Case Presentation: The patient was a 73 year old gentleman with a recent diagnosis of heart failure with preserved ejection fraction presenting with weight gain, worsening dyspnea, lower extremity edema, and urinary incontinence since beginning furosemide two months previously. Labs were notable for a creatinine of 2.68 mg/dL from a baseline of 1.0 mg/dL. The timeline for decline in kidney function correlated with the new heart failure diagnosis. Computed tomography scan of the abdomen and pelvis was remarkable for significant distention of the urinary bladder, measuring 26 x 15 x 17 cm, with secondary severe bilateral hydroureteronephrosis and prostate gland enlargement. Decompression of the bladder resulted in post-obstructive diuresis and decompressive hematuria. Urinary output was 5.9 L with initial catheterization. Bilateral lower extremity edema resolved following bladder decompression. Creatinine improved to 1.1 mg/dL with post-renal obstruction as the etiology of the acute kidney injury. Hematuria and acute blood loss anemia occurred secondary to decompression, requiring transfusion of 4 units of PRBCs, continuous bladder irrigation, 3 cystoscopies under anesthesia for clot evacuation, and aminocaproic acid instillations. His hematuria eventually resolved and patient was discharged home with indwelling foley catheter and eventually transitioned to intermittent catheterization.
Discussion: The objective of presenting this case is to educate heath care professionals on the diagnosis and treatment of post obstructive diuresis and on the risks of decompressive hematuria. Post-obstructive diuresis is the polyuric state exceeding 200mL/hr for 2 consecutive hours or 3L in 24hrs, resulting in copious amounts of salt and water elimination and possible impairment of urinary concentration after relief of a long-standing bilateral ureteral obstruction. Patients are at risk for severe dehydration, hypovolemic shock, hypo- or hypernatremia, hypokalemia, hypomagnesemia, metabolic acidosis, and death. Additionally, sudden withdrawal of high intravesicular pressure can result in hemorrhage into the lumens of the urinary tract, resulting in significant hematuria.
Conclusions: Benign prostatic hyperplasia affects 3 of 4 men over the age of 70 with urinary retention representing the final symptomatic stage. In many inpatient hospitalizations, foley catheter insertion is required for medical management. In addition to the infectious and traumatic risks associated with catheterization, this case brings attention to complications of decompressive hematuria and post-obstructive diuresis. Decompressive hematuria and post-obstructive diuresis are rare but potentially lethal complications that can occur in relief of severe urinary obstructions. These obstructions require strict monitoring of vital signs, hemoglobin levels, fluid status, serum electrolyte levels, and involvement of urology in the inpatient setting.
