfoliate en masse or be cast off in small particles as the degenerative process progresses. The term diphtheritic or croupous arises from the fact numerous cases
520
W. C. STIRLING AND G. A. HOPKINS
been found in which the mucosa and the submucosa were passed as a cast of the bladder. Various German writers describe this condition as a dissecting gangrenous cystitis. The mucosa is often covered with a layer of fibrin, containing pus, degenerating epithelium and microorganisms. This so-called pseudomembranous cystitis, may occur in typhoid fever, measles, diphtheria and puerperal fever. I found this condition present in a case of rupture of the bladder with perivesical suppuration, though actual necrosis of the bladder mucosa was not present. The offending organisms usually present are Streptococcus pyogenes, viridans, Staphylococcus pyogenes, Bacillus coli, Bacillus typhosis and proteus. CYSTOSCOPIC FINDINGS
The cystoscopic picture varies with the duration and severity of the necrosis. In the early cases the trigone is intensely congested, the interior of the bladder is covered by dirty, grayishlooking areas of necrosis, often involving the muscularis with isolated hemorrhagic areas often seen. In other cases a purulent fibrinous exudate predominates with deposits of urinary salts. After separation of the slough, the bladder wall is very pale and trabeculated if distention was present. The ureteral orifices are usually patent, if visible at all. O'Neil describes a peculiar whitish appearance of the bladder wall, with tortuous vessels. After regeneration and fibrosis take place, the bladder shows marked contracture. It is difficult to distend and regurgitation to the kidney pelvis is a common finding, pyelonephritis being the rule rather than the exception. SYMPTOMS-DIAGNOSIS
The clinical picture is that of urosepsis, depending on the severity and extension of the process. Extension to the kidneys is characterized by a profound constitutional reaction. Involvement of the peritonium gives the characteristic board-like rigidity of the abdomen. The urine is very fetid, contains much pus, and is usually alkaline in reaction. The passage of exfoliated debris containing gangrenous portions of the bladder epithelium is
GANGRENE OF BLADDER
521
diagnostic. Inability to evacuate the bladder with interruption the stream during catheterization, suggests gangrene of the bladder. Cystoscopy should be done after degenerative exfoliation occurs to determine the extent of the renal involvement. A cystogram made after the infection subsides, will reveal the degree of contracture of the bladder and also determine the presence of ureteral reflux. Geisicke points out that an early diagnosis is of great prognostic significance. Stoeckel quoted by Patch reported 3 cases in which the ureters were widely dilated. Intravenous urography is valuable these cases where the ureteral orifices are obscured.
in
TREATMENT
The treatment of vesical gangrene is free and adequate drainage. Catheterization with frequent irrigations of 0.5 to l per cent phosphoric acid, are beneficial in the early cases to combat the alkaline cystitis. A spontaneous cure may be effected in females, as the caliber of the urethra is ample to permit the passage of the necrotic material. In males, early suprapubic drainage is indicated, with supportive measures, i.e., transfusion, urinary antiseptics, subcutaneous perfusion, to combat the renal infection. The necrotic membrane should be removed if possible when the bladder is opened. In injuries of the spinal cord, frequent catheterization should be done to prevent overdistention of the bladder, pyelonephritis and later death. I saw a case in which the spinal cord was severed by a rifle bullet, the patient dying six weeks later from urinary sepsis. The bladder mucosa in this case was evidently undergoing degenerative changes as the urine was very foul and containing necrotic material. If recovery takes place, any obstruction in the urethra or neck of the bladder should corrected by dilatation. REPORT OF CASES
I wish to summarize briefly 2 personal cases of vesical gangrene, the first one a complication of labor; the second following prostatic resection. Miss W. B., primipara, white, aged seventeen, seen in consultation on May 25, 1924. Patient gave a history of having been in labor for thirty-six hours without medical attention, in an attempt to conceal
522
W. C. STIRLING AND G. A. HOPKINS
an illegitimate pregnancy. Following a difficult forceps delivery, she was unable to void normally. Catheterization was done until she was admitted to the hospital, four days later. The family and previous history was negative. On physical examination a severe cystitis with foul ammoniacal urine was noted. The patient was very toxic. Intermittent catheterization was unsatisfactory, due to plugging of the catheter, as was cystoscopy due to the cloudy medium, therefore a cystotomy was done on June 3, 1924. The bladder was markedly distended and contained a grayish membrane involving the mucosa and submucosa. This membrane was quite necrotic and was removed with difficulty. Involvement of the kidneys was undoubtedly the cause of the septic type of fever. After drainage was established, a marked improvement was noted in her general condition. A culture showed Bacillus coli and Streptococcus hemolyticus and viridins. The tube was removed two weeks later, an indwelling catheter being placed in the urethra to insure drainage. The urine continued very cloudy and contained much pus. The lacerated perineum was repaired after t he cystotomy wound had healed. The patient left the hospital six weeks following the cystotomy. There was 30 cc. of residual urine present. The bladder capacity was limited to 200 cc. Comment. A prolonged pelvic presentation with circulatory inhibition and overdistention of the bladder, were the outstanding findings, and undoubtedly brought on the necrosis in this case.
Case II. Mr. F. B., male, aged sixty-six, was admitted to Georgetown Hospital on January 24, 1932, with acute retention of urine. Patient had been unable to void for the past four years, catheterizing himself at regular intervals. Rectal examination revealed a very large, symmetrical, type 4 prostatic enlargement. Physical examination was otherwise negative. Cystoscopic examination showed an elongated, tortuous urethra, with large lateral and median lobes introvesical in type. The bladder capacity was 360 cc. The blood findings were as follows: hemoglobin, 75 per cent; red cells, 3,390,000; 91 per cent polymorphonuclears; 8 per cent lymphocytes; blood pressure, 105/65. The phthalein output was 65 per cent for two hours; blood urea, 18 mgm.; blood sugar, 120 mgm.; clotting time, 1 minute. Because of the enormous size of the gland a suprapubic prostatectomy was suggested but the patient refused so a two-stage resection was decided upon. On January 25, 1932, prostatic resection was done, 15 grams of adenomatous tissue
GANGRENE OF BLADDER
523
being removed. There was very little bleeding during the resection which was controlled by light coagulation. A microscopic study of the resected tissue showed no evidence of malignancy. There were, however, marked inflammatory changes present. An indwelling catheter was placed in the urethra. However, on February 3, 1932 (nine days later), the catheter drainage was insufficient, blockage of the catheter occurring several times daily. Therefore a suprapubic cystotomy was done under ethylene anaesthesia, a No. 40 mushroom catheter being placed in the bladder suprapubically. The patient improved very rapidly, the phthalein and blood urea tests again becoming normal after several days forced fluids and drainage. Ten days after the suprapubic operation, the incision was healthy and had healed about the tube, a second resection was done at this time, 18 grams of tissue were removed from the right and left lateral lobes, very little bleeding being observed. No cuts were made high in the bladder. The patient was returned to his room with the bladder irrigation clear, pulse full and regular with no shock being seem. However, on February 15, on the fourth postoperative day, a low grade urosepsis was noted with an elevation in temperature. The thermal curve became steeple-like in character, ranging between 99° and 104°F. The urinary output which had been 3500 to 4000 cc. daily, rapidly diminished. Intravenous glucose was given twice daily, in an attempt to increase the urinary output. Urotropin was given intravenously for the suspected pyelonephritis. A transfusion of 500 cc. of citrated blood was also administered on February 19. The patient gradually became uremic, very restless and hiccoughed constantly. The day preceding death, February 22, the blood urea was 160 mgm. and the urinary output had decreased to 100 cc. for twenty-four hours. Necropsy report (Dr. W. M. Yater): Anatomical diagnosis: (1) Recent suprapubic cystotomy wound, which is necrotic; (2) gangrenous cystitis; (3) nephrosis with pyelonephritis; (4) chronic cholecystitis; (5) acute ulceration of the colon. The bladder wall was markedly thickened and edematous, the mucosa purplish in color, necrotic and covered by a yellowish-green exudate. The bladder wall was intact; no evidence of rupture was seen. Comment. Gangrene of the bladder and cystotomy incision in this case was undoubtedly due to interference with the blood supply probably thrombotic in origin. The necropsy findings showed no evidence of injury to the bladder wall from instrumentation.
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W. C. STIRLING AND G. A. HOPKINS CONCLUSIONS
1.
In any severe chronic cystitis, gangrene should be kept in
mind and drainage instituted as early as possible. 2. Gangrene of the bladder is probably much more common than we have suspected due to failure in diagnosis and obtaining autopsies. 3. Retention of urine and the presence of infection are the chief predisposing factors. 4. Treatment if instituted early, may result favorably even in the presence of severe necrosis. 5. Palliative treatment may be tried in the female, but early drainage by cystotomy offers the best prognosis in the male.
1621 Connecticut Ave., N.W. Washington, D. C. REFERENCES ANTONOUPOLUS ET DOUAY: Gangrene Entendue de la Paroi Vesicale. Quinec. et Obstet., Paris, January, 1931, xxiii, 196- 207. AscHNER, PAUL: Suprapubic prostate. Jour. Urol., 1924, xii, 252- 266. CARSON, W. J.: Gangrene of bladder. Ann. surg., 1927, lxxxv, 269- 274. CARSON, W. J.: Gangrene of bladder. Jour. Urol., February, 1925, xiii, 205. CowEN, L . B., AND CowEN, ROBT.: A fatality following electromic prostatic resection. Report of a case with autopsy findings. Urol. and Cut. Review, February, 1933, 105-107. DucHANOFF, A.: Cystitis Gangraenosa Dessecans. Zeits. fur Urolog. Chir., 1930, xxix, 516-530, Berlin. DuNET ET CREYSSELL: Cystite Gangreneuse Totale Survenue a la Suite d'une Retention Oign. Z. Urol. Chir., 1926. ELIASON, E. H .: Gangrene of the bladder. An,n. Surg., 1925, lxxxvi, 546. FRONSTEIN, R.: Uber Cystitis Gangraenosa. Zeitschrift fur Urol. Chir., 1926, Xl X.
GEISICKE, HELLMUTH VoN: Cystitis Dissecans Gangraenescens. Zeitsch. fur Urologie, 1931, xxv, 561-572, Leipzig. GuYON: Quoted by Patch, 1927, loc. cit. HAULTAIN, F . W. : Laboratory Reports Royal College Phys. Edinburgh, 1890, ii, 216. HEIDLER, HANS: Cystitis Dissecans Gangraenosa Actinogenetica. Z. Geburtsh., 1927, xcii, 1- 13. HEUBNER: Die Experimentelle Diphth. Leipsig, 1883. HrsGEN: Cited by Antonoupolus Munchen. Mediz. Wochenschrift, 1919, 1292. JUDD, E. S., AND MEEKER, W.R.: Jour. Urol., 1924, xi, 411. LEUGUE: Fraite Chir. a Urol., 614, Paris, 1921.
GANGRENE OF BLADDER LEMPERG, FRITZ: Cystitis Gangraenosa Dissecans.
525
Zbl. Quinak., 1926, xviii,
1203.
KARLIN, MAX: Ein. Fall von Cystitis Gangrae. Miro. Wochenbett. Zbl. Gynak., 1926, xviii, 1205-50. LEVER: Guys Hosp. Rep., 1852, no. 51, 49. O'NEIL, R. F.: Necrosis of the bladder with exfoliation. Surg., Gynecol., and Obstet., May, 1910, 503-518. OuGLEV, RouMAN: La Gangrene Vesicale. Jour. d'urol. Medic. et Chir. Paris, 1931, xxxii, 120-132. PATCH, F . S. Gangrenous cystitis. Jour. Urol., June, 1928, xix, 713. PETERS, W.: Uber Cystitis Gangraenosa. Dtsch. Z. Chir., 1924, clxxxvii. PRUDDEN, T . M., AND DELAFIELD, F . : Pathology, 1914. RANDALL, ALEX: Two unusual bladder lesions. Trans. Amer. Assoc. GenitoUrin. Surg., 1923, xvi, 215. STOECKEL: Berliner Klinische Wochen., 1905, 20. WILLIS: Diss. de Urinis, 1650. WoLFERTH, C. C., AND MILLER, T. G.: Necrosis and gangrene of urinary bladder. Review of 153 cases, etc. Amer. Jour. Med. Sci., 1924, clxvii, 339-367.