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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 sinc...
No history of –
• Traumatic catheterisation
• Bleeding diasthesis
• Lump in abdomen
Relatives on enquiry revealed 1 week h...
• Past history-
- H/o recurrent urinary tract infection
- Features of LUTS
- Had retention of urine twice in 6 months requ...
On examination
• Tachycardia- 120/min
• BP- 100/70
• Gross pallor, dehydration
CNS- Disoriented, irrelevant talks
No focal...
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...
Provisional diagnosis
Acute retention of urine
? Bladder outlet obstruction
Hematuria - UTI
? Cystitis
? Bladder mass
Acut...
Course post admission
• Due to poor general condition, he was shifted
to Neuro ICU, where he had one episode of
GTC.
• He ...
Portable ultrasound – Day 1
• RK- 10 * 5.5
• LK- 9.8 * 4.9
• Dilatation of bilateral pelvicalyceal system with
bilateral h...
Non contrast CT- KUB – Day 2
• Similar findings as ultrasound noted.
• Air densities in bladder and the mentioned
mass
• I...
Urology consult
• Large bladder mass with BOO leading to
bilateral hydroureteronephrosis.
• Continued bladder irrigation
•...
Course in wards
• Hematuria stopped on day 4, urine output 1.5 - 2 lit/day
• Required additional 2 units PRC transfusion
•...
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 ...
Trial of catheter removal
• Failed predischarge.
• Hence started on Urimax, Urispas
• Urodynamic studies-
Optimal capacity...
REVIEW OF LITERATURE
“ HEMORRHAGIC CYSTITIS ”
Hemorrhagic cystitis
Diffuse inflammatory condition of the urinary bladder due
to an infectious or noninfectious etiology ...
b) Drugs –
Cyclophosphamide, Iphosphamide
(due to metabolite - Acrolein )
Busulphan, Thiotepa.
Penicillin and its syntheti...
c) Radiation - for pelvic malignancies, atleast 90 day lag
Early - obliterative endarteritis causing ischemia f/b
neovascu...
The  vanishing bladder mass
The  vanishing bladder mass
The  vanishing bladder mass
The  vanishing bladder mass
The  vanishing bladder mass
The  vanishing bladder mass
The  vanishing bladder mass
The  vanishing bladder mass
The  vanishing bladder mass
The  vanishing bladder mass
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The vanishing bladder mass

  1. 1. The Vanishing Bladder Mass
  2. 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. 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. 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. 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.
  6. 6. 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
  7. 7. Provisional diagnosis Acute retention of urine ? Bladder outlet obstruction Hematuria - UTI ? Cystitis ? Bladder mass Acute kidney injury with Uremic Encephalopathy ? Obstructive uropathy
  8. 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. 9. 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
  10. 10. 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.
  11. 11. 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.
  12. 12. 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
  13. 13. Cystoscopy findings – Day 14 NODULAR HEMORRHAGIC CYSTITIS NO BLADDER MASS VISUALISED
  14. 14. Repeat Contrast CT KUB • Thickened enhancing bladder wall , bilateral Vesicoureteric junction and entire course of ureter suggestive of cystitis and urethritis • Bilateral kidneys normal
  15. 15. 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.
  16. 16. REVIEW OF LITERATURE “ HEMORRHAGIC CYSTITIS ”
  17. 17. 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
  18. 18. 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
  19. 19. 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
  • nicolasatte

    Sep. 13, 2014

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