Neurogenic bladder due to peripheral neuropathy and a visual disturbance in an elderly man with systemic lupus erythematosus

Recurrent urinary tract infections and bladder dysfunction in systemic lupus erythematosus

To assess bladder function in systemic lupus erythematosus (SLE) patients with recurrent urinary tract infections (UTIs). A convenience sample of consecutive patients with SLE (American College of Rheumatology criteria), with recurrent UTIs (>/=3 events in the preceding 12 months), without history of central nervous system involvement, urolithiasis or preceding tuberculosis were studied. Disease activity (SLEDAI-2K), damage (SDI), lower urinary tract symptoms [Pelvic pain and Urgency/Frequency (PUF) and the Interstitial Cystitis Symptom and Problem Index (ICSPI) scales] and Autonomic Symptom Profile (ASP) were assessed. All patients underwent urological examination and urodynamic assessment with cystometry, uroflow, micturition and urethral pressure profile. Ten patients (nine women) were included. The majority of the patients reported urinary symptoms: urgency (n = 8), frequency (n = 8), nocturia (n = 9) and pain (n = 10). The patients had a mean (SD) ICSPI score of 18.4 (9.8), PUF score of 17.4 (5.3) and ASP weighted score of 31.7 (16.1). Abnormal urodynamics findings were identified in seven of the 10 patients, including small bladder capacity (two patients), reduced bladder sensation (four patients), subnormal urinary flow rate (one patient) and a significant amount of residual urine (two patients). The urodynamics findings suggest that bladder dysfunction could be one of the mechanisms involved on the occurrence of recurrent UTIs in patients with SLE. These findings have potential implications for the proper assessment and management of SLE patients with recurrent UTIs. Further studies are needed to corroborate our results.

Voiding dysfunction in women with systemic lupus erythematosus

OBJECTIVE

We sought to explore bladder dysfunction in a cohort of women with systemic lupus erythematosus (SLE).

METHODS

We conducted a prospective study of 152 female patients with SLE during a 15-month period. The clinical status of SLE was determined according to the SLE Disease Activity Index (SLEDAI), and bladder function was evaluated by lower urinary tract symptoms and urodynamic studies. We adapted the American Urological Association (AUA) index questionnaire to assess lower urinary tract symptoms in patients, which were compared with those in 227 age-matched healthy women.

RESULTS

The proportion of individuals reporting urinary frequency, urgency, weak urinary stream, and incomplete emptying, as well as severe lower urinary tract symptoms (AUA index score >/=20), was significantly higher in the SLE group when compared with the control group. The AUA index score showed a modest correlation with the SLEDAI score (r = 0.35, P < 0.001) but not with patient age or disease duration. There was a significant relationship between central nervous system involvement and the AUA index score. The most common urodynamic finding was a small cystometric bladder capacity (<150 ml; n = 7 patients), followed by a subnormal urinary flow rate (<12 ml/second; n = 6 patients). In 3 of 7 patients with small cystometric bladder capacities, imaging studies documented a contracted bladder with marked hydroureteronephrosis.

CONCLUSION

Patients with SLE experience an increased prevalence of voiding dysfunction compared with healthy individuals. Voiding dysfunction can be attributable to either direct bladder involvement or other disease-related factors.

Successful treatment of intravenous cyclophosphamide pulse therapy for lupus myelitis with urinary disturbance and acute confusional state

A 18-year-old female had low grade fever, butterfly rush, proteinuria, leukocytopenia and hypocomplimentemia in 1988, and she was diagnosed as systemic lupus erythematosus (SLE) with lupus nephritis (WHOIIb). Treatments with prednisolone and mizoribine resulted in the remission for three years. In May 2001, she presented neurosis and polakisuria despite of the increase of prednisolone to 20 mg/day. Finally, she admitted in our hospital because of manic and repressive state and disorientaion. A brain MRI revealed high intensity lesions in bilateral basal ganglia in T2 weighted images, and cerebrospinal fluid showed elevated protein and IFN-alpha (421 IU/ml). In addition, she manifested neurogenic bladder, muscle weakness and hyperactive deep tendon reflex of bilateral lower limbs due to both supranuclear disorder and hypesthesia under the Th 10 level. Spinal MRI revealed marked atrophy and high intensity signals at the middle to lower thoracic spinal cord in T2 weighted images, indicating complication of lupus myelitis as well as cerebral involvement. Although the symptoms of CNS lupus did not respond to prednisolone, twelve monthly cyclophosphamide pulse therapy (IV-CY) has resolved urinary disturbance, muscle weakness and sensory loss, along with the improvement of both cerebral and spinal MRI images. Lupus myelitis and neurogenic bladder are the rare, but very refractory manifestation among CNS involvement of SLE. We here propose IV-CY as an invaluable choice for the treatment of not only active lupus myelitis but also neurogenic bladder resisted for steroid.

Urinary dysfunction in patients with systemic lupus erythematosis

AIMS

Nervous system involvement occurs in about half of patients with systemic lupus erythematosis (SLE). Seizures and psychiatric disorders are the most common manifestations; spinal cord lesions are uncommon. We had eight such patients who presented with urinary dysfunction.

METHODS

The patients consisted of two men and six women, mean age 42 years, range 28-72 years. All patients were suffering from SLE for 2-25 years under immunosuppressant therapy. Their neurological manifestations were subacute encephalomyelopathy in three, subacute myelopathy in one, and chronic myelopathy in four. Urinary dysfunction included voiding difficulty in six (two of them had urinary retention initially) and urinary incontinence in four. Standard urodynamic studies were performed in the patients 2-3 weeks after admission.

RESULTS

All patients had urodynamic abnormalities, including decreased urinary flow in five, increased post-void residual urine in three (mean 97 ml), increased maximum urethral closure pressure in two, detrusor hyperreflexia (DH) in five, impaired detrusor contractility in five, detrusor-sphincter dyssynergia in four, and neurogenic motor unit potentials of the external sphincter in two of four patients studied. DH was more common in patients with brisk deep tendon reflex (80%) than in those without (33%). Repeated studies showed that one had loss of bladder sensation, one developed a low compliance bladder, and one had decreased bladder capacity from 470 to 40 ml with marked DH during 2 months to 8 years follow-up period.

CONCLUSIONS

Our results suggest that urinary dysfunction can be a feature in SLE patients is most commonly due to, and, in some patients there myelopathy, may be involvement of the spinal cord in a small group of the patients.