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Bladder decompression for chronic urinary retention may lead to upper tract
bleeding

Article  in  The National medical journal of India · October 2013

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Brusabhanu Nayak Nitin Abrol

All India Institute of Medical Sciences Mayo Clinic - Rochester
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82 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 26, NO. 2, 2013

Clinical Case Report

Bladder decompression for chronic

urinary retention may lead to upper tract
bleeding
BRUSABHANU NAYAK, NITIN ABROL,
PRABHJOT SINGH, RAJEEV KUMAR

ABSTRACT
Haematuria following decompression of a distended bladder
is a well known condition. The bleeding in such cases originates
in the bladder and resolves spontaneously. We describe an
elderly man who had bleeding from the kidney following
decompression of the bladder. This resulted in an extensive
search for an upper tract tumour as a cause for haematuria.
Natl Med J India 2013;26:82–3

THE CASE
A 67-year-old man presented with obstructed voiding of 4 years’
duration. His blood urea and creatinine were 282 mg/dl and 11.3
mg/dl, respectively. Ultrasonography showed prostatomegaly with
bilateral hydroureteronephrosis. He was catheterized and 4 litres
of clear urine was immediately drained. He then developed gross
haematuria and hyponatraemia. The haematuria persisted for over
a week and a magnetic resonance urogram (MRU, Fig. 1) was
done to rule out an upper tract lesion as the cause for bleeding. A
suspicion of a right lower ureteric tumour was raised. His azotaemia
persisted and a right-sided nephrostomy was placed. A
nephrostogram through this tube (Fig. 2) was consistent with the FIG 2. Right nephrostogram showing filling defects in the right
MRU findings. A diagnostic cystoscopy and ureteroscopy were pelvicalyceal system extending till the lower end of the ureter

done. The right ureter was filled with clots starting from the
vesico-ureteric junction to the pelvis. No tumour was identified.
His haematuria subsided after 2 weeks and a repeat diagnostic
ureteroscopy was done to rule out a tumour. The right ureter was
still dilated but there were no clots or tumour.

A B
FIG 1. Magnetic resonance urogram (MRU) showing right
hydroureteronephrosis with the ureter filled with clot in a T2-
weighted image (A). The post-gadolinium image (B) showed an
enhancing mass lesion in the lower end of the ureter (arrow)
All India Institute of Medical Sciences, New Delhi 110029, India
BRUSABHANU NAYAK, NITIN ABROL, PRABHJOT SINGH,
RAJEEV KUMAR Department of Urology
Correspondence to RAJEEV KUMAR; rajeev02@gmail.com
© The National Medical Journal of India 2013
DISCUSSION
Decompression of a chronically distended urinary bladder is known
to result in haematuria in 2%–16% of patients.1 This is usually self-
limiting. Experimental evidence in dogs suggests that urinary
retention leads to an increase in intravesical pressure and
overstretching of the bladder wall results in loss of capillary and
tissue integrity.2 The authors recorded haemorrhage of the bladder
wall which increased after decompression. This was related primarily
to the degree of rise in intravesical pressure. The increase in blood
flow to the bladder wall after decompression leads to haematuria.3
While the occurrence of renal origin haematuria following
bladder decompression was known even in 1924 when it was
reported by Shaw and Young, its pathophysiology is still not
clear.4 The renal pelvis and ureter dilate following bladder outlet
obstruction and, similar to the bladder, sudden decrease in
NAYAK et al. : BLADDER DECOMPRESSION FOR CHRONIC RETENTION MAY CAUSE BLEEDING FROM THE UPPER TRACT 83

intraluminal pressure may lead to rupture of the compressed,
congested mucosal veins which are at higher pressure. However,
in an autopsy study on the effects of bladder decompression in 71
patients, Creevy in 1932 demonstrated renal parenchymal infection
as the cause for haematuria.5 We were unable to locate similar
studies from the literature in the past 80 years and found only one
case described in 1944.6
Haematuria in an elderly patient always raises concern about
upper tract tumours. In this patient, this concern became extremely
relevant due to the finding of clots in the entire right nephroureteric
system which was unexpected after bladder decompression alone.
The worry was compounded by the MRU that suggested the
possibility of a ureteric tumour. This concern and unclear imaging
findings resulted in extensive evaluation. It is thus important to
remember that lower tract decompression may on occasion result
in extensive bleeding from a chronically obstructed upper tract.
REFERENCES
1 Nyman MA, Schwenk NM, Silverstein MD. Management of urinary retention: Rapid
versus gradual decompression and risk of complications. Mayo Clin Proc 1997;72:
951–6.
2 Gould F, Cheng CY, Lapides J. Comparison of rapid versus slow decompression of
the distended urinary bladder. Invest Urol 1976;14:156–8.
3 Schröder A, Kogan BA, Lieb J, Levin RM. Increased blood flow after catheterization
and drainage in the chronically obstructed rabbit urinary bladder. Urology 2001;58:
295–300.
4 Shaw EC, Young HH. Gradual decompression in chronic vesical distention. J Urol
1924;11:373–94.
5 Creevy CD. Sudden decompression of the chronically distended urinary bladder: A
clinical and pathological study. Arch Surg 1932;25:356–85.
6 Riches EW. The effects of rapid decompression of the bladder in chronic retention.
Proc R Soc Med 1944;37:226.

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