Clinical History and Symptoms
A 62-year-old female with a medical history of mild uterovaginal (UV) prolapse, diabetes mellitus type 2, hypertension, hyperlipidemia, and ureteral stones initially presented to a local Singapore emergency department (ED) with severe abdominal pain.
Upon examination in the ED, the patient was diagnosed with a grade 2 UV prolapse (descent to the hymen), but she declined a pessary ring because she had previously developed acute urinary retention (AUR) after insertion of a pessary ring by a local gynecologist. The patient reported she had been seen and followed regularly at another local hospital for abdominal pain and urinary retention for the past five months. Previous diagnostic imaging revealed no renal stones, and she was referred to a gynecologist to assess for the source of her pain. She was then initially diagnosed with UV prolapse, and a pessary ring was inserted. Unfortunately, she developed AUR, and an indwelling urinary catheter was inserted.
In our ED, the catheter was removed, and the patient spontaneously voided 200 mL of urine but still complained of severe abdominal pain. An indwelling catheter was reinserted with an immediate return of 600 mL of urine. Just prior to the catheter insertion, she passed a 1 X 1 cm urinary calculus. Her pain level improved after passing the calculus. Urine culture and CT intravenous pyelogram (IVP) were ordered, and the patient was referred to the urology outpatient clinic for further evaluation one week after the CT was completed. She was discharged from the ED with the indwelling catheter in place.
The patient was seen by both a urologist and a urogynecologist during her visit to the urology outpatient clinic. Her CT IVP revealed a non-obstructing 0.9 cm left lower pole kidney calculus and two bladder calculi. Urine culture revealed Klebsiella pneumoniae, and fosfomycin tromethamine (Monurol®) 3 gm by mouth once a week for three weeks was prescribed. She was confirmed to have a grade 2 cystocele and grade 1 uterine descent. The patient was offered cystolitholapaxy for the stones, and she was taught to practice Kegel exercises. It should be noted that fosfomycin tromethamine is approved in the United States only for uncomplicated urinary tract infections. For acute cystitis in women, it is given as a 3 gm single dose packet of powder to be mixed in 3 to 4 oz. of water (Allergan, 2017). Dosing in other parts of the world may vary.
Cystolitholapaxy, which is a procedure to break up bladder stones into smaller pieces and remove them, was completed as an elective admission. On the first post-operative day, the indwelling catheter was removed. She voided spontaneously but had post-void residual urine (PVRU) of 100 mL. The patient was instructed to initiate clean intermittent self-catheterization (CISC). Since she could void spontaneously, and thus, was not in complete retention, she was instructed to catheterize herself twice a day (morning and evening). Video urodynamic studies (VUDS) were scheduled in the outpatient urology clinic to assess for voiding dysfunction that could be causing the formation of bladder stones.
Urodynamic study (UDS) refers to a group of tests used to assess the function of the urinary tract system. It measures the pressure and volume of the fluid in the bladder in the filling, storage, and voiding phases (cystometry), and measures the rate of the urine flow during voiding phase (uroflowmetry) (Flesh, 2017). VUDS combine the use of real-time X-rays and fluoroscopy with cystometry and pressureflow studies. In this case, VUDS was used because of the simultaneous real-time image display of both the bladder neck and urethra (Gill, 2016).
Urol Nurs. 2018;38(1):36-41. © 2018 Society of Urologic Nurses and Associates