CASE REPORT Hourglass Urinary Bladder in a Male Patient with Paraplegia Subramanian Vaidyanathan,1* Bakul M Soni,1 Peter L Hughes,2 Gurpreet Singh,3 Tun Oo1 Keywords: urinary bladder; diseases; pathology; spinal cord injuries; paraplegia; etiology; complications. INTRODUCTION Hourglass deformity of urinary bladder may occur as a result of congenital malformations (the commonest cause), herniated calculous bladder with an incarcerated incisional hernia, hypertonic neurogenic bladders, an improperly constructed augmentation cystoplasty or tuberculous cystitis.(1) We describe a spinal cord injury patient with paraplegia, who had undergone suprapubic cystostomy. Hourglass bladder was detected by computed tomography, which was performed to investigate infected pressure sore in left hip. CASE REPORT A British, Caucasian male, born in 1938, sustained complete paraplegia at T8 level in March 1978 due to fall from a ladder while working on a drain pipe. He had indwelling urethral catheter during the acute stage and then condom drainage. In 1989, he underwent implantation of Medtronic SynchroMed pump for intrathecal delivery of baclofen. In 1997, this patient developed a pressure sore in perineum involving the urethra, which was repaired by posterior thigh flap. The flap broke down. Therefore, suprapubic cystostomy was performed on 12 December 1997. He was not prescribed any antimuscarinic drugs. The bulbar urethra got closed completely. In April 2008, this patient developed urinary tract infection. Computed tomography (CT) scan of urinary tract revealed right renal calculi. The right kidney was hydronephrotic with dilatation of the pelvis and hydroureter extending all the way up to the vesico-ureteric junc- tion with calcification/calculi noted within the right lower ureter. There were also calculi within the right renal pelvis and right lower pelvicalyceal system. Right nephrostomy was performed followed by percutaneous lithotripsy of renal calculi. Regional Spinal Injuries Centre1, Departments of Radiology2 and Department of Urology3, District General Hospital, Southport, Merseyside PR8 6PN, United Kingdom. * Correspondence: Regional Spinal Injuries Centre, District General Hospital, Town Lane, Southport, Merseyside PR8 6PN, United Kingdom. Tel: +44 1704 547471; Fax: +44 1704 543156. E-mail: Subramanian.vaidyanathan@nhs.net. Received April 2011 & Accepted January 2012 Figure 1. Axial section of computed tomography of pelvis showed inflammatory granulation tissue in right hip; there was old dislocation and resorption of right femoral head. In the left hip, there was an abscess. Again there was resorption and lysis of the femoral head. . An incidental finding was hourglass deformity of urinary bladder. Suprapubic catheter was located in the anterosuperior compartment of the hourglass bladder. Figure 2. Axial section of computed tomography of pelvis clearly showed hourglass deformity of urinary bladder. Suprapubic catheter was located in the anterosuperior compartment of the hourglass bladder. Case Report 1908 In 2008, this patient underwent CT scan of pelvis to in- vestigate infected pressure sore in left hip. CT scan re- vealed inflammatory granulation tissue in right hip, old dislocation and resorption of the femoral head. An inci- dental finding was hourglass deformity of urinary bladder (Figures 1, 2 and 3). The balloon of Foley catheter was located in the anterosuperior compartment of hourglass bladder. DISCUSSION Possible reasons for development of hourglass bladder in spinal cord injury patients are: traction applied to dome of urinary bladder by Foley balloon when suprapubic cathe- ter is taped tightly to anterior abdominal wall for several months; uncoordinated contractions of detrusor muscle; and chronic cystitis leading to hypertrophy of bladder wall.(2) Ogawa and colleagues(3) found high-grade (great- er than grade II) bladder deformity more frequently in persons with complete spinal cord injury than in patients with incomplete injury. All patients with low compliance bladder had a high-grade bladder deformity. There was a significant relationship between severity of urinary tract infection and severity of bladder deformity. Our patient had complete paraplegia and was getting urine infections. Probably, the balloon of Foley catheter, which was taped to anterior abdominal wall, had caused continuous, slow traction upon the bladder over a long period. These factors contributed to development of hour- glass deformity of urinary bladder in our patient. Intermittent catheterization program has been shown to be effective in preventing bladder deformity;(4) unfortu- nately, this patient could not manage his bladder by inter- mittent catheterization soon after spinal cord injury. Kim and colleagues(5) studied 109 male spinal cord injured patients at the Houston Veterans Affairs Medical Cen- tre, who had been treated with chronic indwelling cath- eters (80 transurethral and 29 suprapubic). Thirty-eight patients (35%) were identified as using oxybutynin on a regular basis. These patients were compared to those not using oxybutynin with regard to urodynamic parameters and upper tract deterioration. Regular use of oxybutynin was found to be beneficial in spinal cord injured patients Figure 3. Sagittal reformat of computed tomography of pelvis showed thick walled urinary bladder. Suprapubic catheter was located in the anterosuperior compartment of the hourglass bladder. who required chronic indwelling catheters. Hydronephro- sis was present in 15 of 66 patients (23%) without oxybu- tynin versus 1 of 36 (3%) patients, who were taking oxy- butynin (P = .009). Only recently, we started prescribing oxybutynin or propiverine hydrochloride as a routine to spinal cord injury patients with indwelling urinary cathe- ters in order to reduce complications such as low vesical compliance, high-grade bladder deformity, and hydrone- phrosis. Hourglass deformity of urinary bladder is a risk factor for upper urinary tract complications in patients with spinal cord injury.(3,4) This patient with hourglass urinary blad- der also developed upper urinary tract complications; he had stones in right kidney with right hydronephrosis. In order to prevent occurrence of hourglass deformity of urinary bladder in spinal cord injury patients, we have been trying to implement the following measures: •Intermittent catheterization along with antimuscarinic drug therapy should be recommended as the preferred method of bladder management in spinal cord injury pa- tients •If a patient requires chronic indwelling urinary catheter, antimuscarinic drugs should be prescribed routinely to re- duce uncoordinated contractions of detrusor muscle. •All possible measures including improved personal hy- giene should be undertaken to prevent chronic urinary in- fection, as chronic bladder infection leads to hypertrophy of bladder wall. •Traction should not be applied to suprapubic Foley cath- eter while fixing the catheter to anterior abdominal wall. We routinely use CathGrip (BioDerm Inc. Largo, Flori- da 33773, USA) to anchor suprapubic catheters in spinal cord injury patients. CONCLUSION Patients with hourglass deformity of urinary bladder can develop problems with drainage of suprapubic catheter, especially if the tip of Foley catheter is located in the superior compartment of hourglass bladder. But in this patient, suprapubic catheter continued to drain satisfacto- rily, as the bulbous urethra had closed completely. CONFLICT OF INTEREST None declared. REFERENCES 1. Singh I, Goel R, Doddamani D, Ansari MS, Dogra PN. Hourglass bladder – an unusual com- plication of tubercular cystitis. BJU Int. 2002;90:e20-e21. 2. Vaidyanathan S, Hughes PL, Soni BM, Singh G, Mansour P. Hourglass urinary bladder in a spinal cord injury patient - unusual late compli- cation of suprapubic cystostomy: a case report. Cases J. 2009;2:6866. 3. Ogawa T, Yoshida T, Fujinaga T. Bladder de- formity in traumatic spinal cord injury patients. Hinyokika Kiyo. 1988;34:1173-8. 4. Ogawa T. Bladder deformities in patients with neurogenic bladder dysfunction. Urol Int. 1991;47 Suppl 1:59-62. Hourglass Urinary Bladder in Patient with Spinal Cord Injury-Vaidyanathan et al Vol 11. No 05 Sept-Oct 2014 1909 Hourglass Urinary Bladder in Patient with Spinal Cord Injury -Vaidyanathan et al 5. Kim YH, Bird ET, Priebe M, Boone TB. The role of oxybutynin in spinal cord injured patie- nts with indwelling catheters. J Urol. 1997;158:2083-6. Case Report 1910