The Vanishing Bladder Mass

History • Mr ASK• 60yrs old male• Was referred from BARC hospital at midnight with

h/o-1) Acute retention of urine since one day2) Gross hematuria 4-6 hours post foleys

catheterisation (this was after draining initial 300-400 ml of clear urine)3) Disorientation

No history of –• Traumatic catheterisation• Bleeding diasthesis • Lump in abdomen

Relatives on enquiry revealed 1 week history of • Dysuria• Oliguria • Mod grade fever with chills• Poor oral intake

• Past history- - H/o recurrent urinary tract infection

- Features of LUTS

- Had retention of urine twice in 6 months requiring catheterisation.

- Coronary artery disease, systemic hypertension, old stoke

- No h/o of past kidney disease

- Was on dual antiplatelets , antihypertensives and statins

On examination• Tachycardia- 120/min• BP- 100/70• Gross pallor, dehydrationCNS- Disoriented, irrelevant talks No focal neurological deficit No s/o meningeal irritationPer Abdomen- Bladder palpable upto umbillicus. No separate mass felt.

Investigation

• Hb- 7.1 gm% PT- 13• TLC- 13,240/mm3 INR- 1.2• Platelets- 2.3 lacs/mm3 aPTT- 30• BUN- 84• Creatinine- 6.4 mg%• Na- 136 meq/dl• K- 4.8 meq/dl• Ca- 8.1 mg%• PO4- 3.8 mg%• UA- 7.8 mg%• LFT- WNL

Provisional diagnosis

Acute retention of urine ? Bladder outlet obstruction

Hematuria - UTI? Cystitis ? Bladder mass

Acute kidney injury with Uremic Encephalopathy? Obstructive uropathy

Course post admission• Due to poor general condition, he was shifted

to Neuro ICU, where he had one episode of GTC.

• He was dialysed with 2 units of packed red cells transfusion.

• Continous bladder irrigation with NS started, inj Meropenem given suspecting ESBL

Portable ultrasound – Day 1• RK- 10 * 5.5• LK- 9.8 * 4.9• Dilatation of bilateral pelvicalyceal system with

bilateral hydroureters throughout its course.• Distended bladder (420 ml) with thickened wall

with deep trabeculations.• Heterogenous predominantly hyperechoic

vascular mass of size 170 cc arising from post. and right lateral wall of bladder. Internal echoes noted in bladder

• Prostrate volume- 25 gm

Non contrast CT- KUB – Day 2

• Similar findings as ultrasound noted.• Air densities in bladder and the mentioned

mass• Impression of a bladder mass with associated

hematoma, would be worthwhile to obtain a contrast study.

Urology consult

• Large bladder mass with BOO leading to bilateral hydroureteronephrosis.

• Continued bladder irrigation• Bladder mass would require cystoscopic

biopsy and excision (simple/radical cystectomy) on later date.

Course in wards• Hematuria stopped on day 4, urine output 1.5 - 2 lit/day

• Required additional 2 units PRC transfusion

• Sensorium improved , not dialysed further.

• Renal function normalised.

• Shifted to floor on day -5

• Urine Culture- E. Coli – Meropenem sensitive, contd.

• Wait continued for the credit note from BARC for cystoscopy and bladder mass biopsy

Cystoscopy findings – Day 14

NODULAR HEMORRHAGIC CYSTITIS

NO BLADDER MASS VISUALISED

Repeat Contrast CT KUB

• Thickened enhancing bladder wall , bilateral Vesicoureteric junction and entire course of ureter suggestive of cystitis and urethritis

• Bilateral kidneys normal

Trial of catheter removal• Failed predischarge.• Hence started on Urimax, Urispas

• Urodynamic studies-Optimal capacity bladder with good complianceHypocontractile DetrusorSignificant post void residue (390 cc)

Discharged with silicone foleys in situ.

REVIEW OF LITERATURE

“ HEMORRHAGIC CYSTITIS ”

Hemorrhagic cystitisDiffuse inflammatory condition of the urinary bladder due to an infectious or noninfectious etiology resulting inbleeding from the bladder mucosa.

a) Infections –

Bacterial (MC)- E.coli, Klebsiella, Proteus, Staph Viral - BK, Adeno, CMV, JC, HerpesFungal - Candida, Aspergillus, CryptococcusParasites – Schistosomia, Ecchinococus

b) Drugs – Cyclophosphamide, Iphosphamide (due to metabolite - Acrolein ) Busulphan, Thiotepa.Penicillin and its synthetic derivatives.Danazol, Allopurinol.Intravesical instillation of drugs.

c) Occupation hazards –Dyes – Aniline, toulidinePesticides- Chlorodimeform

c) Radiation - for pelvic malignancies, atleast 90 day lag

Early - obliterative endarteritis causing ischemia f/b neovascularisation and bleeding Late – may be beyond 10 yrs, progressive disease associated with fibrosis, reduced capacity bladder

d) Systemic disease- Rheumatoid arthritisAmyloidosisCrohn’s diseaseBoon’s disease – prolonged high altitude air travel