A 24 year old female with uncontrolled Type 1 Diabetes Mellitus was admitted with bilateral lower extremity swelling and abdominal fullness. Three weeks prior she visited the emergency department, was found to have mild bilateral pedal edema, and was given primary care physician follow-up. She was initiated on a diuretic regimen; B-type natriuretic peptide was not suggestive of congestive heart failure, serum creatinine at baseline and a urine albumin to creatinine ratio suggested nephropathy. Lower extremity swelling worsened and glucose was uncontrolled prompting presentation to the hospital.
On admission was afebrile, tachycardic with heart rate in low 100’s, had bilateral 4+ pitting lower extremity edema associated with erythema and tenderness in the right inguinal region, and lab work significant for blood sugar of 456mg/dL without anion gap or urine ketones. Urinalysis was suggestive of urine tract infection (UTI), and was complaining of intermittent urinary incontinence. Her abdomen was distended without tenderness or fluid shift. A Doppler of lower extremities showed complete thrombotic occlusion of the right common femoral vein with partial occlusion in femoral and deep femoral veins without evidence of thrombotic occlusion of the left leg. She denied any oral contraceptive use, extended travel, recent trauma, or recent surgeries.
A Computed Tomography of abdomen and pelvis with delayed contrast was obtained for concern for a proximal thrombus, which revealed a markedly distended bladder (24cmx15cmx13cm) with bilateral hydronephrosis and concern for inferior vena cava compression. A Foley catheter was inserted and immediately drained 2700cc of urine with some symptomatic relief. She was managed with continuous heparin infusion before transitioning to oral anticoagulation with Rivaroxaban. Her hemoglobin A1c returned at 15.8%, diabetic regimen was adjusted, she completed a ten day course of ampicillin-clavulanate for UTI, and was discharged with a Foley catheter. Upon follow-up had marked improvement in her lower extremity edema.
Discussion:
Diabetic cystopathy is a major complication of insulin dependent diabetes. However, this urologic complication predominantly occurs in elderly men, usually in concurrence with Benign Prostatic Hypertrophy (BPH) or other bladder outlet obstructions. In both genders, bladder hypersensitivity, incontinence, and instability are most frequent. An acontractile bladder with urine retention and subsequent massive distention is an uncommon presentation of diabetic cystopathy. Few cases of a distended bladder causing IVC compression have been reported. Nearly all were in the setting of bladder outlet obstruction in elderly men. Diabetic cystopathy severe enough to cause IVC compression and bilateral DVTs has not been reported. Bladder distention severe enough to cause IVC compression is reversible with catheterization with return of baseline kidney function.
Conclusions:
Compared to 30 years prior, the incidence of diabetes mellitus is more than double for those aged 18-44. Severe diabetic cystopathy in a young Type 1 diabetic woman leading to IVC compression with subsequent DVT formation is an uncommon presentation. Given the insidious development, cystopathy should be considered in the young with long standing diabetes. 