Urinary obstruction in pregnancy

Patient, a 39 years old Malay , G4P3 currently at 16 weeks period of amenorrhea  presented with difficulty in urination over 2 weeks. She has no known underlying disease. This was a referred case from Hospital X.

She described that she started to have difficulty in urination in which she need to strain to urinate since last two weeks. It was associated with pain during urination. She described that stream was slow and after micturition, she felt her bladder was not voided well. There was also post-micturition dribbling and she need to wake up at night to go to the toilet. She then decided to use diaper to avoid her from going to toilet too often.

A week ago, she started to experience mild suprapubic pain and tenderness. She noticed that her abdomen is distended as if as her pregnancy was more than 16 weeks. The pain was localized to the suprapubic area, and the suprapubic area became hard and warm with no redness.

Patient then went to nearby hospital in her district, Hospital X at emergency department. She was not admitted but was prescribed with potassium citrate and no other procedure was done. However she symptoms did not subside and the pain worsened, described as 5-6/10. She then started to notice that her urine became cloudy with fishy smell. She denied any other abnormal discharge. It was not associated with fever and there was no changes of bowel habit. She denied any lost of weight or lost of appetite. The was no similar episode of complaint before.

After about a week, she went for her regular antenatal visit in Klinik Kesihatan Y. There, she was told that her SFH was like 26 weeks. Urine test was done showed proteins and white blood cells and her Hb was 8.6 which is low. On the same day, she was referred to Hospital X and immediately was put on CBD to void her bladder, relieving the suprapubic pain and the area became softer. There was blood in her urine but on further questioning, she claimed not to have any anemic symptoms such as palpitation, dizziness, shortness of breath or chest pain.

Ultrasound was done afterwards showed all parameters corresponded to 16 weeks with no abnormality. Fetal movement was good. In Hospital X, she was given intravenous cefuroxime and Ural powders before being sent to Hospital AAA for further investigation and management.

This is how ural sachet looks like. Usually the patient will say " ubat minum tu serbuk macam ubat ENO tu, doktor."

It is a urine alkalinizer, which means it will add base to urine to neutralize it. When acid is neutralized there are fewer H+ molecules, hence the pH rise. Human urine can have pH ranging from about 4 (acid) to about 8 (alkaline). When pH increase, stone will become mores soluble.

PotCit. Most patients are not compliant to this anyway. It tastes suck. 

But, potassium if kidney function is deranged, watch out before prescribing PotCit.

On general examination, patient was alert, concious and pink She was not tachypneic and not in pain. Hydrational and nutritional status was good. Vital signs are normal. There was one branula attached on dorsum of left hand but she was not on any intravenous infusion. She was on catheter which was connected to a reservoir bag containing 1L Sodium chloride 0.9% solution and a CBD bag which contained 600ml haematuria with no clots. Abdomen was slightly distended with cutaneous signs of pregnancy ; linea nigra. On palpation, the abdomen was generally soft but tender at suprapubic area. SFH was 15cm, corresponded to period of amenorrhea. No mass palpable per abdomen. Per rectal examination was not done.Examination of other systems reveal no abnormality.

Management

Few investigations was done

1. Full blood count
• to look for Hb level as she has hematuria after the CBD was inserted
• platelet because of the hemuria
• any leucocytosis which may signify an ongoing infection or inflammation
2. Coagulation profile
3. UFEME
• any trace of protein, leucocyte, nitrite, erythrocyte
• culture and sensitivity
4. Renal profile + albumin

Upon clerking, CBD was already changed once. During the changing, the catheter was changed form 2 ways to 3 ways catheter as the haematuria is not resolving. 3 ways catheter is for bladder irrigation. She can take orally, hence there was no need for isotonic solution infusion. Cefuroxime was given intravenously (antibiotic) with Ural, a urine alkalinizer. 

3 ways

2 ways

Bladder irrigation
Source : http://what-when-how.com/wp-content/uploads/2012/08/tmp325129_thumb22_thumb.png

She was planned for

1. ultrasound KUB to look for any stones, or dilatation.
2. Cystoscopic examination 

In her case of urinary obstruction and frank hematuria, the urologist planned to rule out bladder cancer. It can also be due to traumatic hematuria secondary to catheter insertion." Apart from the direct trauma due to the technique, the catheter itself can sometime cause irritation to bladder mucosa in certain patient. It is usually mild and not require any intervention. All you need to do is to observe the condition and KIV for bladder irrigation if not resolving." -DrJackNaim'sNotes-

Urinary catheter is used to drain bladder

Indications are :

• Urinary incontinence 
• Urinary retention 
• Surgery on the prostate or genitals
• Prolonged immobilization
• Other medical conditions such as multiple sclerosis, spinal cord injury, or dementia

Provisional diagnosis : Bladder in stone (cystolith)

DDxes :

• bladder cancer
• urethral stricture
• pelvic mass