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Vesical Neck Obstruction with Over 8000 Cc Residual Urine
THE JOURNAL OF UROLOGY
Vol. 69, No. I, January 1953 Printed in U.S.A.
VESICAL NECK OBSTRUCTION WITH OVER 8000 CC RESIDUAL URINE REXFORD G. CARTER
Excessively large amounts of residual urine must be very rare or very common. A search of the literature as far back as 1911 shows only a few cases reported, and none over 5000 cc. Some reports stated that the bladder contained massive residual, but did not give the quantity found. Orr, in 1937, reviewed the literature and made the distinction between atony due to neurogenic causes and that due to bladder neck obstruction. In the first, the bladder wall is smooth, symmetrical and not trabeculated. In the latter type, trabeculation is produced by hypertrophy of the muscle bundles resulting in an uneven bladder outline. Cellules and diverticula also develop frequently. In bladders of this type with very large residuals, removal of the obstruction has not been sufficient to restore good function with normal capacity and no residual. More recent papers by Crabtree and Muellner, and by Fish confirm the earlier reports. All agree that best results are obtained by removal of two thirds or more of the bladder wall which leaves a bladder of normal capacity and capable of emptying. CASE REPORT
S. H. B., aged 67, was first seen January 19, 1951, with a tremendously distended abdomen. He had been dribbling a few drops of urine almost constantly for 2 days. During the previous 4 months he had a slow stream with frequency, and nocturia of 4 to 7 times. The past history was of no importance. The patient was having only mild discomfort from distention. The entire abdomen was hard and tight from the ziphoid to the symphysis. The prostate was of normal size but firm. There was no fixation or other evidence of malignancy. A catheter was passed into the bladder easily and during the next hour over 8000 cc of urine were obtained. During this time he showed no evidence of discomfort or shock. Warm water (2500 cc) was placed in the bladder and the catheter clamped. He was sent to the hospital and instructions given to release 400 cc of fluid from the bladder every 30 minutes. Four hours later he complained of a full bladder although over 3000 cc had been removed. The catheter was unclamped and 4000 cc of urine released. No further attempt at decompression was made, and large quantities of urine drained from the catheter during the next 48 hours. There was no discomfort, chills, fever or shock, and no blood appeared in the urme. Laboratory data: Red blood cells, 4,260,000; hemoglobin, 12 grams, or 77 per cent; white blood cells, 10,200 with 71 per cent total polymorphonuclears. Nonprotein nitrogen, 40. Urine: Specific gravity 1.016; sugar, negative; albumin 1 Read at annual meeting, South Central Section, American Urological Association, Houston, Texas, October 31, 1951. 118
VESICAL NECK OBSTRUCTION WITH OVER
8000
CC RESIDUAL URINE
119
plus. Microscopic examination: Many pus cells and red blood cells present. Culture produced E. coli., and a nonhemolytic streptococcus. The patient was kept on constant drainage for 2 days and prepared for operation. Cystoscopy under anesthesia showed a median bar enlargement of the prostate. Several small stones 0.5 to 1 cm. in diameter were seen in the bladder. Another oval stone about 1 by 1.5 cm. was lying between the bladder neck and verumontanum. This stone appeared to block the urethra more completely than the median bar. These stones were removed without difficulty. The bladder neck was then resected in its entire circumference with a total of 11 grams of tissue removed. The pathologist's report showed prostatic hypertrophy and chronic urethritis. The catheter was removed on the afternoon of the sixth day. He voided several times during the night, and the next morning had 2000 cc of residual. The catheter
Frn. 1
Frn. 2
was replaced. Two weeks after operation the bladder capacity was 2000 cc. He voided 800 cc spontaneously, leaving 1200 cc residual. The catheter was left in. At the end of the third week, the capacity was 1000 cc and the residual 500 cc. Again the catheter was left in. At the end of the fourth week the residual was 325 cc, and the catheter was removed. At the end of the 5 weeks he was voiding well and had no residual whatever (fig. 1). This man was last seen on August 28, 1951. At that time he was voiding easily and getting up once or twice at night. The urine was very cloudy. The bladder capacity was 450 cc with the first desire to void at 350 cc. The maximum voluntary pressure on a full bladder was 35 mm. of mercury. There was no residual urme. An excretory urogram showed good function in 5 minutes and no abnormalities of the upper tract. No stone shadows were seen. Cystoscopy showed the bladder wall with many folds and crevices but no di-
120
REXFORD G. CARTER
verticula. The ureteral orifices were normal and urine spurted out normally. There was no apparent obstruction at the bladder neck. A cystogram was made using 300 cc of sodium iodide. This film showed extreme irregularity of the bladder resembling extravasation. There was no reflux up the ureters (fig. 2). DISCUSSION
This case does not fall into the pattern described by Orr, Fish, Crabtree and Muellner. The capacity is not increased and there is no residual; indicating a good functional result. However, the urine remains grossly infected, and the cystogram shows marked deformity of the bladder. For these reasons a partial bladder resection seems indicated. 1709 San Antonio St., Austin, Texas REFERENCES E. G. AND MuELL:'-IER, S. R.: J. Ural., 60: 593, 1948. FrsH, G. W.: J. Ural., 63: 803, 1950. NESBIT, R. M.: J. Urol., 66: 362, 1951. ORR, L. M.: J. Urol., 30: 519, 1937. CRABTREE,
Vol. 69, No. I, January 1953 Printed in U.S.A.
VESICAL NECK OBSTRUCTION WITH OVER 8000 CC RESIDUAL URINE REXFORD G. CARTER
Excessively large amounts of residual urine must be very rare or very common. A search of the literature as far back as 1911 shows only a few cases reported, and none over 5000 cc. Some reports stated that the bladder contained massive residual, but did not give the quantity found. Orr, in 1937, reviewed the literature and made the distinction between atony due to neurogenic causes and that due to bladder neck obstruction. In the first, the bladder wall is smooth, symmetrical and not trabeculated. In the latter type, trabeculation is produced by hypertrophy of the muscle bundles resulting in an uneven bladder outline. Cellules and diverticula also develop frequently. In bladders of this type with very large residuals, removal of the obstruction has not been sufficient to restore good function with normal capacity and no residual. More recent papers by Crabtree and Muellner, and by Fish confirm the earlier reports. All agree that best results are obtained by removal of two thirds or more of the bladder wall which leaves a bladder of normal capacity and capable of emptying. CASE REPORT
S. H. B., aged 67, was first seen January 19, 1951, with a tremendously distended abdomen. He had been dribbling a few drops of urine almost constantly for 2 days. During the previous 4 months he had a slow stream with frequency, and nocturia of 4 to 7 times. The past history was of no importance. The patient was having only mild discomfort from distention. The entire abdomen was hard and tight from the ziphoid to the symphysis. The prostate was of normal size but firm. There was no fixation or other evidence of malignancy. A catheter was passed into the bladder easily and during the next hour over 8000 cc of urine were obtained. During this time he showed no evidence of discomfort or shock. Warm water (2500 cc) was placed in the bladder and the catheter clamped. He was sent to the hospital and instructions given to release 400 cc of fluid from the bladder every 30 minutes. Four hours later he complained of a full bladder although over 3000 cc had been removed. The catheter was unclamped and 4000 cc of urine released. No further attempt at decompression was made, and large quantities of urine drained from the catheter during the next 48 hours. There was no discomfort, chills, fever or shock, and no blood appeared in the urme. Laboratory data: Red blood cells, 4,260,000; hemoglobin, 12 grams, or 77 per cent; white blood cells, 10,200 with 71 per cent total polymorphonuclears. Nonprotein nitrogen, 40. Urine: Specific gravity 1.016; sugar, negative; albumin 1 Read at annual meeting, South Central Section, American Urological Association, Houston, Texas, October 31, 1951. 118
VESICAL NECK OBSTRUCTION WITH OVER
8000
CC RESIDUAL URINE
119
plus. Microscopic examination: Many pus cells and red blood cells present. Culture produced E. coli., and a nonhemolytic streptococcus. The patient was kept on constant drainage for 2 days and prepared for operation. Cystoscopy under anesthesia showed a median bar enlargement of the prostate. Several small stones 0.5 to 1 cm. in diameter were seen in the bladder. Another oval stone about 1 by 1.5 cm. was lying between the bladder neck and verumontanum. This stone appeared to block the urethra more completely than the median bar. These stones were removed without difficulty. The bladder neck was then resected in its entire circumference with a total of 11 grams of tissue removed. The pathologist's report showed prostatic hypertrophy and chronic urethritis. The catheter was removed on the afternoon of the sixth day. He voided several times during the night, and the next morning had 2000 cc of residual. The catheter
Frn. 1
Frn. 2
was replaced. Two weeks after operation the bladder capacity was 2000 cc. He voided 800 cc spontaneously, leaving 1200 cc residual. The catheter was left in. At the end of the third week, the capacity was 1000 cc and the residual 500 cc. Again the catheter was left in. At the end of the fourth week the residual was 325 cc, and the catheter was removed. At the end of the 5 weeks he was voiding well and had no residual whatever (fig. 1). This man was last seen on August 28, 1951. At that time he was voiding easily and getting up once or twice at night. The urine was very cloudy. The bladder capacity was 450 cc with the first desire to void at 350 cc. The maximum voluntary pressure on a full bladder was 35 mm. of mercury. There was no residual urme. An excretory urogram showed good function in 5 minutes and no abnormalities of the upper tract. No stone shadows were seen. Cystoscopy showed the bladder wall with many folds and crevices but no di-
120
REXFORD G. CARTER
verticula. The ureteral orifices were normal and urine spurted out normally. There was no apparent obstruction at the bladder neck. A cystogram was made using 300 cc of sodium iodide. This film showed extreme irregularity of the bladder resembling extravasation. There was no reflux up the ureters (fig. 2). DISCUSSION
This case does not fall into the pattern described by Orr, Fish, Crabtree and Muellner. The capacity is not increased and there is no residual; indicating a good functional result. However, the urine remains grossly infected, and the cystogram shows marked deformity of the bladder. For these reasons a partial bladder resection seems indicated. 1709 San Antonio St., Austin, Texas REFERENCES E. G. AND MuELL:'-IER, S. R.: J. Ural., 60: 593, 1948. FrsH, G. W.: J. Ural., 63: 803, 1950. NESBIT, R. M.: J. Urol., 66: 362, 1951. ORR, L. M.: J. Urol., 30: 519, 1937. CRABTREE,