We report a case of chronic bladder dysfunction (detrusor hyperactivity), associated with severe refractory pain secondary to bladder spasms, in a patient requiring continuous bladder lavage.
A 58-year-old man was admitted to hospital due to hematuria, accompanied by suprapituitary pain, with a urethral catheter 72 h before admission due to acute urinary retention.
His personal history included right lumbar pain due to a biopsy with previous benign disc prostatic hypertrophy, chronic prostatic urolithiasis treated with extracorporeal lithotripsy and a long-standing chronic voiding syndrome in the context of an oral prostate
The patient was admitted to the Urology Department of the hospital and underwent imaging studies.
Diffuse parietal hypertrophy ultrasound showed signs of "fighting bladder", with no data of uropathy. Contrast-enhanced pelvic obstructive tomography showed prostatic hypertrophy and thickened bladder.
A urethral catheter was changed through a catheter adapted to continuous bladder lavage for bladder clot disfunction.
During the installation of the lavage fluid, episodes of localized pain of the colonic type appear, accompanied by intense neurovegetative cortex and reflux of bladder fluid approximately sixty centimeters, against gravity, bladder lavage fluid,
After ruling out obstructive problems and positioning of the urethral catheter, she was diagnosed with bladder spasms due to detrusor overactivity and started treatment with hioscine butylbromide, intravenous metamizole and intravenous chloride.
Due to the painful symptoms and intolerance to bladder lavage therapy, it was decided to place a lumbar epidural catheter at the site of infusion with lidocaine 50/b ratio to L4 and then administer a bolus of 80 mg/g 2% fentanyl per hour.
After establishing the epidural block, an excellent control of painful symptoms and urodynamic manifestations of bladder spasm is achieved, with a level of sensory block at the level of the T12 dermatome and a grade 0 motor block in the scale.
The infusion was maintained until the accidental removal of the epidural catheter, which occurred seven days later, intravenous analgesia was initiated with a chloride 0.9% saline solution.
On the tenth day of admission, she was operated under intradural anesthesia for retropubic prostatectomy according to Millin's technique. Postoperative analgesia was maintained with intravenous paracetamol associated with iv chloride iv.
Tolterodine was also maintained on you.
At 48 h post-operatively, and still under continuous bladder lavage therapy, episodes of painful bladder spasms reappear, of similar characteristics to those previously reported, requiring an increase in chloride infusion rate to 1.8 mg per hour.
A new epidural catheter was discarded due to postoperative prophylactic heparinization.
After removal of continuous postoperative bladder lavage due to cessation of hematuria, the clinical picture completely disappears.
The patient reported greater pain relief with epidural block than with the combination of spasmolytics, chloride and tolterodine.
