This document describes the case of a 60-year-old male who presented with acute urinary retention and hematuria. Initial examinations and tests revealed an enlarged bladder with a suspected mass, hydroureteronephrosis, and acute kidney injury. Further cystoscopy and imaging showed the mass was actually nodular hemorrhagic cystitis rather than a true bladder mass. The patient was treated conservatively and discharged with a foley catheter. A literature review on hemorrhagic cystitis outlines its infectious and non-infectious causes.

1. The Vanishing
Bladder Mass

2. History
• Mr ASK
• 60yrs old male
• Was referred from BARC hospital at midnight
with h/o-
1) Acute retention of urine since one day
2) Gross hematuria 4-6 hours post foleys
catheterisation
(this was after draining initial 300-400 ml of
clear urine)
3) Disorientation

3. No history of –
• Traumatic catheterisation
• Bleeding diasthesis
• Lump in abdomen
Relatives on enquiry revealed 1 week history of
• Dysuria
• Oliguria
• Mod grade fever with chills
• Poor oral intake

4. • Past history-
- H/o recurrent urinary tract infection
- Features of LUTS
- Had retention of urine twice in 6 months requiring
catheterisation.
- Coronary artery disease, systemic hypertension,
old stoke
- No h/o of past kidney disease
- Was on dual antiplatelets , antihypertensives and
statins

5. On examination
• Tachycardia- 120/min
• BP- 100/70
• Gross pallor, dehydration
CNS- Disoriented, irrelevant talks
No focal neurological deficit
No s/o meningeal irritation
Per Abdomen-
Bladder palpable upto umbillicus.
No separate mass felt.

6. Investigation
• Hb- 7.1 gm% PT- 13
• TLC- 13,240/mm3 INR- 1.2
• Platelets- 2.3 lacs/mm3 aPTT- 30
• BUN- 84
• Creatinine- 6.4 mg%
• Na- 136 meq/dl
• K- 4.8 meq/dl
• Ca- 8.1 mg%
• PO4- 3.8 mg%
• UA- 7.8 mg%
• LFT- WNL

7. Provisional diagnosis
Acute retention of urine
? Bladder outlet obstruction
Hematuria - UTI
? Cystitis
? Bladder mass
Acute kidney injury with Uremic Encephalopathy
? Obstructive uropathy

8. Course post admission
• Due to poor general condition, he was shifted
to Neuro ICU, where he had one episode of
GTC.
• He was dialysed with 2 units of packed red
cells transfusion.
• Continous bladder irrigation with NS started,
inj Meropenem given suspecting ESBL

13. Portable ultrasound – Day 1
• RK- 10 * 5.5
• LK- 9.8 * 4.9
• Dilatation of bilateral pelvicalyceal system with
bilateral hydroureters throughout its course.
• Distended bladder (420 ml) with thickened wall
with deep trabeculations.
• Heterogenous predominantly hyperechoic vascular
mass of size 170 cc arising from post. and right
lateral wall of bladder. Internal echoes noted in
bladder
• Prostrate volume- 25 gm

18. Non contrast CT- KUB – Day 2
• Similar findings as ultrasound noted.
• Air densities in bladder and the mentioned
mass
• Impression of a bladder mass with associated
hematoma, would be worthwhile to obtain a
contrast study.

19. Urology consult
• Large bladder mass with BOO leading to
bilateral hydroureteronephrosis.
• Continued bladder irrigation
• Bladder mass would require cystoscopic
biopsy and excision (simple/radical
cystectomy) on later date.

20. Course in wards
• Hematuria stopped on day 4, urine output 1.5 - 2 lit/day
• Required additional 2 units PRC transfusion
• Sensorium improved , not dialysed further.
• Renal function normalised.
• Shifted to floor on day -5
• Urine Culture- E. Coli – Meropenem sensitive, contd.
• Wait continued for the credit note from BARC for
cystoscopy and bladder mass biopsy

21. Cystoscopy findings – Day 14
NODULAR HEMORRHAGIC
CYSTITIS
NO BLADDER MASS VISUALISED

22. Repeat Contrast CT KUB
• Thickened enhancing bladder wall , bilateral
Vesicoureteric junction and entire course of
ureter suggestive of cystitis and urethritis
• Bilateral kidneys normal

23. Trial of catheter removal
• Failed predischarge.
• Hence started on Urimax, Urispas
• Urodynamic studies-
Optimal capacity bladder with good compliance
Hypocontractile Detrusor
Significant post void residue (390 cc)
Discharged with silicone foleys in situ.

24. REVIEW OF LITERATURE
“ HEMORRHAGIC CYSTITIS ”

25. Hemorrhagic cystitis
Diffuse inflammatory condition of the urinary bladder due
to an infectious or noninfectious etiology resulting in
bleeding from the bladder mucosa.
a) Infections –
Bacterial (MC)- E.coli, Klebsiella, Proteus, Staph
Viral - BK, Adeno, CMV, JC, Herpes
Fungal - Candida, Aspergillus, Cryptococcus
Parasites – Schistosomia, Ecchinococus

26. b) Drugs –
Cyclophosphamide, Iphosphamide
(due to metabolite - Acrolein )
Busulphan, Thiotepa.
Penicillin and its synthetic derivatives.
Danazol, Allopurinol.
Intravesical instillation of drugs.
c) Occupation hazards –
Dyes – Aniline, toulidine
Pesticides- Chlorodimeform

27. c) Radiation - for pelvic malignancies, atleast 90 day lag
Early - obliterative endarteritis causing ischemia f/b
neovascularisation and bleeding
Late – may be beyond 10 yrs, progressive disease
associated with fibrosis, reduced capacity bladder
d) Systemic disease-
Rheumatoid arthritis
Amyloidosis
Crohn’s disease
Boon’s disease – prolonged high altitude air travel