CASE REPORT Open Access
Distended bladder presenting with constipation
and venous obstruction: a case report
Anu Sharma* and Vijay Naraynsingh
Abstract
Introduction: A distended urinary bladder has been known to cause venous obstruction or rarely bowel
obstruction. We report the first case in the literature in which urinary bladder distension presented with both
venous obstruction and constipation. This is an unusual presentation of urinary bladder distension and serves to
broaden our differential diagnoses for a patient with clinical venous obstruction.
Case presentation: An 83-year-old man of African descent presented with constipation and bilateral lower limb
edema. A huge abdominal mass was evident which was a large, distended urinary bladder confirmed by
computed tomography. Promptly after urethral catheterization, both constipation and lower limb edema resolved.
Conclusions: To the best of our knowledge distended urinary bladder causing both constipation and lower limb
edema has never previously been reported. Analysis of the literature revealed several factors resulting in the
patient’s presentation. A high level of suspicion for urinary bladder distension must be maintained for prompt
diagnosis and to avoid improper management.
Introduction
Chronically distended urinary bladder is diagnosed in
only 0.8% [1] of elderly men annually. A distended urin-
ary bladder causing inferior vena cava and external iliac
venous obstruction has been commonly described [2]
but is infrequently encountered. Its presentation with
bilateral pedal edema poses a clinical dilemma as it can
be easily misdiagnosed as deep venous thrombosis or
congestive heart failure. Bladder distension causing con-
stipation, however, is very rare with few reports in the
literature. To the best of our knowledge and after exten-
sive literature review, we present the first case of
chronic bladder distension presenting with both consti-
pation and bilateral pedal edema.
Case Presentation
An 83-year-old diabetic man of African descent pre-
sented with a four week history of constipation and a
two week history of obstipation to our emergency
department. He noticed painless increasing abdominal
distension with concomitant leg edema. He denied any
history of vomiting, fever or anorexia. He used several
laxative concoctions with no relief. He revealed a long
standing history of incontinence at night with hesitancy
and poor stream but denied frequency and strangury.
He had been diabetic and on treatment for 25 years
with a history of diabetic retinopathy.
On admission, he was tachycardic (pulse 102 beats per
minute) with a blood pressure of 160/85 mm Hg and
random blood glucose of 511 mg/dL (28.39 mmol/L).
He had bilateral pitting edema up to mid leg. A large
abdominal mass extended out of the pelvis just below
the xiphisternum (Figure 1). The mass was dull to per-
cussion and tender on palpation. His bowel sounds were
hyperactive. A symmetrically enlarged, smooth, rubbery
prostate was felt on palpation with a bulge above the
prostate. All other examinations were normal. Blood test
results revealed a normochromic normocytic anemia
(hemoglobin 10.4 g/dL, MCV 90.9 fL) with renal impair-
ment (blood urea nitrogen (BUN) 30 mg/dL, creatinine
1.8 mg/dL) and a normal prostate-specific antigen (PSA)
level (4 ng/mL). Computed tomography (CT) of the
abdomen was ordered with a working diagnosis of
bowel obstruction likely secondary to a tumor in mind.
The results showed gross distension of the urinary blad-
der above the level of the umbilicus with marked bilat-
eral hydronephrosis and hydroureter (Figures 2 and 3).
* Correspondence: anu.sharma25@gmail.com
Faculty of the Clinical Surgical Sciences, University of the West Indies, St.
Augustine, Trinidad & Tobago
Sharma and Naraynsingh Journal of Medical Case Reports 2012, 6:34
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CASE REPORTS
© 2012 Sharma and Naraynsingh; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Figure 1 Large abdominal mass extending to the epigastric region. The photograph shows the large abdominal mass found on general
inspection of the abdomen. It arose out of the pelvis and was felt up to 4 cm below the xiphisternum.
Figure 2 Computed tomography scan of the abdomen showing a distended urinary bladder. Computed tomography image of the
abdomen found a grossly distended urinary bladder extending out of the pelvis.
Sharma and Naraynsingh Journal of Medical Case Reports 2012, 6:34
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Page 2 of 4
A Foley catheter was inserted which yielded 5000 ml
of clear urine. On the following day the patient passed
flatus and his leg edema had decreased markedly. He
passed stool on the third day with the aid of a supposi-
tory. The catheter was removed at the patient’s request
and he was sent home passing urine freely. His renal
impairment resolved (creatinine (Cr) 1.5 mg/dL) on dis-
charge. He was non-compliant with follow up.
One week later, he returned to the emergency depart-
ment with constipation and bilateral pedal edema. A
Foley catheter was re-inserted and 3100 ml of clear
urine was drained. The edema completely resolved
thereafter and the patient was sent home with the cathe-
ter in situ.
Discussion
Due to its fixed volume of the pelvis, bladder distension
can compress adjacent structures. It has been known to
compress the inferior vena cava [2] and both right and
left external iliac veins [3]. In a few cases, this had led
to deep vein thrombosis formation [3]. Hopkins et al.
[4] demonstrated elevated pressures in the femoral
veins, more so in cases with urinary retention with blad-
der capacities more than 1000 ml. Those patients with
leg edema were found to have the highest femoral vein
pressures. This can account for the lower limb edema
found in our case as well as the numerous case reports,
albeit small incidence, of venous stasis secondary to
bladder distention.
A distended bladder can also compress the recto-sig-
moid colon. Kleinhaus et al. [5] described four cases of
pseudostenosis of the recto-sigmoid colon due to com-
pression by a dilated urinary bladder. Rarely subacute
[6] or acute [7] intestinal obstruction can occur. In this
case, our patient’s clinical presentation was consistent
with subacute intestinal obstruction.
In addition to the compressive effect of the distended
bladder, constipation would be worsened by the recto-
vesicourethral reflex. Buntzen et al. [8] showed that anal
pressure was markedly increased and rectal motility was
absent as bladder distention worsened. This was attribu-
ted to the excitatory ‘vesico-anal’ reflex produced at the
spinal cord level. In this case, there was marked bladder
distention with a volume of 5000 mLs. Not only was
this bladder large enough to compress the colon, but
the gross distention would have caused physiological
reflex fecal stasis.
Our patient’s long standing diabetic status also con-
tributed. Similar to the case presented by Ghebontni et
al. [6], our patient had long standing diabetes mellitus
and prostatic disease. His urinary distension was primar-
ily due to benign prostatic hypertrophy but was signifi-
cantly worsened by diabetic neuropathy. In evaluating
the diabetic neurogenic bladder, it was found that 37.5%
Figure 3 Computed tomography scan of the abdomen showing bilateral hydronephrosis and hydroureters. Computed tomography
image showing bilateral hydronephrosis and hydroureters due to bladder outlet obstruction. The patient’s creatinine was significantly elevated
from post-renal failure. After catheterization, creatinine normalized.
Sharma and Naraynsingh Journal of Medical Case Reports 2012, 6:34
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Page 3 of 4
[9] of patients had diminished bladder sensation and/or
impaired detrusor contractility. In long-standing dia-
betes mellitus (more than 10 years) significantly reduced
basal and anal squeeze pressures and reduced amplitude
slow waves were measured [10]. These findings suggest
that both the patient’s painless bladder distention and
constipation could also be attributed to type two dia-
betes mellitus. The relief of symptoms after catheteriza-
tion however, suggests that his diabetes played more of
an aggravating rather than a causative factor.
Conclusion
This was an unusual case and first report of a patient
presenting primarily for obstipation who was found to
have both a clinical subacute intestinal obstruction and
lower limb edema due to gross urinary bladder disten-
tion aggravated by complicated diabetes mellitus. His
urinary symptoms were minimal, leading to his diagno-
sis by physical and radiological assessments. A high
index of suspicion must be maintained for prompt diag-
nosis and to avoid improper management.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompany-
ing images. A copy of the written consent is available
for review by the Editor-in-Chief of this journal.
Authors’ contributions
AS and VN analyzed the patient’s data and provided medical assistance to
the case. AS performed the literature search and wrote the manuscript. VN
edited the manuscript. Both authors read and approved the manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 28 September 2011 Accepted: 24 January 2012
Published: 24 January 2012
References
1. Meigs JB, Barry MJ, Giovannucci E, Rimm EB, Stampfer MJ, Kawachi I:
Incidence rates and risk factors for acute urinary retention: the health
professionals follow up study. J Urol 1999, 162:376-382.
2. Davis GC, Aronson NE, Moul JW: Inferior vena cava compression due to
massive hydronephrosis from bladder outlet obstruction. Tech Urol 2000,
6:226-227.
3. Liu D, Torreggiani WC, Munk PL, Ho S, Morris C, Legiehn G: Iliofemoral
deep vein thrombosis secondary to venous compression by a massively
distended bladder. Journal of the Hong Kong College of Radiologists 2002,
5:43-46.
4. Hopkins WF, Mattens WA, Pierce JM: Increased venous pressure and
edema in the lower extremities secondary to urinary retention. Invest
Urol 1965, 3:117-121.
5. Kleinhaus U, Kaftori J: Rectosigmoid pseudostenosis due to urinary
retention. Radiology 1978, 127:645-647.
6. Ghebontni L, el-Khoury J, Nguyen-Khaç E, Bernard J, Grenier P, Bellin MF:
Subacute intestinal obstruction due to bladder distention. J Radiol 1998,
79:880-882.
7. Shaked G, Czeiger D: Distended urinary bladder and diverticulum-a rare
cause of large bowel obstruction. Am J Surg 2009, 197:e23-24.
8. Buntzen S, Nordgren S, Delbro D, Hulten L: Anal and rectal motility
responses to distension of the urinary bladder in man. Int J Colorect Dis
1995, 10:148-151.
9. Koubaa S, Ben Salah FZ, Miri I, Ghorbel S, Lebib S, Dziri C, Rokbani L:
Neurogenic bladder in diabetes mellitus. Tunis Med 2009, 87:279-282.
10. Epanomeritakis E, Koutsoumbi P, Tsiaoussis I, Ganotakis E, Vlata M,
Vassilakis JS, Xynos E: Impairment of anorectal function in diabetes
mellitus parallels duration of disease. Dis Colon Rectum 1999,
42:1394-1400.
doi:10.1186/1752-1947-6-34
Cite this article as: Sharma and Naraynsingh: Distended bladder
presenting with constipation and venous obstruction: a case report.
Journal of Medical Case Reports 2012 6:34.
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