Metabolic acidosis during urinary retention in a patient with an enterovesical fistula

We report a patient known to have an enterovesical fistula who presented severe acute metabolic acidosis during an episode of urinary retention. The enterovesical fistula which had been intermittently symptomatic for 4 years, had developed after several intestinal surgical procedures and related intraperitoneal sepsis following resection of colon cancer 21 years previously. The patient who had a total colectomy and ileostomy, was admitted for hip replacement with the routine placement of a Foley bladder catheter. Three weeks post-operatively, the patient developed acute urinary retention following removal of the urinary catheter. The output from his ileostomy was immediately markedly increased, presumably from bladder urine diverted into the intestines through the enterovesical fistula. Within a few days he presented a normal anion gap metabolic acidosis with raised urea and stable creatinine; his clinical status deteriorated markedly with profound obtundation. These metabolic abnormalities were readily corrected by re-insertion of the Foley catheter with restoration of normal urine flow and immediate corresponding fall in the ileostomy output. Radiographic studies showed the presence of the enterovesical fistula originating from the jejunum. This is the first report of acute metabolic acidosis in association with an enterovesical fistula; the severe metabolic disturbances were triggered by the development of urinary retention resulting in the diversion of urine into the small bowel through the fistula.

Morbidity and the impact on daily activities associated with catheter drainage after acute urinary retention

OBJECTIVE

To evaluate the effect on quality of life of being discharged home with a catheter before definitive treatment in patients with acute urinary retention (AUR).

PATIENTS AND METHODS

Patients attending the emergency department with AUR were assessed and discharged home with a catheter if they fulfilled predetermined criteria. They were admitted to the day-care unit for urological assessment and completed a disease-specific quality-of-life questionnaire.

RESULTS

Of 101 patients presenting to the emergency department in AUR, 84 were sent home after catheterization (83%); 78 (93%) patients completed the questionnaire. The major side-effects reported were urinary leak (46%), mild haematuria (44%), urgency (42%), pain around the penis (42%), painful erection (31%) and catheter blockage (26%). Only 12% of patients felt having a catheter was very inconvenient and 93% would find it acceptable to have a catheter in future.

CONCLUSION

A significant minority of patients discharged home with a catheter had side-effects related to their catheter but were not greatly inconvenienced, and their capacity to carry out normal daily activities was not impaired. The immediate discharge of patients in AUR and planned treatment will enable better use of inpatient urology resources.

Acute renal failure occurring from urinary retention due to a müllerian duct cyst

A patient with a müllerian duct cyst, which caused acute renal failure secondary to urinary retention, is reported. The case was treated successfully by transurethral unroofing of the cyst.

[Partial Currarino syndrome in a non-pediatric patient. A rare cause of bacterial meningitis]

Enterogenic meningitis is an infrequent cause of central nervous system infection. Among these causes the Currarino syndrome may be found presenting sacral agenesis, presacral mass and anorectal stenosis. This syndrome normally causes enterogenic meningitis in the early years of life. The case reported corresponds to a 24-year-old male presenting polymicrobial meningitis with fecal flora germs (anerobic enterococci, Bacteroides fragilis and Escherichia coli). These clinical findings led to radiologic lumbar study with the diagnosis of Currarino syndrome. The existence of neuroenteric fistulas justifies the development of fecal flora meningitis. The nosology of the syndrome as well as the therapeutic strategy are reviewed.

[Dermoid cyst of the conus medullaris revealed by chronic urinary retention. Contribution of imaging]

We report a case of congenital dermoid cyst of the conus medullaris without associated dysraphic lesion treated surgically. An 18-year-old man had a one-year history of bladder sphincter disorders and more recent acute renal failure with urinary tract infection. The diagnosis of intramedullary tumor was provided by myelo CT and MRI confirmed by histology. At 10-month follow-up, the postoperative course was good.

An unusual case of urinary retention due to imperforate hymen

A 15 year old girl presented to the accident and emergency (A&E) department with a 24 hour history of lower abdominal pain, and was found to have acute urinary retention. She was discovered to have an imperforate hymen with associated haematocolpos and haematometrium. This is rare and is hence a very unusual presentation to the A&E department. Patients presenting with retention of urine should be carefully assessed for the cause.

Unilateral iliac vein occlusion, caused by bladder enlargement, simulating deep venous thrombosis

A variety of conditions cause unilateral leg swelling and thus mimic deep venous thrombosis (DVT). A heretofore-underappreciated condition that may lead to unilateral iliac vein compression, simulating DVT, is massive enlargement of the bladder caused by urinary retention. A case that demonstrates this condition is described. Although this disorder has been reported only three times before, its occurrence should be recognized by clinicians in light of the overall aging of our society. In addition, this case highlights the need for careful and thorough evaluation of patients who have unilateral lower-extremity edema.

An unusual cause of obstructive sleep apnoea

Obstructive sleep apnoea is usually associated with obesity and is caused by recurrent collapse of the pharyngeal airway during sleep at multiple levels. Vocal cord paralysis is an uncommon cause of obstructive sleep apnoea. We describe a patient with obstructive sleep apnoea caused by idiopathic vocal cord paralysis. He also had features of autonomic failure including orthostatic hypotension and urinary retention.

[Subacute intestinal obstruction due to bladder distension]

We report a case of subacute bowel obstruction due to a compression of the rectosigmoid junction by a chronically distended bladder, occurring in a 91-year-old male suffering from a long-standing diabetes mellitus and a prostatic adenoma. Radiographic, water-soluble contrast enema and pelvic CT features are reported.

[Hypertension with neurologic manifestations caused by an enlarged prostate]

A 74-year-old man suffering from hypertension had transient loss of strength in his left arm and leg. His severe hypertensive spells were caused by high-pressure chronic bladder retention. The patient had benign hyperplasia of the prostate for which transvesical enucleation was performed. The blood pressure then returned to normal. The transient neurological deficits had probably been caused by the abrupt blood pressure changes. In older male patients the possibility of this reversible cause of hypertension should be kept in mind.

[Treatment of restlessness in dying patients: more than just sedation]

Restlessness can make dying unnecessarily difficult, not only for the patient himself, but also for his family and the physician in charge. Four cancer patients, three men aged 69, 80 and 66 and a woman aged 88, displayed severe terminal restlessness, caused by nicotine abstinence, hypoglycaemia, constipation and urinary retention, respectively. Suitable interventions helped the patients to die in peace and dignity. Facing restless terminal patients the physician should think of withdrawal symptoms, metabolic derangements, full bladder and (or) rectum and intoxication by drugs, frequently morphine. Interventions directed at those problems may bring surprising results.

Antibiotic prophylaxis in patients with urinary retention undergoing transurethral prostatectomy

BACKGROUND AND AIMS

The risk of severe infection and complications in connection with transurethral resection of the prostate (TURP) has clearly increased in patients with urinary retention and an indwelling catheter. The aim of this study was to determine whether the antibiotics ciprofloxacin and ceftazidime are equally efficient in preventing infective complications in these patients.

MATERIAL AND METHODS

An open randomized prospective study was carried out on 72 patients with urinary retention undergoing TURP, to compare of 500 mg of ciprofloxacin (CF) orally twice daily and 1 g of ceftazidime (CT) intravenously twice daily.

RESULTS

The incidence of early complications was 26% in the CF group and 17% in the CT group. All the complications were minor. On removal of the indwelling catheter, a positive urinary culture was detected in 6% of the patients in the CF group and in 3% in the CT group. One month after TURP, a positive urinary culture was detected in 14% of the patients in the CF group and in 18% of the CT group.

CONCLUSIONS

It is concluded that both of the antibiotics used in this trial were equally effective in the prevention of early urinary and other infections and also late complications, in patients with urinary retention undergoing TURP.

Transurethral electrovaporization of the prostate: preliminary clinical results with pressure-flow analysis

BACKGROUND

We evaluated the safety and efficacy of transurethral electrovaporization of the prostate (TVP) as a new alternative treatment for patients with benign prostatic hyperplasia.

METHODS

A total of 22 patients with symptomatic benign prostatic hyperplasia, including 4 with urinary retention, underwent TVP. If enough of a cavity was not created after 60 minutes of vaporization, transurethral resection of the prostate (TURP) was performed successively. International Prostate Symptom Score (I-PSS) with quality-of-life index, maximum flow rate, and postvoid residual volume were measured at baseline and at 2 weeks, 1, 3, and 6 months. A pressure-flow study was performed at baseline and at 3 or 6 months after surgery.

RESULTS

TURP was required in 10 of 22 patients. At 6 months, mean I-PSS decreased from 20.0 to 5.2, quality-of-life index decreased from 4.6 to 1.1, mean maximum flow rate increased from 6.9 to 16.7 mL/s, and postvoid residual volume decreased from 152 to 32 mL. Detrusor pressure at maximum flow decreased from 108 to 39 cm H2O, with a significant relief of bladder outlet obstruction in 93% of the patients. Mean decrease in hematocrit was 4.4%, and in serum sodium, 4.8 mEq/L. None of the patients required transfusions or had TUR syndrome. A urethral stricture and a severe stress incontinence developed in 1 patient.

CONCLUSION

TVP seems to be a safe and effective alternative to a standard TURP associated with fewer intraoperative complications. Although preliminary clinical results have been promising, further study is necessary to establish long-term efficacy and safety of this procedure.

Management of urinary retention: rapid versus gradual decompression and risk of complications

The literature was reviewed to quantify the risk of complications related to the relief of obstruction in urinary retention. We also sought to determine whether the risk of complications is higher with rapid or gradual decompression (or "clamping") of the obstructed urinary bladder. The medical literature was identified by a search of the MEDLINE database and a manual review of the bibliographies of the identified articles. Studies show that, after quick, complete relief of obstruction, hematuria occurs in 2 to 16% of patients; however, clinically significant hematuria is rare. After relief of obstruction, blood pressure often decreases, but it usually normalizes and does not progress to clinically significant hypotension. Postobstructive diuresis occurs after relief of obstruction in 0.5 to 52% of patients; however, it is easily managed and rarely of clinical significance. We were unable to identify any randomized controlled studies that directly compared quick, complete emptying with gradual emptying of the obstructed bladder. Moreover, we identified no studies supporting the practice of gradual emptying of the obstructed bladder. The available published studies support quick, complete emptying for relief of the obstructed urinary bladder. We conclude that hematuria, hypotension, and postobstructive diuresis may occur after decompression of the obstructed urinary bladder, but these complications are rarely clinically significant. Quick, complete emptying of the obstructed bladder is safe, simple, and effective and is recommended as the optimal method for decompressing the obstructed urinary bladder. Prudent, supportive care is needed for all patients, with special attention to elderly patients and those with hypovolemia.

Bilateral lower limb oedema due to a distended urinary bladder

A 91-year-old Chinese man developed bilateral lower limb oedema due to venous obstruction resulting from a distended urinary bladder. After the bladder was decompressed by urethral catheterisation, the bilateral lower limb oedema promptly subsided. Although a distended urinary bladder is a rare cause of bilateral lower limb oedema, it can be easily recognised by palpation of the lower abdomen and the relief of symptoms by urethral catheterisation is most rewarding.

Vertebral osteomyelitis caused by group B streptococci (Streptococcus agalactiae) secondary to urinary tract infection

Infections due to group B streptococci usually occur in the peri- and neonatal setting or in adults with chronic underlying diseases. A case of pyogenic vertebral osteomyelitis caused by Streptococcus agalactiae in a 54-year-old man suffering from phimosis with urinary retention and urinary tract infection is reported. This case adds to the few existing reports of vertebral osteomyelitis caused by group B streptococci.

[Inferior vena cava obstruction syndrome caused by urinary retention]

OBJECTIVE

To report an unusual case of inferior vena cava obstruction secondary to urinary retention.

METHODS/RESULTS

A 72-year-old male patient with a history of bilateral inguinal hernia and a recent hip surgery, presented with deep venous thrombosis in the left leg. A CT scan disclosed significant thickening of the bladder wall and grade III-IV hypertrophy of the prostate. Abdominal ultrasound disclosed a cystic mass compressing the vena cava and moderate ureterohydronephrosis. Edema spontaneously resolved following insertion of a urethral catheter and renal function returned to normal.

CONCLUSION

Obstruction of the inferior vena cava secondary to an enlarged bladder is rare. To our knowledge only two such cases have been reported in the literature. In the case described herein, urinary retention may have been exacerbated by prostatic hypertrophy, anesthesia and bed confinement due to hip surgery.

Reversible urinary retention as the main symptom in the first manifestation of a syringomyelia

A neurogenic bladder is seldom described as the first manifestation of syringomyelia. A patient is reported with an extensive syrinx along the entire spinal cord and a Chiari type I malformation, who experienced dysaesthesia and weakness during shooting practice and presented with urinary retention.

Epidural hematoma of a cauda equina in a child with hemophilia A

PURPOSE

The presenting signs, treatment, and outcome of an epidural hematoma of the cauda equina in a child with severe hemophilia are reported for the first time.

PATIENTS AND METHODS

A 20-month-old boy with severe hemophilia A (factor VIII <0.01 U/ml) presented with a 12-day history of refusal to stand and constipation of 5-7 days duration. He had normal deep tendon reflexes with normal sensation and withdrawal to pinprick of his lower extremities bilaterally. He stood on his right leg, but had inversion of his left foot and refused to bear weight on his left leg. MRI revealed an epidural hematoma of the cauda equina and a distended bladder. Factor VIII replacement therapy and lumbosacral laminectomy with evacuation of the hematoma resulted in recovery of a normal gait, but bladder dysfunction persisted for 11 months. Clean intermittent catheterization (CIC) was required until bladder function returned.

RESULTS

Complete neurologic recovery occurred 11 months after presentation

CONCLUSION

This case demonstrates the following points: (a) an epidural hematoma of the cauda equina in a child with severe hemophilia can present with neurologic findings that are as subtle as those seen in normal children; (b) CIC can be performed safely over an extended period without factor VIII replacement; and (c) complete recovery is possible, despite prolonged bladder dysfunction and a 12-day interval between the onset of symptoms and treatment.

[Psychogenic urinary retention in childhood. A severe case treated by an integrated global approach]

Micturating dysfunctions with urinary retention and with diurnal and nocturnal enuresis in children sometimes have a psychogenic genesis. They can appear during the period of development of complete control of micturition. A late recognition of this condition makes the prognosis worse, since high pressure and infections in the urinary tract can cause end-stage renal failure. Here we describe a dramatic case of a 3 year-old boy affected by a psychogenic urine and faecal retention with recurrent pyelonephritis, that was favourably treated for five years by an integrated approach involving clinicians, psychologist, educational and social operators and adoptive parents.

Hospital acquired pre-prostatectomy bacteriuria: risk factors and implications

One hundred and one consecutive prostatic patients with sterile urines were prospectively studied for the risk factors involved in the hospital acquired pre-prostatectomy bacteriuric and its implications. Eleven out of 101 patients (11%) became bacteriuric at operation whereas ninety of 101 patients (89%) remained abacteriuric. Nine of the eleven bacteriuric patients (82%) had pre-operative indwelling urethral catheters compared to 37/90 (41%) abacteriurics (P < 0.05). Mean catheter duration was 22.22 and 9.92 days respectively (P < 0.05). Three out of eleven (27%) bacteriuric patients had chronic retention of urine compared to one of ninety (1%) abacteriuric patients. Past history of acute retention, vesical stones, vesical diverticulae, diabetes mellitus and azotaemia were not significant risk factors. Post-operative fever did not correlate with positive blood cultures. However, eight of the eleven (73%) bacteriurics developed bacteraemia compared to only one out of ninety (1%) abacteriuric patients. It is concluded that the significant risk factors which would be strong indications for antimicrobial prophylaxis in prostatectomy are chronic retention of urine and prolonged pre-operative indwelling urethral catheterization for more than ten days. Azotaemia, diabetes mellitus and associated bladder pathologies were not significant and therefore do not warrant antimicrobial prophylaxis.

Herpes simplex virus type 2 infection associated with urinary retention in the absence of genital lesions

A 14-year-old boy had inguinal lymphadenitis and associated urinary retention; herpetic genital and anal lesions were absent. Lymph node biopsy established the presence of infection with herpes simplex virus type 2. We recommend that this infection be considered in the differential diagnosis of adolescent patients with urinary retention and constipation, even when the diagnostic clue provided by genital ulcers is absent.

Laparoscopic cholecystectomy in the elderly

BACKGROUND

Few studies have examined the results of laparoscopic cholecystectomy (LC) in the elderly. We reviewed our experience with the procedure in 194 patients age 65 and older.

METHODS

A chart review was performed on patients who underwent attempted LC over a 4-year period. Age, conversion rate to open cholecystectomy (OC), length of stay, and morbidity and mortality rates were compared between elective and inpatients as well as between patients age 65-75 and patients over age 75.

RESULTS

Conversion rate to OC was 10.6%. Mean length of hospital stay was 2.7 days. Morbidity and mortality rates were 18% and 1%. Elective patients experienced significantly fewer medical complications. There were no differences in complication rates between patients age 65-75 and patients over 75 years, but younger patients had a significantly shorter mean length of hospitalization.

CONCLUSIONS

Elderly patients experience more complications and longer lengths of stay than the general population. However, our results compare favorably with OC series in elderly patients.

[Urocolpos: a cause of pseudo-incontinence in aged women]

Presentation of our experience in three cases of urocolpos (acquired pudendal lip fusion), a series numerically equivalent to the total number of cases published until now. All patients in our series were older women and presented complete fusion of the small pudendal lips, with only a small pointed puncture in the lower part of the vulva. The main clinical signs and symptoms in our series were: urinary infection in 100%, false incontinence in 66% due to output of urine retained in the vagina, a symptom that has not been described earlier, and acute urine retention in 33%. All patients were successfully treated by means of surgical loosening of the fusioned lips and application of topical estrogens. An analysis is made of clinical and pathoanatomical features which differentiate this entity from the sclerotic and atrophic lichen. Finally, an etiopathogenic hypothesis is raised to explain the fusion acquired by the small pudendal lips in the urocolpos.

[Value of PSA/gamma-Sm ratio (P/S ratio) for diagnosis of prostate cancer in patients with urinary retention]

It is known that serum prostate specific antigen (PSA) in urinary retention due to benign prostatic hypertrophy (BPH) increase. To evaluate prognostic value of the ratio of serum PSA to gamma-seminoprotein (P/S Ratio) for prostate cancer (PC) in patients with urinary retention, we have studied the P/S Ratio at the initial examination in 33 patients with untreated PC (10 with and 23 without urinary retention) and 193 patients with untreated BPH (38 with and 155 without urinary retention) histopathologically diagnosed at our hospital between January, 1992 and December, 1993. The results were as follows: 1) The mean P/S ratio of PC patients was significantly higher than that of BPH patients in both groups with and without urinary retention. 2) When the cut off value of P/S Ratio was determined to be 1.35, the highest efficiency, 59.3% was obtained in the group without urinary retention. The sensitivity and specificity were 65.2% and 91.0%. 3) In the group with urinary retention, the efficiency was also the highest, 80.0% with a cut off value of 1.35. The sensitivity and specificity were 80.0% and 100%. 4) In all patients, the efficiency was 64.6%, the sensitivity was 69.7%, and the specificity was 92.7% with a cut off value of 1.35. 5) Positive rate of serum PSA in BPH patients with urinary retention was 47.4% and that in BPH patients without urinary retention was 17.4%. The mean P/S ratio of the BPH patients with urinary retention was significantly lower than that of BPH patients without urinary retention, which suggested that the serum free PSA increase in the former.(ABSTRACT TRUNCATED AT 250 WORDS)

Bladder catheterization and a plasma prostate-specific antigen in patients with benign prostatic hyperplasia and complete urine retention

Nineteen men with BPH (benign prostatic hyperplasia) were studied who had up to 6 months prior to complete urine retention PSA levels measured (PSA I). Subsequent PSA levels were obtained at 2 weeks post catheterization upon catheter removal (PSA II) and at 4 (PSA III) and 6 weeks post catheterization (PSA IV). Analysed were 18 mean PSA values [ng/ml] (as one patient was found to have prostatic cancer and his data were discarded): PSA I - 6.46, PSA II - 14.26, PSA III - 9.83 and PSA IV - 7.47. Initial data suggest that the irritation of the adenoma by the catheter may cause PSA levels to rise.

Benzodiazepine use as a cause of cognitive impairment in elderly hospital inpatients

BACKGROUND

Benzodiazepine drugs are used very frequently by the elderly and have been associated with a number of untoward events in them. In an earlier publication, we showed that there was an association between benzodiazepine use and episodes of confusion in hospital. The purpose of this study was to examine that association in more detail by studying only patients with intact cognitive function on admission and by taking into consideration a range of demographic, drug use, and clinical confounders.

METHODS

A prospective cohort study was carried out of inpatients who had normal cognitive function on admission to hospital. The subjects were 418 hospital inpatients who had a normal result of a Mini-Mental State Examination (MMSE) performed within 24 hours of admission. They were aged 59-88 years. A clinical history and detailed drug use history were taken on admission and then the patients were followed prospectively for 10 days or until discharge, whichever was sooner. The MMSE was repeated every 2 days and all significant clinical events and episodes of delirium noted.

RESULTS

10.8% (95% Confidence Interval [CI]: 7.8-13.8%) of patients developed cognitive impairment (as indicated by a decrease in the MMSE). Factors that were statistically significantly related to the development of cognitive impairment included admission diagnoses of cancer or central nervous system (CNS) disease, alcohol consumption > 40 gms/day, hypoxia, and presence of benzodiazepines in the urine on admission. After adjusting for age, alcohol consumption, and admission diagnoses, those who reported taking benzodiazepines in daily doses equivalent to 5 mg or more of diazepam were at significantly higher risk of cognitive impairment than those who had not taken benzodiazepines (adjusted odds ratio = 3.5; 95% CI: 1.4-8.8). Twenty-one (5.0%, 95% CI: 2.9-7.1%) patients developed delirium as defined by the DSM-IIIR criteria. Age and hypoxia were statistically significantly related to the development of delirium. Due to the small number of cases of delirium, the power of the study to detect significant associations was low.

CONCLUSIONS

Elderly hospital inpatients who have intact cognitive function on admission to hospital have a low risk of developing cognitive impairment and delirium during their hospital stay. In this population, however, benzodiazepine use accounted for 29% of cases of cognitive impairment which did occur. The data also suggest that dehydration, urinary retention, and an admission diagnosis of CNS disease may be important risk factors for delirium.

Non-neurogenic bladder and chronic renal insufficiency in childhood

Functional voiding disorders and urinary tract infections are common in childhood, but are usually not accompanied by upper urinary tract deterioration. Nevertheless a small group of children remain at risk of developing chronic renal insufficiency (CRI). Clinically these children present day and night wetting. The most important parameter, however, is urinary retention which is reflected by an abnormal voiding pattern in the uroflow curve. After ruling out patients with neurogenic or anatomical disorders, nine girls with psychogenic urine retention were observed for 5 years. Terminal renal insufficiency was seen in one, CRI in five patients and in three patients the kidney function could be maintained, but they all had severe scarring of at least one kidney. Furthermore, all revealed a dilation of the bladder and the upper urinary tract. Vesicoureteral reflux occurred in six and obstruction of the ureterovesical junction in three patients. Two girls underwent repeated reflux surgery resulting in a rapid deterioration of renal function. Three patients developed hypertension and one had a hypertensive crisis with microangiopathic anaemia and acute renal failure. Psychogenic disorders and problematic family settings were observed in all cases. Bladder training, transitory suprapubic catheters, intermittent catheterisation, medication and psychotherapy can avoid severe kidney damage and achieve a stabilisation of renal function. It is important to bear this syndrome in mind when evaluating girls with asymptomatic bacteriuria and urinary retention.

Constipation and reversible urinary tract abnormalities

Urinary tract anomalies were prospectively investigated with ultrasound in 29 children with functional constipation. These children were compared before and after treatment with 451 age matched healthy controls without constipation. The bladder residue and upper renal tract dilatation after micturition were significantly increased in the group with constipation and improved after treatment.

Bowel dysfunction in young women with urinary retention

Urinary retention in young women is rare, but a syndrome has recently been described in which urinary retention is associated with abnormal periurethral electromyography. The incidence of bowel dysfunction in these women was investigated, in an attempt to determine whether this might be a more widespread disorder. Of 12 patients with this urological abnormality, eight were constipated. No consistent anorectal abnormality was identified on anorectal physiological testing. The electromyographic abnormality was not seen in the external anal sphincter. One patient had an abnormality of the internal anal sphincter smooth muscle, while another had a generalised disorder of the gastrointestinal tract and urinary bladder resembling a visceral myopathy. Bowel symptoms are common in this group of women with urinary retention, but abnormalities of bowel function are not specific. A common mechanism for bladder and bowel symptoms remains a possibility.

Megacystis and megacolon in an infant with Ehlers-Danlos syndrome

We report a 14 month old male infant with Ehlers-Danlos syndrome who became 'anuric' due to an acutely dilated urinary bladder. Although the patient was also found to have megacolon, no diverticulum was seen in his gastrointestinal tract or urinary bladder. In order to decompress the urinary bladder and colonic wall, we put an indwelling urinary catheter in place for 2 months, and carried out daily glycerin enema for 3 months. All urological and gastrointestinal symptoms subsided with this intensive medical treatment. The diagnosis of megacystis and megacolon was made very early in life for this patient. This may indicate that the striking extension of gastrointestinal and bladder wall may lead to the development of diverticula of gastrointestinal and urinary tracts in later life.

[Spontaneous bladder perforation--a rare complication of neurogenic bladder dysfunction]

Spontaneous rupture of the urinary bladder which is not associated with trauma is uncommon. A case of spontaneous bladder perforation (triggered by an episode of urinary retention) and peritonitis in a 69-year old male patient with neurogenic bladder dysfunction is reported. The latter was due to disseminated sclerosis and was complicated by recurrent urinary tract infection and two bladder calculi. The etiology, diagnosis and treatment of spontaneous bladder perforation is briefly discussed. The diagnosis spontaneous bladder perforation should be considered in patients with non-characteristic acute abdominal conditions and voiding symptoms, especially if they have neurogenic bladder dysfunction and a history of recurrent lower urinary tract infections and/or bladder calculi. We recommend that bladder stones should be removed--also in asymptomatic cases.

Transurethral balloon dilation of the external urinary sphincter: effectiveness in spinal cord-injured men with detrusor-external urethral sphincter dyssynergia

The authors investigated balloon dilation as a minimally invasive alternative to transurethral external sphincterotomy for the treatment of detrusor-external urethral sphincter dyssynergia (DESD). Seventeen spinal cord-injured men with voiding pressures greater than 60 cm H2O underwent balloon dilation of the external sphincter to 90 F at 4 atm of pressure for 10 minutes. The mean voiding pressures before and 12 months after dilation were 83 cm H2O +/- 35 and 37 cm H2O +/- 15, respectively (P = .008). There was a significant decrease in residual urine volume, from 163 mL +/- 162 to 68 mL +/- 59 (P = .05), whereas bladder capacity remained relatively unchanged at 253 mL +/- 181 and 230 mL +/- 97 (P = .30). Complications included one case of postoperative bleeding necessitating transfusion, two treatment failures, and one bulbous urethral stricture. Fourteen of the 17 patients (82%) now void without the aid of an indwelling catheter or alternative therapy. Balloon dilation has no detrimental effect on erectile function and may improve fertility.

Neuromodulation of sacral nerves for incontinence and voiding dysfunctions. Clinical results and complications

Neuromodulation of sacral nerves is a new form of treatment for patients with refractory voiding dysfunctions such as incontinence, retention and chronic pelvic pain. Electrical stimulation of S3 activates the pelvic floor and modulates innervation of the bladder, sphincter and pelvic floor, restoring the balance and coordination in sacral reflexes. 19 of 23 patients with an implanted neuroprosthesis for neuromodulation have a more than 50% improvement in their main symptoms after a median follow-up of 12 months. In urge-incontinent patients the number of leakings decreased from 7.4 to 1.5/day, and the functional capacity increased from 135 to 227 ml.

[Incidence of urothelial carcinoma of the bladder in males with chronic urinary retention]

The author studied all of the 1361 male patients that had been hospitalized from December 1986 to September 1990 for chronic urinary retention to determine the incidence of urothelial tumor of the bladder. Sixty-nine (5.07%) were found to have primary urothelial carcinoma of the bladder. However, in another study group comprised of 433 males over 55 with no problems of obstruction, 0.23% had a bladder tumor. This study underscores the role of urinary stasis in the development of urothelial carcinoma of the bladder.

[New classification of vesicoureteral reflux]

Five illustrative cases of vesicoureteral reflux, of different age and sex, are described. All patients were submitted to urodynamic evaluation. A new classification based on the underlying cause is purported. Ureterovesical reflux may be passive or active. The latter type may be involuntary, voluntary or caused by abdominal pressure. In our view, this new classification could be useful in the management of vesicoureteral reflux.