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Correspondence to Dr Jakko A Nieuwenhuijzen, [email protected]
Background
Necrosis of the bladder is a rare condition that varies from partial necrosis (mucosa and/or submucosa) to necrosis of the entire detrusor wall. In the literature it is mostly described as vesical necrosis, bladder necrosis and gangrenous cystitis.1–3 Factors that may contribute to bladder necrosis can be divided into indirect and direct factors.4 Indirect factors lead to impaired blood supply, such as pressure from the outside of the bladder (eg, pregnancy, prolonged labour), inside (overdistention of the bladder due to urinary retention), or blockage of the venous or arterial vessels (eg, emboli). Direct factors cause direct damage to the bladder wall, such as instillations with chemotherapeutic agents for the treatment of bladder cancer, radiation therapy and infections.
Although already rare in the past, to date, the incidence has decreased even more due to improved obstetrical care and better and earlier antibiotic treatment. The largest documented series originate from the 1930s and 1940s.5 After the 1980s only occasional cases have been reported.1–3 6–8 The symptoms of bladder necrosis are non-specific, such as pain in the lower abdomen, frequency, urgency, haematuria and pyuria, which hampers early diagnosis.
We report the case of a 90-year-old man with a massive chronic urinary retention in whom, after bladder drainage, recurrent blockade of the transurethral catheter (TUC) turned out to be caused by bladder necrosis. Additionally, we demonstrate that transurethral drainage of the Retzius cavity in a patient without a bladder, except for the trigone, can serve as a temporary solution in a fragile patient. Without performing a urinary diversion (Bricker deviation), the kidney function was preserved and no infectious complications occurred.
Case presentation
A 90-year-old man presented to the emergency room with progressive pain in the lower abdomen after constipation for 1 week and a period of frequency, urgency and urge incontinence. Three days before presentation, his urine became haemorrhagic.
His medical history included an ischaemic cerebrovascular accident, atrial fibrillation, intermittent claudication and lower urinary tract symptoms. Medication included acenocoumarol, verapamil and tamsulosin.
Physical examination revealed a painful lower abdomen and a full bladder, which was palpated up until the umbilicus. The patient did not have fever, and on digital rectal examination a small, firm...