We present a clinical case of chronic bladder dysfunction (detrusor hyperactivity), associated with intense refractory pain, secondary to bladder spasms, in a patient requiring continuous bladder lavage.
A 58-year-old man was admitted to hospital with macroscopic haematuria, accompanied by suprapubic pain, and had been wearing a urethral catheter for 72 hours prior to admission due to acute urinary retention. His personal history included right lumbosciatica due to lumbar disc protrusions, remote urolithiasis treated with extracorporeal lithotripsy and a long-standing chronic voiding syndrome, in the context of benign prostatic hypertrophy according to prostate biopsy, chronically treated with oral tamsulosin (vo), after two previous transurethral prostate resections. The patient was admitted to the hospital's Urology Department and underwent imaging tests. An abdominopelvic ultrasound scan showed signs of "wrestling bladder", with no evidence of obstructive uropathy, and an abdominopelvic CT scan with contrast revealed prostatic hypertrophy and diffuse parietal bladder thickening, compatible with detrusor hypertrophy. The urethral catheter was replaced with a catheter adapted for continuous bladder lavage to dissolve intravesical clots. During the establishment of bladder lavage, episodes of suprapubic colic pain appeared, accompanied by intense neurovegetative cramping and reflux of haematuric bladder fluid, against gravity, from the bladder lavage serum, located about sixty centimetres above the patient's level. After ruling out obstructive problems and urethral catheter positioning, a diagnosis of bladder spasm due to detrusor hyperactivity was made and treatment was started with intravenous (IV) hyoscine butylbromide, metamizole and dexketoprofen, tolterodine and alprazolam, both by IV, and subcutaneous morphine chloride, without success. Given the persistence of the painful symptoms and intolerance to bladder lavage therapy, it was decided to place a lumbar epidural catheter in the L3-L4 intervertebral space, through which a bolus of 80 mg of lidocaine 2% with 50 μg of fentanyl was administered, followed by a perfusion of levobupivacaine 0.125% with fentanyl, at a rate of 5 mg/hour and 4 μg/hour respectively. After the introduction of the epidural block, excellent control was achieved of the painful symptoms and the urodynamic manifestations of bladder spasm, with a level of sensory block at the level of the T12 dermatome and a motor block at grade 0 on the Bromage scale. She was maintained on the aforementioned perfusion until the accidental explantation of the epidural catheter, which occurred seven days later, and iv analgesia was started with morphine chloride at 0.96 mg/hour. On the tenth day of admission, the patient underwent scheduled surgery under intradural anaesthesia for retropubic prostatic adenomectomy, according to Millin's technique, and postoperative analgesia was maintained with iv morphium chloride, associated with iv paracetamol. In addition, tolterodine by mouth was maintained. At 48 h postoperatively, and still under continuous bladder lavage therapy, the episodes of painful bladder spasms reappeared, with similar characteristics to the previous ones, requiring an increase in the morphium chloride infusion rate to 1.8 mg/hour. Placement of a new epidural catheter was ruled out, due to postoperative prophylactic heparinisation. After withdrawal of continuous postoperative bladder lavage due to cessation of haematuria, the clinical picture disappeared completely. The patient reported greater pain relief with epidural block compared to the therapeutic combination of spasmolytics, morphine chloride and tolterodine.