American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
An unusual adverse event of acute urinary retention: ST-segment elevation myocardial infarction Acute urinary retention (AUR) is a common urologic emergency, often the result of benign prostatic hyperplasia. Transurethral catheterization provides immediate relief without clinically significant complications. We present a case of ST-segment elevation myocardial infarction (STEMI) shortly after urethral catheterization in a 73-year-old man with AUR. The patient visited our emergency department complaining of inability to pass urine and lower abdominal pain. After placement of a Foley catheter, his symptoms quickly improved. However, 2 minutes later, he complained of chest discomfort. An electrocardiogram showed STsegment elevation in leads V1 to V6. Urgent coronary angiography was performed and revealed 99% stenosis of the left anterior descending artery. Percutaneous coronary intervention was then performed. He was symptom-free after percutaneous coronary intervention. We concluded that a patient with AUR can develop STEMI after urinary catheterization. Careful history taking is necessary to identify underlying problems for treatment of AUR. We should consider the occurrence of STEMI if a patient has chest discomfort after decompression of an obstructed urinary bladder. Acute urinary retention (AUR) is a common urologic condition in the emergency department and is usually treated safely with urethral catheterization. Blood pressure sometimes decreases after emptying of the obstructed bladder, but it does not progress to serious clinical consequences. We present a case of AUR in which ST-segment elevation myocardial infarction (STEMI) occurred soon after urethral catheterization. A 73-year-old man with benign prostatic hyperplasia (BPH) visited our emergency department complaining of inability to pass urine and low abdominal pain, but he had no fever or chest discomfort. He had AUR one time before. On examination, blood pressure was 202/112 mm Hg, heart rate was 93 beats/min, and his lower abdomen was distended. Abdominal ultrasound showed a markedly enlarged bladder. After placement of a 12gauge French Foley catheter, straw-colored urine was drained and his symptoms quickly improved. However, 2 minutes later, he complained of chest discomfort. On reexamination, blood pressure was 160/80 mm Hg, heart rate was 95 beats/min, and his lower abdomen was flat. An electrocardiogram showed ST-segment elevation in leads V1 to V6 (Fig. 1), and an echocardiogram revealed hypokinesia of the anterior wall. The initial treatment was 100 mg aspirin, 300 mg clopidogrel, and infusion of unfractionated heparin, and urgent coronary angiography was performed. The coronary angiography showed 99% stenosis of the left anterior descending artery (Fig. 2), and percutaneous coronary intervention (PCI) was performed with thrombus aspiration and coronary stent implantation. Symptom-to-balloon time was 40 minutes. His chest discomfort disappeared and ST-segment elevation was resolved. In laboratory tests at the onset of chest discomfort, troponin T was negative and levels of creatine kinase (CK) and CK-MB were 76 IU/L (reference range, 62-287 IU/L) and 12 IU/L (reference range, 2-24 IU/L), respectively. Six hours later, the
levels of CK and CK-MB were slightly elevated at 233 and 25 IU/L, respectively. After the hospitalization, it was revealed that he had experienced intermittent chest discomfort for a few weeks but did not see a doctor regularly and he had smoked 20 cigarettes per day for 50 years. The course of the patient suggested 2 important clinical issues. A patient with AUR can develop STEMI after urinary catheterization, and careful history taking is necessary to identify underlying problems for treatment of AUR. First, a patient with AUR can develop STEMI after urinary catheterization. Initial management of AUR is drainage of the bladder by a Foley catheter. Complications related to urinary catheterization include hematuria, hypotension, and postobstructive diuresis. Hypotension sometimes occurs but usually normalizes spontaneously with no serious clinical consequences [1]. Traditionally, gradual decompression of the extended bladder has been believed to minimize the risk of hypotension. However, randomized controlled trial comparing the effect of gradual decompression and rapid decompression showed no significant difference in the occurrence of hypotension, and there were no patients who had circulatory collapse after urethral catheterization [2]. This case is the first reported case of STEMI after urethral catheterization in a patient with AUR. Acute triggers of myocardial infarction include mental, physical, and environmental stressors [3]. In this case, acute pain and fluctuation of blood pressure contributed to the occurrence of STEMI. In laboratory tests, cardiac biomarkers before PCI were negative, and CK and CK-MB levels after PCI were only slightly increased, indicating that STEMI was provoked by AUR and urethral catheterization. Second, careful history taking is necessary to identify underlying problems for treatment of AUR. Generally, healthy patients with AUR, especially BPH, are treated easily and can be discharged home with urologist's follow-up. However, the mortality rate in the first year for men admitted to hospital with AUR is high and increases with age and comorbidities, even in BPH patients. Also, about half of the deaths after AUR occur within the first 90 days. This high mortality rate seems to be linked mainly to underlying comorbidities, especially cardiovascular diseases [4,5]. Therefore, men with AUR should undergo a comprehensive investigation, not just urethral catheterization, for identification of underlying diseases. Our patient had intermittent chest discomfort before visiting our emergency department. If we had screened for nonurologic underlying comorbidities, more careful treatment could have been performed. In conclusion, a patient with AUR can develop STEMI after urinary catheterization, and careful history taking is necessary to identify the underlying problems for treatment of this condition. We must be aware of STEMI if a patient has chest discomfort after decompression of an obstructed urinary bladder. Acute urinary retention is a common problem among elderly men in the emergency department. We always routinely drain the bladder by a Foley catheter and discharge them from the emergency department. This case suggested that we must treat AUR
http://dx.doi.org/10.1016/j.ajem.2015.06.042 0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Ichiba T, An unusual adverse event of acute urinary retention: ST-segment elevation myocardial infarction, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.06.042
2
T. Ichiba / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Fig. 1. Electrocardiogram in the patient showed marked ST elevations in leads V1 to V6 and ST depressions in leads II, III, and aVF.
more carefully and consider not only urologic problems but also underlying cardiovascular comorbidities. Toshihisa Ichiba MD Department of Emergency Medicine, Hiroshima City Hospital Hiroshima-shi, Hiroshima, Japan Hiroshima City Hospital, 7-33 Motomachi, Naka-Ku Hiroshima-shi, Hiroshima 730-8518, Japan Tel.: +81 82 221 2291; fax: +81 82 223 5514 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.06.042
References [1] Nyman MA, Schwenk NM, Silverstein MD. Management of urinary retention: rapid versus gradual decompression and risk of complications. Mayo Clin Proc 1997;72: 951–6. [2] Boettcher S, Brandt AS, Roth S, et al. Urinary retention: benefit of gradual bladder decompression—myth or truth? A randomized controlled trial. Urol Int 2013;91: 140–4. [3] Newby DE. Triggering of acute myocardial infarction: beyond the vulnerable plaque. Heart 2010;96:1247–51. [4] Armitage JN, Sibanda N, Cathcart PJ, et al. Mortality in men admitted to hospital with acute urinary retention: database analysis. BMJ 2007;335:1199–202. [5] Kirby RS, Kirby M. The urologist as an advocate of men's health: 10 suggested steps toward helping patients achieve better overall health. Urology 2005;66: 52–6.
Fig. 2. Coronary angiography in the right anterior oblique view showed a filling defect (arrow) in the left anterior descending artery.
Please cite this article as: Ichiba T, An unusual adverse event of acute urinary retention: ST-segment elevation myocardial infarction, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.06.042
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
An unusual adverse event of acute urinary retention: ST-segment elevation myocardial infarction Acute urinary retention (AUR) is a common urologic emergency, often the result of benign prostatic hyperplasia. Transurethral catheterization provides immediate relief without clinically significant complications. We present a case of ST-segment elevation myocardial infarction (STEMI) shortly after urethral catheterization in a 73-year-old man with AUR. The patient visited our emergency department complaining of inability to pass urine and lower abdominal pain. After placement of a Foley catheter, his symptoms quickly improved. However, 2 minutes later, he complained of chest discomfort. An electrocardiogram showed STsegment elevation in leads V1 to V6. Urgent coronary angiography was performed and revealed 99% stenosis of the left anterior descending artery. Percutaneous coronary intervention was then performed. He was symptom-free after percutaneous coronary intervention. We concluded that a patient with AUR can develop STEMI after urinary catheterization. Careful history taking is necessary to identify underlying problems for treatment of AUR. We should consider the occurrence of STEMI if a patient has chest discomfort after decompression of an obstructed urinary bladder. Acute urinary retention (AUR) is a common urologic condition in the emergency department and is usually treated safely with urethral catheterization. Blood pressure sometimes decreases after emptying of the obstructed bladder, but it does not progress to serious clinical consequences. We present a case of AUR in which ST-segment elevation myocardial infarction (STEMI) occurred soon after urethral catheterization. A 73-year-old man with benign prostatic hyperplasia (BPH) visited our emergency department complaining of inability to pass urine and low abdominal pain, but he had no fever or chest discomfort. He had AUR one time before. On examination, blood pressure was 202/112 mm Hg, heart rate was 93 beats/min, and his lower abdomen was distended. Abdominal ultrasound showed a markedly enlarged bladder. After placement of a 12gauge French Foley catheter, straw-colored urine was drained and his symptoms quickly improved. However, 2 minutes later, he complained of chest discomfort. On reexamination, blood pressure was 160/80 mm Hg, heart rate was 95 beats/min, and his lower abdomen was flat. An electrocardiogram showed ST-segment elevation in leads V1 to V6 (Fig. 1), and an echocardiogram revealed hypokinesia of the anterior wall. The initial treatment was 100 mg aspirin, 300 mg clopidogrel, and infusion of unfractionated heparin, and urgent coronary angiography was performed. The coronary angiography showed 99% stenosis of the left anterior descending artery (Fig. 2), and percutaneous coronary intervention (PCI) was performed with thrombus aspiration and coronary stent implantation. Symptom-to-balloon time was 40 minutes. His chest discomfort disappeared and ST-segment elevation was resolved. In laboratory tests at the onset of chest discomfort, troponin T was negative and levels of creatine kinase (CK) and CK-MB were 76 IU/L (reference range, 62-287 IU/L) and 12 IU/L (reference range, 2-24 IU/L), respectively. Six hours later, the
levels of CK and CK-MB were slightly elevated at 233 and 25 IU/L, respectively. After the hospitalization, it was revealed that he had experienced intermittent chest discomfort for a few weeks but did not see a doctor regularly and he had smoked 20 cigarettes per day for 50 years. The course of the patient suggested 2 important clinical issues. A patient with AUR can develop STEMI after urinary catheterization, and careful history taking is necessary to identify underlying problems for treatment of AUR. First, a patient with AUR can develop STEMI after urinary catheterization. Initial management of AUR is drainage of the bladder by a Foley catheter. Complications related to urinary catheterization include hematuria, hypotension, and postobstructive diuresis. Hypotension sometimes occurs but usually normalizes spontaneously with no serious clinical consequences [1]. Traditionally, gradual decompression of the extended bladder has been believed to minimize the risk of hypotension. However, randomized controlled trial comparing the effect of gradual decompression and rapid decompression showed no significant difference in the occurrence of hypotension, and there were no patients who had circulatory collapse after urethral catheterization [2]. This case is the first reported case of STEMI after urethral catheterization in a patient with AUR. Acute triggers of myocardial infarction include mental, physical, and environmental stressors [3]. In this case, acute pain and fluctuation of blood pressure contributed to the occurrence of STEMI. In laboratory tests, cardiac biomarkers before PCI were negative, and CK and CK-MB levels after PCI were only slightly increased, indicating that STEMI was provoked by AUR and urethral catheterization. Second, careful history taking is necessary to identify underlying problems for treatment of AUR. Generally, healthy patients with AUR, especially BPH, are treated easily and can be discharged home with urologist's follow-up. However, the mortality rate in the first year for men admitted to hospital with AUR is high and increases with age and comorbidities, even in BPH patients. Also, about half of the deaths after AUR occur within the first 90 days. This high mortality rate seems to be linked mainly to underlying comorbidities, especially cardiovascular diseases [4,5]. Therefore, men with AUR should undergo a comprehensive investigation, not just urethral catheterization, for identification of underlying diseases. Our patient had intermittent chest discomfort before visiting our emergency department. If we had screened for nonurologic underlying comorbidities, more careful treatment could have been performed. In conclusion, a patient with AUR can develop STEMI after urinary catheterization, and careful history taking is necessary to identify the underlying problems for treatment of this condition. We must be aware of STEMI if a patient has chest discomfort after decompression of an obstructed urinary bladder. Acute urinary retention is a common problem among elderly men in the emergency department. We always routinely drain the bladder by a Foley catheter and discharge them from the emergency department. This case suggested that we must treat AUR
http://dx.doi.org/10.1016/j.ajem.2015.06.042 0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Ichiba T, An unusual adverse event of acute urinary retention: ST-segment elevation myocardial infarction, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.06.042
2
T. Ichiba / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Fig. 1. Electrocardiogram in the patient showed marked ST elevations in leads V1 to V6 and ST depressions in leads II, III, and aVF.
more carefully and consider not only urologic problems but also underlying cardiovascular comorbidities. Toshihisa Ichiba MD Department of Emergency Medicine, Hiroshima City Hospital Hiroshima-shi, Hiroshima, Japan Hiroshima City Hospital, 7-33 Motomachi, Naka-Ku Hiroshima-shi, Hiroshima 730-8518, Japan Tel.: +81 82 221 2291; fax: +81 82 223 5514 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.06.042
References [1] Nyman MA, Schwenk NM, Silverstein MD. Management of urinary retention: rapid versus gradual decompression and risk of complications. Mayo Clin Proc 1997;72: 951–6. [2] Boettcher S, Brandt AS, Roth S, et al. Urinary retention: benefit of gradual bladder decompression—myth or truth? A randomized controlled trial. Urol Int 2013;91: 140–4. [3] Newby DE. Triggering of acute myocardial infarction: beyond the vulnerable plaque. Heart 2010;96:1247–51. [4] Armitage JN, Sibanda N, Cathcart PJ, et al. Mortality in men admitted to hospital with acute urinary retention: database analysis. BMJ 2007;335:1199–202. [5] Kirby RS, Kirby M. The urologist as an advocate of men's health: 10 suggested steps toward helping patients achieve better overall health. Urology 2005;66: 52–6.
Fig. 2. Coronary angiography in the right anterior oblique view showed a filling defect (arrow) in the left anterior descending artery.
Please cite this article as: Ichiba T, An unusual adverse event of acute urinary retention: ST-segment elevation myocardial infarction, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.06.042
