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MICTURITION SYNCOPE AS THE PRESENTING SYMPTOM IN A PATIENT WITH PROSTATIC ENLARGEMENT AND OBSTRUCTION
00226347/98/1606-2156$03.00/0
Val. 160,2156-2157.December 1998 Printed i n U.S.A.
THE JOLIRNAL OF U R O m Y
Copyright 0 1998 by AMERICANURO~~DCICAL ASSOCIATION, INC
MICTURITION SYNCOPE AS THE PRESENTING SYMPTOM IN A PATIENT WITH PROSTATIC ENLARGEMENT AND OBSTRUCTION H. JOHN, P. JAEGER, P. GREMINGER
AND
S . V. YALLA
From the Urologic Clinic of Winterthur, Winterthur and Department of Medicine, University Hospital Zurich, Zurich, Sloitzerland, and Division of Urology, West Roxbury Veterans Affairs Medical Center, Harvard Medical School, Boston, Massachusetts KEY WORDS:urodynamics, prostate, prostatic hyperplasia, syncope
Micturition syncope is a sudden and temporary loss of consciousness during or shortly after voiding. Our case is atypical in that micturition syncope was the presenting symptom of benign prostatic enlargement and obstruction. We describe simultaneous urodynamic and cardiovascular findings in our patient during a n episode of syncope. CASE REPORT
A 76-year-old man with known arterial hypertension complained of loss of consciousness every 2 to 3 weeks during or shortly after voiding. He had a weak urinary stream, strained to begin urination and voided 3 times nightly. Medication included 50 mg. losartan and 50/125 mg. atenolov chlorthalidone daily. Two clinical tests excluded a n orthostatic blood pressure reaction. Computerized tomography of the head revealed chronic ischemic pons lesions. Doppler ultrasound of the extracranial arteries showed 30 to 60% stenosis of the right internal carotid artery and occlusion of the left vertebral artery. Holter electrocardiography demonstrated a regular, mostly bradycardiac rhythm with a minimal frequency of 39 beats per minute. Echocardiography showed no output failure or valve constrictions. "here was no urinary tract infection. Cystoscopy revealed trilobular prostatic enlargement and 260 ml. post-void residual urine volume. Monitored voiding, including measurement of blood pressure through arterial access, abdominal pressure and urinary flow, showed ab-
FIG. 2. Rectal pressure measurement during uroflowmetry. A, Valsalva maneuver during voiding preoperatively with rectal pressure up to 150 cm. water. B, no Valsalva maneuver during voiding postoperatively.
dominal strain up to 150 cm. water and a decreased maximum urinary flow of 12 ml. per second (figs. 1 to 3). Synchronous systolic arterial pressure decreased by 48 mm. Hg while pulse frequency remained stable (fig. 1). The patient became dizzy and sat down. Six weeks after transurethral prostate resection t h e patient denied any attacks of dizziness or syncope during voiding. Repeat monitored voiding showed 198 ml. urine voided within 24 seconds with a peak flow rate of 28 ml. per second and no abdominal straining (figs. 2 and 3). Arterial pressure and pulse frequency remained stable. Intermittent arterial hypertension persisted in the first months postoperatively with documented systolic pressures up to 204 mm. Hg. Medication was changed from losartan to 25 mg. captopril daily.
DISCUSSION
Accepted for publication July 31, 1998.
Micturition syncope is rare, occurring in approximately 5 to 8% of all cases of syncope. The condition was first described in 1959 by Proudfit and Fertenza.1 Cardiac dis300 ease (bradyrhythmia, tachyarrhythmia and obstruction of VOIDING the left ventricular outflow), cardiovascular disease (carotid sinus syncope and orthostatic hypotension) and neurological disorders (unwitnessed seizure) a r e the other factors that cause syncope.2 Therefore, physical studies, electrocardiography, echocardiography a n d electroencephalography are usually normal in patients with micturition syncope.3 The exact pathophysiological mechanism of micturition syncope is unclear. Vagal stimulation with cardiac inhibition due to detrusor contraction or abdominal strain, loss of pressor receptor effects caused by bladder wall distention and extra-adrenal pheochromocytoma of the bladder have been implicated. Indeed, postoperative antihyperten", ~ - . ~ , ,. , . , . . sive therapy may have led to a higher threshold in our 0 2 4 6 8 10 patient, triggering micturition syncope. Since intermittent time [min] arterial hypertension persisted postoperatively, we hyFIG. 1. Synchronous monitored blood pressure (P)and pulse rate pothesize that vasovagal responses due to the Valsalva during voiding. syst, systolic. diast, diastolic. maneuver in this patient with bladder outlet obstruction
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MICTURITION SYNCOPE AND PROSTATIC ENLARGEMENT
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FIG.3. A, preoperatively urinary flow (Qura)was 299 ml. per 63 seconds with decreased maximum flow of 12 ml. per second and residual urine volume of 260 ml. B , postoperatively urinary flow was 198 ml. per 24 seconds with maximum flow of 28 ml. per s e c o n f ! % ~ ~ ~ ~ strain during voiding and no post-void residual urine volume.
may have beenprimarily responsible for micturition syncope. However, it is unclear why syncope is not more common i n patients with hypertension and prostatic obstruction. I n conclusion, to OUT knowledge we r e p o d the first documented case i n the literature i n which micturition syncope w a s the presenting symptom of prostatic enlargement and obstruction.
REFERENCES
1. Proudfit, W. L. and Ferteza, M. E.: Micturition syncope. New Engl. J . Med., 260 328, 1959. 2. Farrehi, P. M., Santinga, J . T. and Eagle, K A.: Syncope: diagnosis of cardiac and noncardiac causes. Geriatrics, 50: 24, 1995. 3. Kapoor, W. N., Peterson, J . R. and Karpf, M.: Micturition syncope. A reappraisal. J.A.M.A., 2 5 3 796, 1985.
Val. 160,2156-2157.December 1998 Printed i n U.S.A.
THE JOLIRNAL OF U R O m Y
Copyright 0 1998 by AMERICANURO~~DCICAL ASSOCIATION, INC
MICTURITION SYNCOPE AS THE PRESENTING SYMPTOM IN A PATIENT WITH PROSTATIC ENLARGEMENT AND OBSTRUCTION H. JOHN, P. JAEGER, P. GREMINGER
AND
S . V. YALLA
From the Urologic Clinic of Winterthur, Winterthur and Department of Medicine, University Hospital Zurich, Zurich, Sloitzerland, and Division of Urology, West Roxbury Veterans Affairs Medical Center, Harvard Medical School, Boston, Massachusetts KEY WORDS:urodynamics, prostate, prostatic hyperplasia, syncope
Micturition syncope is a sudden and temporary loss of consciousness during or shortly after voiding. Our case is atypical in that micturition syncope was the presenting symptom of benign prostatic enlargement and obstruction. We describe simultaneous urodynamic and cardiovascular findings in our patient during a n episode of syncope. CASE REPORT
A 76-year-old man with known arterial hypertension complained of loss of consciousness every 2 to 3 weeks during or shortly after voiding. He had a weak urinary stream, strained to begin urination and voided 3 times nightly. Medication included 50 mg. losartan and 50/125 mg. atenolov chlorthalidone daily. Two clinical tests excluded a n orthostatic blood pressure reaction. Computerized tomography of the head revealed chronic ischemic pons lesions. Doppler ultrasound of the extracranial arteries showed 30 to 60% stenosis of the right internal carotid artery and occlusion of the left vertebral artery. Holter electrocardiography demonstrated a regular, mostly bradycardiac rhythm with a minimal frequency of 39 beats per minute. Echocardiography showed no output failure or valve constrictions. "here was no urinary tract infection. Cystoscopy revealed trilobular prostatic enlargement and 260 ml. post-void residual urine volume. Monitored voiding, including measurement of blood pressure through arterial access, abdominal pressure and urinary flow, showed ab-
FIG. 2. Rectal pressure measurement during uroflowmetry. A, Valsalva maneuver during voiding preoperatively with rectal pressure up to 150 cm. water. B, no Valsalva maneuver during voiding postoperatively.
dominal strain up to 150 cm. water and a decreased maximum urinary flow of 12 ml. per second (figs. 1 to 3). Synchronous systolic arterial pressure decreased by 48 mm. Hg while pulse frequency remained stable (fig. 1). The patient became dizzy and sat down. Six weeks after transurethral prostate resection t h e patient denied any attacks of dizziness or syncope during voiding. Repeat monitored voiding showed 198 ml. urine voided within 24 seconds with a peak flow rate of 28 ml. per second and no abdominal straining (figs. 2 and 3). Arterial pressure and pulse frequency remained stable. Intermittent arterial hypertension persisted in the first months postoperatively with documented systolic pressures up to 204 mm. Hg. Medication was changed from losartan to 25 mg. captopril daily.
DISCUSSION
Accepted for publication July 31, 1998.
Micturition syncope is rare, occurring in approximately 5 to 8% of all cases of syncope. The condition was first described in 1959 by Proudfit and Fertenza.1 Cardiac dis300 ease (bradyrhythmia, tachyarrhythmia and obstruction of VOIDING the left ventricular outflow), cardiovascular disease (carotid sinus syncope and orthostatic hypotension) and neurological disorders (unwitnessed seizure) a r e the other factors that cause syncope.2 Therefore, physical studies, electrocardiography, echocardiography a n d electroencephalography are usually normal in patients with micturition syncope.3 The exact pathophysiological mechanism of micturition syncope is unclear. Vagal stimulation with cardiac inhibition due to detrusor contraction or abdominal strain, loss of pressor receptor effects caused by bladder wall distention and extra-adrenal pheochromocytoma of the bladder have been implicated. Indeed, postoperative antihyperten", ~ - . ~ , ,. , . , . . sive therapy may have led to a higher threshold in our 0 2 4 6 8 10 patient, triggering micturition syncope. Since intermittent time [min] arterial hypertension persisted postoperatively, we hyFIG. 1. Synchronous monitored blood pressure (P)and pulse rate pothesize that vasovagal responses due to the Valsalva during voiding. syst, systolic. diast, diastolic. maneuver in this patient with bladder outlet obstruction
-\
2156
MICTURITION SYNCOPE AND PROSTATIC ENLARGEMENT
2157
B r ' O ' "
c
1
FIG.3. A, preoperatively urinary flow (Qura)was 299 ml. per 63 seconds with decreased maximum flow of 12 ml. per second and residual urine volume of 260 ml. B , postoperatively urinary flow was 198 ml. per 24 seconds with maximum flow of 28 ml. per s e c o n f ! % ~ ~ ~ ~ strain during voiding and no post-void residual urine volume.
may have beenprimarily responsible for micturition syncope. However, it is unclear why syncope is not more common i n patients with hypertension and prostatic obstruction. I n conclusion, to OUT knowledge we r e p o d the first documented case i n the literature i n which micturition syncope w a s the presenting symptom of prostatic enlargement and obstruction.
REFERENCES
1. Proudfit, W. L. and Ferteza, M. E.: Micturition syncope. New Engl. J . Med., 260 328, 1959. 2. Farrehi, P. M., Santinga, J . T. and Eagle, K A.: Syncope: diagnosis of cardiac and noncardiac causes. Geriatrics, 50: 24, 1995. 3. Kapoor, W. N., Peterson, J . R. and Karpf, M.: Micturition syncope. A reappraisal. J.A.M.A., 2 5 3 796, 1985.