Photodiagnosis and Photodynamic Therapy (2013) 10, 203—205

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CASE REPORT/RESEARCH LETTER

Acute urinary retention in elderly femalepatients after photodynamic therapy ofurethral condyloma — Report of two cases

Hong-Wei Wanga,b, Ling-Lin Zhanga, Xiao-Dong Songc,Zheng Huanga, Xiu-Li Wang MD, PhDa,∗

a Department of Dermatology and Venereology, Shanghai Skin Disease Hospital, Shanghai, Chinab Department of Dermatology, Shanghai Huadong Hospital, Shanghai, Chinac Department of Urologic Surgery, Tongji Hospital of Tongji Medical College, Wuhan, ChinaAvailable online 4 December 2012

KEYWORDSAcute urinary

Summary We report two cases of acute urinary retention (AUR) occurred after intra-urethralaminolevulinic acid (ALA)-mediated photodynamic therapy (PDT) in elderly females (>66 yearsold) with urethral condylomas.

retention;

5-Aminolaevulinicacid;Photodynamictherapy;Urethral condylomata

© 2012 Elsevier B.V. All rights reserved.

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Introduction

Condyloma acuminata is a common virally transmitted dis-ease. Twenty percent of genital condylomas caused byhuman papillomaviruses (HPV) are found in the urethra, pre-dominantly on the external orifice. Some may be located inthe proximal urethra and hence difficult to treat [1].

Endogenous production of protoporphyrin IX in condylo-mas after topical 5-aminolaevulinic acid (ALA) implicates

the use of ALA-mediated photodynamic therapy (ALA PDT) intreating condylomas [2,3]. The procedure is well tolerated

∗ Corresponding author. Tel.: +86 21 61833004;fax: +86 21 61833021.

E-mail address: xlwang2001@yahoo.cn (X.-L. Wang).

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1572-1000/$ — see front matter © 2012 Elsevier B.V. All rights reserved.http://dx.doi.org/10.1016/j.pdpdt.2012.11.003

nd no significant urethral complications have been reported3,4].

Over the past 10 years, we treated 1050 patientsF:M = 1:4.6). The complete remission after multiple ALADT is >95% and the recurrence <5%. Although the major-ty of our patients (>80%) were between 20 and 45 yearsld, 1.1% male and 6.5% female patients were >60 yearsld. Recently, acute urinary retention (AUR) occurred in twolderly female patients. Details of this rare adverse effectre presented and discussed below.

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ase 1

he 66 years old female was seeking treatment becausef neoplasia in the urethra and occasional hematuria for 3

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onths. She received CO2 laser treatment 3 months ago.nder urethroscopy examination, a 0.5 cm caruncle waseen near the urethral orifice and a soybean-size pinkishart seen 0.5 cm away from the orifice without a clear foun-ation and touch-bleeding.

Intra-urethral ALA PDT was carried out after signinghe consent form. After voiding, 20% ALA solution (Fudanhangjiang Bio-Pharmaceutical Co. Ltd., Shanghai, China)as applied to the warty areas for 3 h. After emptying theladder again, light (100 J/cm2 at 100 mW/cm2) was deliv-red through a cylindrical diffuser coupled to a diode laser635 nm; Biolitec GmbH). The patient felt tingling duringight irradiation and pain after light irradiation. Swellingould be seen in the external urethral orifice and anteriorrethral segment. Four hours later, she had a strong desireo void but unable to. Percussion of the bladder produced

dull sound and the bladder position was 4-finger belowhe umbilicus. Catheterization was used after the Credéaneuver, the residual volume was 650 ml of clean urine.he catheter was removed next day and self-voiding wasesumed.

Another three sessions of PDT were prescribed. Norinary retention occurred during these treatments. Ure-hroscopy examination revealed that all warts wereemoved, the external urethral orifice slightly narrowed,nd the surface of urethral mucosa and bladder neck wasmooth. The patient had no history of urinary retention,terine tumors nor diabetes. She denied taking medicationshat might cause voiding dysfunction.

ase 2

he 69 years old female was seeking treatment becausef foreign body sensation in the urethra for 2 months. Herusband had a history of genital condyloma. Urethroscopyxamination revealed the retraction of the external urethralrifice, significant mucosal congestion, and smooth bladdereck. At 3 and 6 o’clock and 0.5 cm away from the urethralrifice there were two soybean-size warts.

Same PDT procedure was carried out after signing theonsent form. The patient felt tingling and pain in the ure-hral area during and after light irradiation. Five hours later,he had a strong desire to void but unable to. Ultrasoundxamination confirmed AUR. Catheterization was used afterhe Credé maneuver, the residual volume was 750 ml of cleanrine. The catheter was removed next day and self-voidingas resumed.

Another two sessions of PDT were carried out to com-letely remove residual lesions. Pain feeling was less intensend no urinary retention occurred during these treatments.he patient had no history of urinary retention, cancer noriabetes. She denied taking medications that might causeoiding dysfunction.

iscussion

oth cases were elderly women who had a history of ure-

hral condylomas accompanied with senile urinary tracthanges (urethral caruncle and retraction in the externalrifice of the urethra) but the bladder neck was smooth.UR occurred a few hours after PDT, which suggested

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H.-W. Wang et al.

hat its occurrence was related to the intra-urethral PDT.lthough intra-urethral PDT-induced temporary urinary painnd difficulty are common but AUR has not been reportedefore.

Possible reasons for PDT-induced AUR might include: (i)DT-induced local tissue hypoxia and the accumulation ofetabolites could damage the urethral nerves and causeain and stress responses that trigger urethral sphincterpasm, which was worsened by mental stress, external ure-hral stenosis, and sympathetic nerve activity. (ii) The usef diffuser fiber in intra-urethral PDT might cause edema inhe entire urethral tract, and even spread to the bladdereck and ureter. (iii) Age factor. The contraction functionf the detrusor gradually decreased with aging. Espe-ially when holding back voiding for too long, the detrusorecame over-relaxed and unable to contract. Senile urethralhange, retraction in the external orifice of the urethra,nd urethral caruncle could also cause the narrowing of therethra.

Interestingly, during repeated treatments, pain feelingas less intense than the first treatment since urethral sub-ucosal nerve endings became less sensitive. The reduction

n the size/number of the warty lesion might be associatedith a reduction in the degree of edema during the second

reatment. Better physician—patient communication mightlso ease the nervousness and tension. These factors mightxplain why urinary retention did not occur in following ses-ions.

Although urinary retention is more common in men thann women, we did not observe PDT-induced urinary retentionn male patients during our practice. This may be related tohe structural differences of the urethral anatomy of dif-erent genders. The middle section of the urethra is theost important functional part in controlling urination. The

ast majority of male urethral condyloma occur below theavicular fossa. Therefore, intra-urethral PDT is unlikely toause urinary retention in male patients. Nevertheless, tovoid the occurrence of AUR, especially for elderly femaleatients, better physician-patient communication is essen-ial. Meanwhile, the fluence rate and total fluence mighte reduced to avoid PDT-induced severe urethral pain anddema.

onflict of interest

he authors declare no conflict of interest.

cknowledgements

his work was supported in part by the National Naturalcience Foundation Grant (30972665) and Talent Trainingroject of Shanghai Health Institution of Shanghai Municipalealth Bureau (XBR2011059).

eferences

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urethral tissues and anterior vaginal wall. Current UrologyReports 2008;9:389—96.

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T

[parative study of cryotherapy plus photodynamic therapy vs.cryotherapy in the treatment of multiple condylomata acumi-

Acute urinary retention in female patients after urethral PD

topical application of 5-aminolaevulinic acid: implicationsfor photodynamic treatment. British Journal of Dermatology1997;137:736—42.

[3] Wang XL, Wang HW, Wang HS, Xu SZ, Liao KH, HillemannsP. Topical 5-aminolevulinic acid-photodynamic therapy for thetreatment of urethral condylomata acuminata. British Journalof Dermatology 2004;151:880—5.

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