Bladder irrigation and urothelium disruption: a reminder apropos of a case of fatal fluid absorption

Abstract

BackgroundIrrigation or washouts of the bladder are usually performed in various clinical settings. In the 1980s Elliot and colleagues argued that urothelial damage could occur after washouts and irrigations of the bladder. The exact mechanism underlying urothelial damage has not yet been discovered. To our knowledge, this is the first report of fatal fluid overload and pulmonary edema, due to urothelium disruption occurring during bladder irrigation, approached performing complete histological and immunohistochemical investigation on bladder specimens. The exposed case deserves attention since it demonstrates that, although very rarely, irrigation or washouts of the bladder may have unexpected serious clinical consequences.Case presentationAn 85 year-old Caucasian man, unable to eat independently and whose fluid intake was controlled, underwent continuous bladder irrigation with a 3-way catheter due to a severe episode of macrohematuria. During the third day of hospitalization, while still undergoing bladder irrigation, he suddenly experienced extreme shortness of breath, breathing difficulties, and cough with frothy sputum. His attending nurse immediately noted that there was no return of the fluid (5 liters) introduced through bladder irrigation. He was treated urgently with hemodialysis. At the beginning of the dialysis treatment, the patient had gained 7.4 kg since the previous measurement (24 hours prior) without any clear explanation. Although a significant weight loss (from 81 to 76 kg) due to the dialysis procedure, the patient died shortly after the final treatment. The autopsy revealed that the brain and the lungs were heavily edematous. Microscopic examination of bladder specimens revealed interstitial and mucosal swelling, and loss of the superficial cell layer. Intermediate and basal urothelial cells were preserved. Altogether the abovementioned findings were suggestive of a diffuse disruption of the urothelium. In conclusion the death of the man was attributed to an acute severe pulmonary edema due to massive fluid absorption.ConclusionOur case demonstrates that urothelium disruption may occur during irrigation and washouts of the bladder, also in the absence of other well-known predisposing conditions. Inappropriate use of bladder irrigation should be avoided and a close attention is required of the fluid balance is mandatory when irrigating the bladder.

Spontaneous Bladder Perforation in a Patient with a Long-Term Intraurethral Catheter

“…Additionally, in a case report by Di Paolo et al [9], urothelial disruption occurred after bladder irrigation, which led to the absorption of a massive amount of fluid through the bladder wall. In summary, chronic inflammation and distension of the bladder wall caused by the intraurethral catheter contributed to the acute perforation, which was compounded by the manual irrigation of the bladder.…”

First Reported Case of Hyperchloremic Non-Anion Gap Metabolic Acidosis in a Patient Undergoing Continuous Bladder Irrigation for Hemorrhagic Cystitis

“…In 2014 Paolo et al reported acute severe pulmonary edema in an 85-year-old male who underwent CBI. Autopsy performed on bladder sample revealed a highly damaged urothelium with mucosal and interstitial edema on histological and immunohistochemical study [ 6 ]. Likewise, in our patient bladder irrigation led to systemic absorption of fluid from bladder urothelium that manifested as NAGMA.…”

What triggered massive hemoptysis in Goodpasture syndrome with isolated pulmonary involvement in a 14-year-old boy?

“…It is known that bladder irrigation with normal saline may cause uroepithelial injury which may, in turn, cause inflammation. 9 We thought that massive hemoptysis may be caused by the same mechanism: Due to lavage with saline and suctioning, inflammation may have been triggered with the occurrence of massive hemoptysis. Renal biopsy was not performed due to rapidly progressive life threatening course, also there were no hematuria, proteinuria or deteriorated renal function tests.…”