Skip to main content

Main menu

  • Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Info for
    • Authors
    • Reviewers
  • About Us
    • About the Ochsner Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
  • Other Publications
    • Ochsner Journal Blog

User menu

  • My alerts
  • Log in

Search

  • Advanced search
Ochsner Journal
  • Other Publications
    • Ochsner Journal Blog
  • My alerts
  • Log in
Ochsner Journal

Advanced Search

  • Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Info for
    • Authors
    • Reviewers
  • About Us
    • About the Ochsner Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
Case ReportCase Reports and Clinical Observations

Distended Bladder Presenting with Altered Mental Status and Venous Obstruction

Vaughan Washco, Lee Engel, David L. Smith and Ross McCarron
Ochsner Journal March 2015, 15 (1) 70-73;
Vaughan Washco
1Department of Internal Medicine, Louisiana State University Health Sciences Center, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Lee Engel
1Department of Internal Medicine, Louisiana State University Health Sciences Center, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
David L. Smith
2Department of Radiology, Louisiana State University Health Sciences Center, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ross McCarron
1Department of Internal Medicine, Louisiana State University Health Sciences Center, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
Loading

Abstract

Background New onset or acute worsening of bilateral lower extremity swelling is commonly caused by venous congestion from decompensated heart failure, pulmonary disease, liver dysfunction, or kidney insufficiency. A thromboembolic event, lymphatic obstruction, or even external compression of venous flow can also be the culprit.

Case Report We report the case of an 83-year-old male with a history of myelodysplastic syndrome that progressed to acute myeloid leukemia, bipolar disorder, and benign prostatic hypertrophy. He presented with altered mental status and new onset lower extremity edema caused by acute bladder outflow obstruction. Computed tomography of the abdomen and pelvis showed the patient's distended bladder compressing bilateral external iliac veins.

Conclusion Insertion of a Foley catheter resulted in several liters of urine output and marked improvement in his lower extremity edema and mental status a few hours later. Our extensive workup failed to reveal a cause of the patient's acute change in mental status, and we attributed it to a concept known as cystocerebral syndrome.

Keywords
  • Cystocerebral syndrome
  • edema
  • urethral obstruction
  • urinary retention
  • venous thromboembolism

INTRODUCTION

Among the many causes of bilateral lower extremity swelling, common etiologies are liver disease, kidney disease, heart failure, pulmonary hypertension, chronic venous stasis, and side effects of medication such as dihydropyridine calcium channel blockers. A distended urinary bladder compressing the inferior vena cava or external iliac vein can also produce bilateral pedal edema and is easily misdiagnosed. We report the case of a patient who presented with altered mental status and new onset lower extremity edema resulting from compression of the external iliac veins by a distended bladder.

CASE REPORT

An 83-year-old male with a history of myelodysplastic syndrome with progression to acute myeloid leukemia (AML), idiopathic thrombocytopenic purpura, adrenal insufficiency, a questionable history of dementia, bipolar disorder, and benign prostatic hypertrophy (BPH) presented to the emergency department with altered mental status. His daughter found him walking around his apartment complex in an agitated and confused state. The patient lived alone and was known to be fully functional and independent, although he likely had an underlying history of dementia with worsening intermittent confusion in the several months prior to admission. He did not have a history of drug or alcohol abuse. His home medications included tamsulosin, prednisone, and metoprolol tartrate. The patient was not on any medications for bipolar disorder, and it was not known if he had ever been hospitalized for psychiatric disease. He also had a history of chronic urinary retention caused by BPH with previous postvoid residuals as high as 600 mL of urine. Recently, his BPH had been medically managed with postvoid residuals of <200 mL of urine.

On admission, the patient's vitals were within normal range, and his body mass index was 22. His jugular venous pressure was 6 cm H2O, and his lungs were clear to auscultation. His S1 and S2 sounds were normal, and no murmurs were heard. He had new onset moderate lower extremity edema that extended from his feet to his sacrum. He had a mildly distended and nontender abdomen with no suprapubic fullness. His prostate was also mildly enlarged without nodularity. The patient was alert but confused and agitated and could not answer questions in full sentences.

The altered mental status workup revealed normal results for complete blood count, complete metabolic panel, B12 levels, and thyroid-stimulating hormone. Urinalysis was normal. Urine and serum toxicology screens were negative. His electrocardiogram demonstrated normal sinus rhythm, and his troponin level was normal. Chest radiographs did not reveal an acute cardiopulmonary process. Computed tomography (CT) of the head did not show an acute process. Magnetic resonance imaging of the patient's brain was also negative for an acute event and showed no signs of metastatic disease. Abdominal radiograph showed prominent gas-filled loops of the small and large bowel, concerning for an ileus. Bilateral lower extremity ultrasound was negative for deep vein thrombosis.

A cardiac or pulmonary cause of the patient's new onset lower extremity swelling was quickly ruled out based on normal results of a B-type natriuretic peptide blood test and a recent transthoracic echocardiogram from a previous admission that showed normal left ventricular function, an ejection fraction of 60%, and an estimated systolic pulmonary artery pressure of 21 mmHg.

CT performed after intravenous administration of iodinated contrast demonstrated marked distension of the bladder with the dome extending to the level of the umbilicus (Figure 1). Sagittal imaging to the left of midline demonstrated a few urothelial trabeculations and septations near the dome, sequelae of chronic bladder outlet obstruction. Axial and coronal imaging demonstrated symmetric compression of the external iliac veins as they course past the bladder (Figures 2 and 3).

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Computed tomography sagittal image of the abdomen and pelvis (with contrast) reveals marked distention of the bladder.

Figure 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2.

Coronal view shows compression of the bilateral external iliac veins (arrows).

Figure 3.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 3.

Axial view shows the distended bladder compressing the iliac veins (arrows).

A Foley catheter was placed that drained 3 liters of urine. Within hours of placement of the catheter, the patient's lower extremity edema and mental status significantly improved. Since admission, the patient had been incontinent and wearing a diaper; thus urine output was not accurately measured, and his acute urinary retention (AUR) was only revealed by CT. The workup conclusion was that his AUR was caused by BPH. After resolution of his symptoms, the patient was discharged home with a urethral Foley catheter and instructed to continue tamsulosin. He was also instructed to follow up with urology for a spontaneous voiding trial in 2 weeks. The patient did not have the opportunity to do a voiding trial without a catheter. His health quickly deteriorated because of his underlying AML, and he died.

DISCUSSION

AUR classically presents with abdominal pain and the inability to void. New onset lower extremity swelling caused by venous obstruction from a distended bladder is uncommon and was first reported in 1960.1 Other case descriptions followed.2-4 More common causes of new onset lower extremity swelling include heart failure, cirrhosis, proteinuria, kidney failure, bilateral lower extremity deep vein thrombosis, thrombosis of the inferior vena cava, or even vasodilating medication side effects. Extrinsic compression by a tumor, aneurysm, or retroperitoneal hematoma should also be considered. Additionally, as presented here, a distended bladder can produce critical compression.

We concluded the patient's altered mental status was caused by his distended bladder, a condition that has been called cystocerebral syndrome. Altered mental status associated with AUR was first reported in 1990.5 Several case reports and series followed, and most patients were elderly men presenting with AUR secondary to BPH.6-8 Interestingly, most of the patients also had an underlying psychiatric disorder or preexisting cognitive impairment. The pathophysiology of cystocerebral syndrome is not fully understood, but a hypothesis is that increased bladder wall tension induces sympathetic tone and catecholamine release that trigger an acute change in mental status.9

Of the several causes of AUR, BPH is the most common etiology in the elderly male. Other causes include medication side effects, neurologic disease, urethral stricture, and urolithiasis.10 Evaluation of a patient with AUR starts with a good history focusing on previous episodes of retention, cancer, surgery, radiation therapy, trauma, neurologic disease, and medication or drug use. On abdominal examination, a distended bladder is palpated as a suprapubic fullness with dullness to percussion. A rectal examination with assessment of prostate size is also necessary. Look for abnormal laboratory findings such as worsening kidney function, hematuria, leukouria, or bacteriuria. Imaging studies—bladder scan, renal ultrasound, or CT scan—may be necessary to determine the cause of AUR.

Initial management of AUR is bladder decompression that is usually successful with a urethral or suprapubic catheter.11 The catheter is generally left in place for several days prior to a trial without catheter. As with patients who present with BPH, an alpha adrenergic receptor antagonist should be initiated at the time of catheterization because alpha blockers have been shown to increase the success of voiding without a catheter.11-13 Five-alpha reductase inhibitors can decrease the incidence of AUR but do not increase the success of trials without a catheter and thus are not used to treat AUR caused by BPH.14 Multiple failed trials without a catheter while being treated with an alpha receptor blocker often lead to surgical intervention.15 Urodynamic evaluation is generally performed prior to surgical intervention to determine whether retention is directly related to outlet obstruction with concomitant elevation in bladder pressures or to an inefficient bladder muscle.

CONCLUSION

The manifestations of urinary retention are diverse and can be confusing for the physician. Although the condition is uncommon, clinicians should maintain a high index of suspicion for bladder distention as a cause of venous obstruction, especially in elderly patients presenting with altered mental status in whom it is difficult to assess or recognize symptoms of urinary retention.

This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.

Footnotes

  • The authors have no financial or proprietary interest in the subject matter of this article.

  • © Academic Division of Ochsner Clinic Foundation

REFERENCES

  1. ↵
    1. Carlsson E,
    2. Garsten P
    (6, 1960) Compression of the common iliac vessels by dilatation of the bladder. Report of a case. Acta radiol 53:449–453, pmid:13807782.
    OpenUrlPubMed
  2. ↵
    1. Sharma A,
    2. Naraynsingh V
    (1 24, 2012) Distended bladder presenting with constipation and venous obstruction: a case report. J Med Case Rep 6:34, pmid:22272565.
    OpenUrlPubMed
    1. Lokhandwala J,
    2. Gornik H
    (11, 2006) Leg swelling due to urinary obstruction. Vasc Med 11(4):263–265, pmid:17390552.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Evans JM,
    2. Owens TP Jr.,
    3. Zerbe DM,
    4. Rohren CH
    (11, 1995) Venous obstruction due to a distended urinary bladder. Mayo Clin Proc 70(11):1077–1079, pmid:7475337.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Blackburn T,
    2. Dunn M
    (12, 1990) Cystocerebral syndrome. Acute urinary retention presenting as a confusion in elderly patients. Arch Intern Med 150(12):2577–2578, pmid:2244775.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Waardenburg IE
    (12, 2008) Delirium caused by urinary retention in elderly people: a case report and literature review on the “cystocerebral syndrome.” J Am Geriatr Soc 56(12):2371–2372, pmid:19093953.
    OpenUrlPubMed
    1. Blè A,
    2. Zuliani G,
    3. Quarenghi C,
    4. Gallerani M,
    5. Fellin R
    (8, 2001) Cystocerebral syndrome: a case report and literature review. Aging (Milano) 13(4):339–342, pmid:11695503.
    OpenUrlPubMed
  6. ↵
    1. Waale WH,
    2. Bruijns E,
    3. Dautzenberg PJ
    (6, 2001) Delirium due to urinary retention: confusing for the patient and the doctor [in Dutch]. Tijdschr Gerontol Geriatr 32(3):100–103, pmid:11455868.
    OpenUrlPubMed
  7. ↵
    1. Liem PH,
    2. Carter WJ
    (9, 1991) Cystocerebral syndrome: a possible explanation. Arch Intern Med 151(9):1884–1886, pmid:1888260.
    OpenUrlCrossRefPubMed
  8. ↵
    1. Curtis LA,
    2. Dolan TS,
    3. Cespedes RD
    (4, 2001) Acute urinary retention and urinary incontinence. Emerg Med Clin North Am 19(3):591–619, pmid:11554277.
    OpenUrlPubMed
  9. ↵
    1. Fitzpatrick JM,
    2. Kirby RS
    (4, 2006) Management of acute urinary retention. BJU Int 97(Suppl 2):16–20, pmid:16507048, discussion 21-22.
    OpenUrlPubMed
    1. Lucas MG,
    2. Stephenson TP,
    3. Nargund V
    (2, 2005) Tamsulosin in the management of patients in acute urinary retention from benign prostatic hyperplasia. BJU Int 95(3):354–357, pmid:15679793.
    OpenUrlCrossRefPubMed
  10. ↵
    1. Fisher E,
    2. Subramonian K,
    3. Omar MI
    (2014) The role of alpha blockers prior to removal of urethral catheter for acute urinary retention in men. Cochrane Database Syst Rev, Jun 10;6:CD006744.
  11. ↵
    1. McConnell JD,
    2. Roehrborn CG,
    3. Bautista OM,
    4. et al.
    (12 18, 2003) The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 349(25):2387–2398, pmid:14681504.
    OpenUrlCrossRefPubMed
  12. ↵
    1. Wasson JH,
    2. Reda DJ,
    3. Bruskewitz RC,
    4. Elinson J,
    5. Keller AM,
    6. Henderson WG
    (1 12, 1995) A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J Med 332(2):75–79, pmid:7527493.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Ochsner Journal
Vol. 15, Issue 1
Mar 2015
  • Table of Contents
  • Index by author
Print
Download PDF
Email Article

Thank you for your interest in spreading the word on Ochsner Journal.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Distended Bladder Presenting with Altered Mental Status and Venous Obstruction
(Your Name) has sent you a message from Ochsner Journal
(Your Name) thought you would like to see the Ochsner Journal web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Distended Bladder Presenting with Altered Mental Status and Venous Obstruction
Vaughan Washco, Lee Engel, David L. Smith, Ross McCarron
Ochsner Journal Mar 2015, 15 (1) 70-73;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Distended Bladder Presenting with Altered Mental Status and Venous Obstruction
Vaughan Washco, Lee Engel, David L. Smith, Ross McCarron
Ochsner Journal Mar 2015, 15 (1) 70-73;
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • CASE REPORT
    • DISCUSSION
    • CONCLUSION
    • Footnotes
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • References
  • PDF

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Spontaneous Coronary Artery Dissection With Systemic Lupus Erythematosus
  • Jaundice Caused by Hyperemesis Gravidarum
  • Three-Dimensional Visualization With Virtual Reality Facilitates Complex Live Donor Renal Transplant
Show more CASE REPORTS AND CLINICAL OBSERVATIONS

Similar Articles

Keywords

  • Cystocerebral syndrome
  • edema
  • urethral obstruction
  • urinary retention
  • venous thromboembolism

Current Post at the Blog

American Association for the Advancement of Science Surveys Scientists About Article Publishing Charges—And Uncovers More Problems

Our Content

  • Home
  • Current Issue
  • Ahead of Print
  • Archive
  • Featured Contributors
  • Ochsner Journal Blog
  • Archive at PubMed Central

Information & Forms

  • Instructions for Authors
  • Instructions for Reviewers
  • Submission Checklist
  • FAQ
  • License for Publishing-Author Attestation
  • Patient Consent Form
  • Submit a Manuscript

Services & Contacts

  • Permissions
  • Sign up for our electronic table of contents
  • Feedback Form
  • Contact Us

About Us

  • Editorial Board
  • About the Ochsner Journal
  • Ochsner Health
  • University of Queensland-Ochsner Clinical School
  • Alliance of Independent Academic Medical Centers

© 2023 Ochsner Clinic Foundation

Powered by HighWire