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Renal Pain: A Symptom in Acute Cystitis
RENAL PAIN: A SYMPTOM IN ACUTE CYSTITIS RALPH L. DOURMASHKIN AND A. ALFRED SOLOMON
Careful review of the literature fails to reveal that renal pain often occurs in so prevalent a condition as acute cystitis. Lewis called attention to regurgitation colic which occurs in obstructive lesions at the neck of the bladder, but in his excellent review of the numerous causes of renal pain, acute cystitis was not mentioned. That renal pain, in our series, was not due to reflux through a patent malfunctioning ureteral orifice was definitely proven by the fact that the kidney specimens of urine in all of our cases in which catheterization was done were free of pus and bacteria. The nearest analogous reference was made by Jona who stressed the occurrence of kidney pain in cases of chronically inflamed, spastic bladder which he attributed to anti-peristalsis in the ureter. In acute cystitis renal pain is undoubtedly due to an inflammatory occlusion of the lower end of the ureter. The intramural portion of the ureter or the orifice itself becomes involved in the general inflammatory process of the bladder mucosa with consequent narrowing or complete closure of the lumen. This results in intermittent or constant retention of urine in the uretero-pelvic tract and pain just as in any other type of ureteral obstruction. In a series of 160 cases of acute cystitis which came under our observation, pain in the kidney region was present in 38 cases (24 per cent). A symptom of such frequent occurrence would seem to merit much consideration. We have not included in our series cases of acute bladder infection associated with obstructive lesion at the vesical neck or spinal cord lesions associated with residual urine in the bladder. It is for this reason that the vast majority of patients were women (153 cases) in whom primary cystitis is common. Only 7 men were encountered of whom 2 had the syndrome. Cases of pyelo-cystitis, in which the catheterized kidney specimens of urine contained pus and bacteria, were likewise excluded. Even those with lesions of the upper urinary tract, not associated with renal infection, but which could have accounted for renal pain such as calculi, nephroptosis, ureteral kinks, aberrant vessel hydronephrosis, etc. were carefully excluded. The renal pain varied in intensity from dull intermittent aching to severe attacks of typical renal colic. Twenty-four patients suffered 1 or •
28
RENAL PAIN IN ACUTE CYSTITIS
29
more attacks of colic; the remaining 14 had pain of aching nature, dull in some instances and moderately severe in others. In 24 cases the pain occurred shortly after the onset of bladder symptoms, in 12 cases the pain was felt simultaneoulsy, while in 2 cases pain in the kidney region was experienced shortly before bladder distress became apparent. In some instances pain in the kidney region was so marked that it overshadowed the symptoms of bladder infection especially when these were mild in character. Indeed a number of cases were referred to us with a tentative diagnosis of ureteral stone obstruction. This undoubtedly accounts for the high incidence of renal pain in our series, as many of the uncomplicated cases of acute cystitis probably would not have come under our observation. In over 81 per cent of the cases the pain was unilateral, the right side being affected in 14 and the left in 17 cases. In 7 cases the pain was bilateral. We were particularly careful to include only those cases in which the localization of pain pointed definitely to its renal character. Cases in which the complaint was that of mid-lumbar or sacral pain, so commonly encountered in conditions associated with pelvic congestion, were not included in this series. The associated symptoms such as nausea, vomiting, radiation of pain to abdomen and groin, differed in no way from those caused by any other obstructive lesion. Clinically the important consideration in this syndrome is the history of bladder distress symptoms, such as dysuria, urgency, frequency and hematuria preceding in a majority of cases the onset of renal pain. The absence of fever is another important clue which should exclude the possibility of renal infection in cases of sudden onset of bladder symptoms associated with pyuria and renal pain. In this series the temperature remained normal in 30 of 38 cases or nearly 80 per cent. The roentgenographic examination should exclude the presence of stone in the ureter as the possible cause of obstruction in a large majority of cases. The clinical picture in acute cakulous obstruction of the ureter is entirely different in that bladder symptoms rarely occur prior to the onset of renal pain and that pyuria is nearly always absent during the first attack, If present at all it occurs as a result of renal infection: a late manifestation of the disease. Cystoscopic examination establishes the diagnosis definitely. Confronted with a patient who complains of renal pain associated with bladder symptoms, one's attention is inevitably focused on the kidney. In the absence of x-ray shadows pointing to a stone in the ureter, the cystoscopic examination is apt to be particularly prolonged inasmuch as
30
RALPH L. DOURMASHKIN AND A. ALFRED SOLOMON
it may include such additional diagnostic procedures as the passage of a wax bulb into the ureter or injection of an opaque medium for pyelography. Such examinations in the presence of an acutely inflamed bladder, as a rule, impose untold suffering upon the patient and may even in some instances carry the infection to the kidney. It was our rule in the past, nevertheless, to subject nearly every case to a cystoscopic examination. However, since sulphanilamide and its allied compounds came into use, with the aid of which it was possible to produce rapid amelioration of symptoms and disappearance of pyuria, we found no necessity to resort to early instrumental investigation except in cases which presented some special diagnostic problem or cases which were seen during an acute attack of renal colic and in which it was necessary to pass a catheter to the kidney to release the retained urine and thus bring about relief. Cystoscopically the most important observation was the absence of pus and bacteria in the urine catheterized from the side on which the pain was present. Ureteral catheterization was resorted to in 23 of the 31 cases which were subjected to cystoscopic examination. In addition, the cystoscope sometimes revealed evidence of ureteral obstruction on the affected side which was particularly marked when the patient was examined during the attack of pain. In the majority of cases, however, the examination was performed during a quiescent stage. In a number of cases there was a retardation of indigo carmine elimination on the side of pain. In other cases there was a visible change in the patency of the orifice such as edematous tumefaction or gluing of the ureteral lips. The edema of the orifice and the ureteral mound in no case assumed the huge proportions so often observed in calculous impaction within the intramural portion of the ureter. Intravenous urography showed a varying degree of dilatation of the uretero-pelvic tract on the affected side which was by no means as marked as in cases of tight stone impaction. This examination does not, of course, exclude renal infection. The secondary nature of the ureteropyelectasis, however, should be at once recognised in the light of the history of the case and further instrumental investigation should not be undertaken unless the patient fails to respond to chemotherapy. It is important to confirm the temporary nature of the urinary stasis by another intravenous pyelography taken after pyuria and symptoms of bladder infection have subsided (figs. 1 and 2). The elementary truth that a subsequent cystoscopic examination should be undertaken during
31
RENAL PAIN IN ACUTE CYSTITIS
a quiescent stage to exclude intravesical conditions which may have induced the acute cystitis, needs, of course, no emphasis here. The following recent cases were selected to illustrate some of the points mentioned above. Case 1. E. female, aged 26, had been married 2 months. The patient was seen on June 24, 1940, complaining of frequency, nocturia and pain on urination for one week and moderate pain in the left kidney region accompanied by nausea for last 12 hours.
FIG.
1
FIG.
2
FIG. 1. Intravenous urogram showing pyelactasis on the left side and a spastic bladder
in Case 3. Only the upper portion of the ureter is visualized showing considerable dilatation. Culture of the kidney urine showed no evidence of infection. The patient had an acute Staphylococcus aureus infection of the bladder. FIG. 2. Same case. Intravenous urogram taken 2 weeks after pus and bacteria disappeared from the urine. Note that the contour of the pelvis and calices has now assumed a perfectly normal appearance. The bladder outline no longer shows the spasticity.
Urine showed thick pus and numerous colon bacilli. Plain x-ray of the urinary tract was negative. The patient evidently had a "honeymoon" cystitis. She was placed on sulfanilamide and the bladder symptoms disappeared within 2 days. The left kidney pain persisted, however, and on June 26 she was subjected to a cystoscopic examination. The bladder mucosa showed evidence of subsiding cystitis. The left ureteral orifice was edematous and previously injected indigo carmine flowed from it in lazy jets. A No. 6 catheter was passed up the ureter and clear urine free of pus and bacteria was obtained in a rapid flow indicating
32
RALPH L. DOURMASHKIN AND A. ALFRED SOLOMON
retention. The patient was immediately relieved of pain. intravenous urogram was negative.
A subsequent
Case 2. M. G., female, aged 24, had been married 1½ years. She was referred by father and brother, both physicians, with a diagnosis of stone in the ureter, October 11, 1939. She complained of urgency and painful urination of 1 week's duration. During the past 4 days she had suffered 2 attacks of severe pain in the right costo-vertebral angle radiating to the lower abdominal quadrant requiring morphine for relief. The urine was loaded with pus and staphylococci. Plain x-rays showed no evidence of calculi in the urinary tract. The intravenous urogram, taken during quiescent period, was likewise negative. Patient was given sulfanilamide and within 2 days all symptoms had disappeared. The urine became clear and no longer contained pus and bacteria. Cystoscopic examination was not thought to be necessary in this case. Case 3. M. H., male, aged 32, a German refugee, was seen on June 6, 1940 complaining of frequency and pain on urination of 3 months' duration following passage of instruments into his bladder in a foreign country. X-rays of the urinary tract were negative. The urine contained innumerable pus cells in thick clumps and culture showed a Staphylococcus aureus infection. Cystoscopy revealed a marked cystitis. He was placed on sulfanilamide and after temporary improvement his bladder symptoms became much worse and gross hematuria was present. He now had violent urgency and nocturia . .On June 29 he was seized with an attack of severe left renal colic. Intravenous urography showed definite evidence of retention in the left pelvic tract and a spastic bladder (figs. 1 and 2). He was cystoscoped again on July 1. The vesical mucosa showed a marked intensification of the inflammatory process. A wax bulb catheter was passed into the left kidney apparently without any obstruction. On subsequent examination it showed no scratch marks. The urine from the left kidney came through in a very rapid flow, indicating retention, and microscopical examination showed neither pus nor bacteria. The urine from the right kidney was likewise negative. The cultures of both kidney urines showed no growths after 48 hours. Bladder symptoms continued to be severe and he suffered 2 more attacks of left renal colic lasting 3 to 4 hours on July 20. He was now placed on sulfathiazole, which had just become available, and after 10 days his urine became crystal clear, pus and bacteria free, and he was entirely free of symptoms. A subsequent intravenous urogram revealed that the dilatation of the pelvis previously observed had completely disappeared and the bladder outline no longer showed the spasticity (fig. 2).
RENAL PAIN IN ACUTE CYSTITIS
33
SUMMARY AND CONCLUSIONS
There is a striking lack of reference in the literature to renal pain as a symptom of acute cystitis. This symptom was present in 24 per cent of a series of 160 cases of primary bladder infection. Pain is undoubtedly caused by stasis due to inflammatory occlusion of the ureteral orifice. Recognition of this syndrome should obviate extensive cystoscopic procedures in attempts to explain the cause of the renal pain.
104 E. 40th St., New York, N. Y. REFERENCES JONA, J. L. : Kidney Pain: Its causation and Treatment. London, J. and A. Churchill,
1937. LEWIS, BRANSFORD: Regurgitation renal colic.
J. A. M.A., 98: 609, 1932.
Careful review of the literature fails to reveal that renal pain often occurs in so prevalent a condition as acute cystitis. Lewis called attention to regurgitation colic which occurs in obstructive lesions at the neck of the bladder, but in his excellent review of the numerous causes of renal pain, acute cystitis was not mentioned. That renal pain, in our series, was not due to reflux through a patent malfunctioning ureteral orifice was definitely proven by the fact that the kidney specimens of urine in all of our cases in which catheterization was done were free of pus and bacteria. The nearest analogous reference was made by Jona who stressed the occurrence of kidney pain in cases of chronically inflamed, spastic bladder which he attributed to anti-peristalsis in the ureter. In acute cystitis renal pain is undoubtedly due to an inflammatory occlusion of the lower end of the ureter. The intramural portion of the ureter or the orifice itself becomes involved in the general inflammatory process of the bladder mucosa with consequent narrowing or complete closure of the lumen. This results in intermittent or constant retention of urine in the uretero-pelvic tract and pain just as in any other type of ureteral obstruction. In a series of 160 cases of acute cystitis which came under our observation, pain in the kidney region was present in 38 cases (24 per cent). A symptom of such frequent occurrence would seem to merit much consideration. We have not included in our series cases of acute bladder infection associated with obstructive lesion at the vesical neck or spinal cord lesions associated with residual urine in the bladder. It is for this reason that the vast majority of patients were women (153 cases) in whom primary cystitis is common. Only 7 men were encountered of whom 2 had the syndrome. Cases of pyelo-cystitis, in which the catheterized kidney specimens of urine contained pus and bacteria, were likewise excluded. Even those with lesions of the upper urinary tract, not associated with renal infection, but which could have accounted for renal pain such as calculi, nephroptosis, ureteral kinks, aberrant vessel hydronephrosis, etc. were carefully excluded. The renal pain varied in intensity from dull intermittent aching to severe attacks of typical renal colic. Twenty-four patients suffered 1 or •
28
RENAL PAIN IN ACUTE CYSTITIS
29
more attacks of colic; the remaining 14 had pain of aching nature, dull in some instances and moderately severe in others. In 24 cases the pain occurred shortly after the onset of bladder symptoms, in 12 cases the pain was felt simultaneoulsy, while in 2 cases pain in the kidney region was experienced shortly before bladder distress became apparent. In some instances pain in the kidney region was so marked that it overshadowed the symptoms of bladder infection especially when these were mild in character. Indeed a number of cases were referred to us with a tentative diagnosis of ureteral stone obstruction. This undoubtedly accounts for the high incidence of renal pain in our series, as many of the uncomplicated cases of acute cystitis probably would not have come under our observation. In over 81 per cent of the cases the pain was unilateral, the right side being affected in 14 and the left in 17 cases. In 7 cases the pain was bilateral. We were particularly careful to include only those cases in which the localization of pain pointed definitely to its renal character. Cases in which the complaint was that of mid-lumbar or sacral pain, so commonly encountered in conditions associated with pelvic congestion, were not included in this series. The associated symptoms such as nausea, vomiting, radiation of pain to abdomen and groin, differed in no way from those caused by any other obstructive lesion. Clinically the important consideration in this syndrome is the history of bladder distress symptoms, such as dysuria, urgency, frequency and hematuria preceding in a majority of cases the onset of renal pain. The absence of fever is another important clue which should exclude the possibility of renal infection in cases of sudden onset of bladder symptoms associated with pyuria and renal pain. In this series the temperature remained normal in 30 of 38 cases or nearly 80 per cent. The roentgenographic examination should exclude the presence of stone in the ureter as the possible cause of obstruction in a large majority of cases. The clinical picture in acute cakulous obstruction of the ureter is entirely different in that bladder symptoms rarely occur prior to the onset of renal pain and that pyuria is nearly always absent during the first attack, If present at all it occurs as a result of renal infection: a late manifestation of the disease. Cystoscopic examination establishes the diagnosis definitely. Confronted with a patient who complains of renal pain associated with bladder symptoms, one's attention is inevitably focused on the kidney. In the absence of x-ray shadows pointing to a stone in the ureter, the cystoscopic examination is apt to be particularly prolonged inasmuch as
30
RALPH L. DOURMASHKIN AND A. ALFRED SOLOMON
it may include such additional diagnostic procedures as the passage of a wax bulb into the ureter or injection of an opaque medium for pyelography. Such examinations in the presence of an acutely inflamed bladder, as a rule, impose untold suffering upon the patient and may even in some instances carry the infection to the kidney. It was our rule in the past, nevertheless, to subject nearly every case to a cystoscopic examination. However, since sulphanilamide and its allied compounds came into use, with the aid of which it was possible to produce rapid amelioration of symptoms and disappearance of pyuria, we found no necessity to resort to early instrumental investigation except in cases which presented some special diagnostic problem or cases which were seen during an acute attack of renal colic and in which it was necessary to pass a catheter to the kidney to release the retained urine and thus bring about relief. Cystoscopically the most important observation was the absence of pus and bacteria in the urine catheterized from the side on which the pain was present. Ureteral catheterization was resorted to in 23 of the 31 cases which were subjected to cystoscopic examination. In addition, the cystoscope sometimes revealed evidence of ureteral obstruction on the affected side which was particularly marked when the patient was examined during the attack of pain. In the majority of cases, however, the examination was performed during a quiescent stage. In a number of cases there was a retardation of indigo carmine elimination on the side of pain. In other cases there was a visible change in the patency of the orifice such as edematous tumefaction or gluing of the ureteral lips. The edema of the orifice and the ureteral mound in no case assumed the huge proportions so often observed in calculous impaction within the intramural portion of the ureter. Intravenous urography showed a varying degree of dilatation of the uretero-pelvic tract on the affected side which was by no means as marked as in cases of tight stone impaction. This examination does not, of course, exclude renal infection. The secondary nature of the ureteropyelectasis, however, should be at once recognised in the light of the history of the case and further instrumental investigation should not be undertaken unless the patient fails to respond to chemotherapy. It is important to confirm the temporary nature of the urinary stasis by another intravenous pyelography taken after pyuria and symptoms of bladder infection have subsided (figs. 1 and 2). The elementary truth that a subsequent cystoscopic examination should be undertaken during
31
RENAL PAIN IN ACUTE CYSTITIS
a quiescent stage to exclude intravesical conditions which may have induced the acute cystitis, needs, of course, no emphasis here. The following recent cases were selected to illustrate some of the points mentioned above. Case 1. E. female, aged 26, had been married 2 months. The patient was seen on June 24, 1940, complaining of frequency, nocturia and pain on urination for one week and moderate pain in the left kidney region accompanied by nausea for last 12 hours.
FIG.
1
FIG.
2
FIG. 1. Intravenous urogram showing pyelactasis on the left side and a spastic bladder
in Case 3. Only the upper portion of the ureter is visualized showing considerable dilatation. Culture of the kidney urine showed no evidence of infection. The patient had an acute Staphylococcus aureus infection of the bladder. FIG. 2. Same case. Intravenous urogram taken 2 weeks after pus and bacteria disappeared from the urine. Note that the contour of the pelvis and calices has now assumed a perfectly normal appearance. The bladder outline no longer shows the spasticity.
Urine showed thick pus and numerous colon bacilli. Plain x-ray of the urinary tract was negative. The patient evidently had a "honeymoon" cystitis. She was placed on sulfanilamide and the bladder symptoms disappeared within 2 days. The left kidney pain persisted, however, and on June 26 she was subjected to a cystoscopic examination. The bladder mucosa showed evidence of subsiding cystitis. The left ureteral orifice was edematous and previously injected indigo carmine flowed from it in lazy jets. A No. 6 catheter was passed up the ureter and clear urine free of pus and bacteria was obtained in a rapid flow indicating
32
RALPH L. DOURMASHKIN AND A. ALFRED SOLOMON
retention. The patient was immediately relieved of pain. intravenous urogram was negative.
A subsequent
Case 2. M. G., female, aged 24, had been married 1½ years. She was referred by father and brother, both physicians, with a diagnosis of stone in the ureter, October 11, 1939. She complained of urgency and painful urination of 1 week's duration. During the past 4 days she had suffered 2 attacks of severe pain in the right costo-vertebral angle radiating to the lower abdominal quadrant requiring morphine for relief. The urine was loaded with pus and staphylococci. Plain x-rays showed no evidence of calculi in the urinary tract. The intravenous urogram, taken during quiescent period, was likewise negative. Patient was given sulfanilamide and within 2 days all symptoms had disappeared. The urine became clear and no longer contained pus and bacteria. Cystoscopic examination was not thought to be necessary in this case. Case 3. M. H., male, aged 32, a German refugee, was seen on June 6, 1940 complaining of frequency and pain on urination of 3 months' duration following passage of instruments into his bladder in a foreign country. X-rays of the urinary tract were negative. The urine contained innumerable pus cells in thick clumps and culture showed a Staphylococcus aureus infection. Cystoscopy revealed a marked cystitis. He was placed on sulfanilamide and after temporary improvement his bladder symptoms became much worse and gross hematuria was present. He now had violent urgency and nocturia . .On June 29 he was seized with an attack of severe left renal colic. Intravenous urography showed definite evidence of retention in the left pelvic tract and a spastic bladder (figs. 1 and 2). He was cystoscoped again on July 1. The vesical mucosa showed a marked intensification of the inflammatory process. A wax bulb catheter was passed into the left kidney apparently without any obstruction. On subsequent examination it showed no scratch marks. The urine from the left kidney came through in a very rapid flow, indicating retention, and microscopical examination showed neither pus nor bacteria. The urine from the right kidney was likewise negative. The cultures of both kidney urines showed no growths after 48 hours. Bladder symptoms continued to be severe and he suffered 2 more attacks of left renal colic lasting 3 to 4 hours on July 20. He was now placed on sulfathiazole, which had just become available, and after 10 days his urine became crystal clear, pus and bacteria free, and he was entirely free of symptoms. A subsequent intravenous urogram revealed that the dilatation of the pelvis previously observed had completely disappeared and the bladder outline no longer showed the spasticity (fig. 2).
RENAL PAIN IN ACUTE CYSTITIS
33
SUMMARY AND CONCLUSIONS
There is a striking lack of reference in the literature to renal pain as a symptom of acute cystitis. This symptom was present in 24 per cent of a series of 160 cases of primary bladder infection. Pain is undoubtedly caused by stasis due to inflammatory occlusion of the ureteral orifice. Recognition of this syndrome should obviate extensive cystoscopic procedures in attempts to explain the cause of the renal pain.
104 E. 40th St., New York, N. Y. REFERENCES JONA, J. L. : Kidney Pain: Its causation and Treatment. London, J. and A. Churchill,
1937. LEWIS, BRANSFORD: Regurgitation renal colic.
J. A. M.A., 98: 609, 1932.