G.Bertelli's Bladder Globe

Generality

The bladder orb is a painful swelling of the lower part of the abdomen, caused by failure to empty the bladder, for a prolonged period of time.

The causes that favor its onset can be different and include obstructions of the genito-urinary tract, dysfunctions of the muscles or nerves that control the bladder and the intake of certain drugs.

The bladder globe is associated with difficult or absent urination, suprapubic pain (especially during palpation) and reduction of bladder contractility . This condition, if not resolved in a short time, can lead to permanent damage to the detrusor muscle, in addition to preparing for urinary tract infections and nephropathies.

Bladder globe therapy depends on the specific cause that led to the accumulation and retention of urine in the bladder.

What's this

The bladder globe is an important, albeit rare, medical complication. In detail, this consists of an excessive distension of the bladder due to the increase in the volume of urine it contains, which can reach up to 4000 ml (note: the normal capacity of the bladder is about 400-600 ml ). The bladder globe is secondary to acute urinary retention and is observed more frequently in men than in women.

Bladder Globe: definition and characteristics

The bladder globe is defined as an increase in the volume of urine contained in the bladder, so as to exceed its actual capacity (400-600 ml). This condition is accompanied by difficult or absent pain and urination, which occurs as a result of excessive distention of the bladder and consequent reduction in its contractility.

Causes

The bladder globe is a complication that is most frequently observed with increasing age, especially among men, in whom prostatic pathologies (such as prostate cancer and hypertrophy) or urethral strictures cause an obstruction to urine outflow. Other common causes of bladder globe are lithiasis, dysfunctions of the nerves that control the bladder or the inability to stretch the pelvic floor.

Bladder: increase in urinary volume

The bladder is capable of containing an average of 400-500 ml of urine. Once this limit is exceeded, this organ is stretched increasing in volume.

If the accumulation of urine exceeds the capacity of the bladder itself to retain it, acute urinary retention and, consequently, the formation of the bladder globe can be encountered.

Bladder Globe: what can it be provoked?

The bladder globe is due to acute urinary retention, which can be of two types:

• Obstructive : retention is caused by obstacles to urine outflow. The obstructions can be various and include, for example, prostatic pathologies, the narrowing of the urethra or bladder neck, the presence of stones, tumors and urinary polyps;
• Non-obstructive : retention is not caused by an obstruction, but by other factors such as:
  • Nerve deficiency that controls urination;
  • Damage to the bladder muscle wall.

The causes of the bladder globe can also be distinguished in urogenital, neurological, iatrogenic (post-operative drugs and complications) and psychological causes.

Urogenital causes of bladder globe

• Kidney stones : in addition to nephrolithiasis, urethral sphincter stenosis, an urethral infection or ulcer can cause total or partial blockage of urination;
• Bladder stones : lithiasis of the organ can block the urinary flow, giving rise to its distension;
• Fecaloma : when a hard mass of fecal material accumulates in the intestine, a pelvic compression of the urinary tract can occur, from which it can achieve a bladder globe;
• Infections of bladder and / or urethra (cystitis and urethritis), more frequent in women;
• Stenosis of the urethra ;
• Tumors of various types that compress the urinary tract .

In humans, the bladder globe can develop under the following conditions:

• Benign prostatic hypertrophy : in men over the age of 60, prostate enlargement can block the passage of urine partially or completely;
• Prostatitis ;
• Prostate cancer ;
• Phimosis (narrowing of the foreskin of the penis).

In women, the bladder globe may result from compression of the bladder neck and obstruction of urinary flow, in the presence of:

• Fibroids ;
• Ovarian cysts ;
• Carcinoma of the uterine cervix ;
• Pregnancy and childbirth (after prolonged laborious labor or carrying out by caesarean section, the tone of the bladder smooth muscle could decrease, thus favoring the onset of the bladder globe).

Neurological causes of bladder globe

• Parkinson's disease;
• Transverse myelitis;
• Brain stroke;
• Multiple sclerosis;
• Dislocation of the spine or fracture of the spine with compression of the nerves that control the bladder;
• Spina bifida (in children).

drugs

The bladder globe may represent the adverse effect of some drugs able to interact with the ability of the bladder muscles to contract during emptying.

These medicines include:

• Antidepressants (especially tricyclic ones);
• muscle relaxants;
• anesthetics;
• Drugs for the treatment of urinary incontinence.
• Nasal congestion drugs.

In most cases, reducing drug intake, urinary retention and the resulting bladder globe improves.

Other possible causes

• In several cases, the bladder globe appears after surgery. This condition can be favored by:
  • Lack of infused liquids before, during and after surgery;
  • Inability to go to the bathroom following the surgical procedure;
  • Anesthetic drugs that can slow down kidney activity.
• Rarely, in the absence of obvious organic causes, the bladder globe may depend on:
  • Polydipsia from psychiatric diseases;
  • Anxiety;
  • Psycho-physical stress.

Symptoms and Complications

The increase in urinary volume that occurs in the presence of the bladder globe is generally associated with the appearance of an evident suprapubic painful swelling and the reduction of bladder contractility.

Bladder Globe: how it manifests

At the level of the suprapubic region, in correspondence of the bladder, the globe appears as a bulge which, in some cases, can reach the navel. The palpation of the swelling induces intense pain.

The bladder globe also involves the following manifestations:

• Difficulty urinating (dysuria);
• Difficult or absent urination (stranguria);
• Suprapubic pain and sense of weight .

Some people with a bladder globe do not show pain, but perceive a sense of discomfort in the lower part of the abdomen. This symptom is associated with an uncontrollable drip, due to excessive distension of the bladder, which can be confused with urinary incontinence. In the presence of the bladder globe, however, as the dilatation of the organ increases, pain also typically increases.

In the most serious cases of bladder orb, it is impossible to urinate . In particular, we talk about oligo-anuria (if the amount of urine produced daily is less than 250 ml) and anuria (when the urine produced in one day is less than 100 ml).

Possible complications of the bladder globe

If the bladder globe is not adequately treated, some complications may occur, such as:

• Reduced urge to urinate : this may occur, for example, following surgery and may be accompanied by hypotension and tachycardia secondary to the increase in intra-abdominal pressure . Excessive bladder distention can lead to reflux of urine into the kidneys resulting in a picture of hydronephrosis and acute renal failure .
• Bladder damage : if the distension of the bladder lasts for long periods, the muscles could be damaged, compromising the correct functioning of the organ.
• Urinary tract infections : in the presence of the bladder globe, urine stagnation can favor the proliferation of bacteria and other microorganisms.
• Chronic kidney disease : in some people, urinary retention causes urine to rise from the bladder to the kidney (urinary tract reflux). This situation, if neglected, damages the kidneys and predisposes to chronic kidney diseases.

Diagnosis

The diagnosis of the bladder globe is established on the basis of the symptoms reported by the patient (typically, the subject is not able to make the urine escape) and of the objective examination of the abdomen

First of all, the doctor tries to obtain a general clinical picture of the characteristics of daily urination, evaluating the level of hydration, arterial pressure and the state of the bladder and kidneys.

The objective examination involves inspection, palpation and percussion, to look for asymmetries or suspicious swellings.

The bladder globe may be visible as a mass in the suprapubic area; on percussion, dullness is evident, while palpation shows a swelling that denotes bladder distension and pain.

To determine the presence or causes of the bladder globe, the doctor collects a urine sample to assess kidney function and detect any infections ( urine culture ). Furthermore, blood tests (CBC, PSA dosage, ESR, azotemia, creatinine clearance, etc.) and diagnostic imaging, such as bladder ultrasound may be necessary. The latter, in particular, in addition to identifying the presence of the bladder globe, contributes to measuring the actual volume of the bladder and adequately evaluates the therapeutic interventions to be adopted to prevent complications.

Treatment

In the case of a bladder orb, catheterization is the therapeutic intervention of first choice to resolve bladder distension .

The application of the catheter can be:

• Intermittent : the catheter is removed after draining the urine from the bladder;
• Short term : the catheter is kept in place until the cause of the bladder globe has been resolved.

Emergency measures

The bladder globe requires timely intervention in order to avoid blocking kidney function and to resolve bladder distention.

Usually, when the subject is totally unable to urinate, an emergency bladder catheter is inserted to evacuate the urine quickly and provide relief.

The drainage of the bladder globe can be performed through the urethra or from the bladder itself by positioning a suprapubic catheter, at the level of the abdominal wall, to perform a gradual emptying of the organ.

Case management

Once the exact cause of the bladder globe has been identified, it is possible to intervene to avoid the recurrence of the situation and the onset of the complications associated with it.

For example:

• If the bladder globe depends on the assumption of certain drugs, it is possible that the doctor remodels or stops the therapy, replacing it with an alternative medicine.
• For men suffering from prostatic hypertrophy, surgery or medication can be recommended to reduce the prostate (for example: finasteride or dutasteride) or to relax the bladder neck muscles (such as terazosin or tamsulosin).
• Individuals with neurological disorders that interfere with contractions or bladder function may need to learn to introduce a catheter themselves or have the device positioned permanently.

Occasionally, surgery is required to prevent the urine from passing from the bladder to the kidney and to prevent reflux nephropathy.