2. History
• Mr ASK
• 60yrs old male
• Was referred from BARC hospital at midnight
with h/o-
1) Acute retention of urine since one day
2) Gross hematuria 4-6 hours post foleys
catheterisation
(this was after draining initial 300-400 ml of
clear urine)
3) Disorientation
3. 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
4. • 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
5. On examination
• Tachycardia- 120/min
• BP- 100/70
• Gross pallor, dehydration
CNS- Disoriented, irrelevant talks
No focal neurological deficit
No s/o meningeal irritation
Per Abdomen-
Bladder palpable upto umbillicus.
No separate mass felt.
7. Provisional diagnosis
Acute retention of urine
? Bladder outlet obstruction
Hematuria - UTI
? Cystitis
? Bladder mass
Acute kidney injury with Uremic Encephalopathy
? Obstructive uropathy
8. 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
9.
10.
11.
12.
13. 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
14.
15.
16.
17.
18. 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.
19. 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.
20. 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
21. Cystoscopy findings – Day 14
NODULAR HEMORRHAGIC
CYSTITIS
NO BLADDER MASS VISUALISED
22. Repeat Contrast CT KUB
• Thickened enhancing bladder wall , bilateral
Vesicoureteric junction and entire course of
ureter suggestive of cystitis and urethritis
• Bilateral kidneys normal
23. Trial of catheter removal
• Failed predischarge.
• Hence started on Urimax, Urispas
• Urodynamic studies-
Optimal capacity bladder with good compliance
Hypocontractile Detrusor
Significant post void residue (390 cc)
Discharged with silicone foleys in situ.
25. Hemorrhagic cystitis
Diffuse inflammatory condition of the urinary bladder due
to an infectious or noninfectious etiology resulting in
bleeding from the bladder mucosa.
a) Infections –
Bacterial (MC)- E.coli, Klebsiella, Proteus, Staph
Viral - BK, Adeno, CMV, JC, Herpes
Fungal - Candida, Aspergillus, Cryptococcus
Parasites – Schistosomia, Ecchinococus
26. 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, toulidine
Pesticides- Chlorodimeform
27. 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 arthritis
Amyloidosis
Crohn’s disease
Boon’s disease – prolonged high altitude air travel