Neurosyphilis, one rarely seen cause of neurogenic bladder

Göksel BAYAR,Sedat ÇAKMAK,Sibel GÜMÜŞ,Çiğdem DÖNDAR,Fatma Münevver GÖKYİĞİT,Serdar ARISAN

Özet

On altıncı yüzyılda Avrupayı kasıp kavuran sifilizin, penisilinin keşfiyle 1940 yılından sonra insidansı hızla düşmüştür. Penisilin çağından sonra nadir görülen sifilizin dördüncü evresi olan nörosifiliz ve nörojen mesane gelişmiş bir hastayı paylaşmayı amaçladık. Kırk altı yaşında erkek hasta unutkanlık, nöbet geçirme ve idrar kaçırma şikayetiyle eşi tarafından acil servise getirildi. Nöroloji kliniğine yatırılan hastada yapılan incelemede beyin omurilik sıvısı ve kanda treponema pallidum hemagglutination (TPHA) değerinin yüksek titrede pozitif olması üzerine nörosifiliz tanısı kondu. Yapılan dolum sistometrisinde taşma inkontinansından önceki maksimum mesane kapasitesinin 490 mL olduğu görüldü. İlk idrar hissinin 350 mL hacim ve 26 cm H2O basınçta, idrara sıkışıklık hissinin 460 mL hacim 35 cm H2O basınçta ancak oluştuğu görüldü. Mesanenin duyu hissinde hasar oluşmaya başladığı; ancak halen hissin tamamen kaybolmadığı görüldü. 300 mL hacimde mesane içi basıncın arttığı ve işlemin sonun doğru 40 cm H2O basıncını geçtiği görüldü. Mesane kompliansının 12,4 mL/ cm H2O olduğu ve orta düzeyde komplians kaybı olduğuna karar kılındı. Basınç akım çalışmasında 2 dakika boyunca miksiyon için teşvik edilen hastanın ancak karın içi basıncını artırarak miksiyon yapabildiği ve detrusör basınıcının hiç artmadığı görüldü. Bu haliyle hiposensitif ve akontraktil mesane tanısı kondu. Günde dört kez temiz aralıklı kateterizasyon (TAK) ve oral antikolinerjik tedavi başlandı. Nörosifiliz günümüzde nadir görülen bir hastalıktır. Nörosifilize bağlı gelişen nörojen mesaneyse üroloji pratiğinde çok daha nadir görülmektedir. Böyle bir hastayla karşılaşıldığında mesane fonksiyonları hakkında bilgi sahibi olunmak için ürodinamik değerlendirme yapılmalı; mesane boynu rezeksiyonu, üriner diversiyon ve TAK arasında bir seçim yapılmalıdır.

Abstract

With the exploration of penicillin, incidents of syphilis, which swept the Europe during the 16th century, decreased after 1940. Neurogen bladder arising from neurosyphilis was seen frequently before the penicillin period. We aimed to share a patient who has this rarely seen association. A 46-year-old male patient was admitted to a neurology clinic because of convulsion, dementia, and incontinence. No lesion determined in brain at magnetic resonance study. In the cerebrospinal fluid investigation, an increase in the number of leukocytes with lymphocytes and amount of protein was determined. Based on high positive treponema palladium hemagglutination assay (TPHA) test in the cerebrospinal fluid and blood, the presence of suspect sexual intercourse history, and occurrence of eruption on hands and feet that cleared up 10 years ago, a neurosyphilis diagnosis was made, and 6x4 M IU/d units iv penicillin treatment was applied for 21 days. After the completion of the patients treatment in the neurology clinic, further examination was decided, because it was thought that neurogen bladder arising from neurosyphilis might develop because of the presence of urinary incontinence and pollakiuria complaints. At the beginning, uroflowmetry was worked to be done; however, the patient could not make enough (at least 150 mL) micturation. Thereupon, we decided to do filling cystometry and pressure-flow study. It was seen in the ultrasonography that bladder volume was 500 mL, thickness of the bladder wall was at normal level, prostate volume was 20 cc, and kidneys were bilaterally normal. It was seen that residual urine was approximately 400 cc after micturition. In filling cystometry, it was seen that maximum bladder capacity before the overflow incontinence was 490 mL. It was seen that the first urinary feeling occurred at 350 mL of volume and 26 cm H2O of pressure; first urge to void feeling occurred at 460 mL volume and 35 cm pressure. It was seen that sense of bladder started to get damaged; however, the sense was not completely gone yet. It was seen that intra-vesicular pressure increased at 300 mL of volume and was more than 40 cm H2O of pressure at end of study. It was decided that the bladder compliance was 12.4 mL/cm H 2O and that there was a medium-level loss of compliance. It was seen at the pressure- flow study that the patient who was encouraged to micturate for 2 minutes could only micturate by increasing intra-abdominal pressure, and detrusor pressure did not increase. As is, a hyposensitive and acontractile bladder diagnosis was made. It was thought that aseptic intermittent catheterization (AIC) and oral anticholinergic treatment were appropriate for the patient. Neurosyphilis is a rarely seen disease nowadays. Neurogen bladder arising from neurosyphilis is much rare in urology practices. When encountering a patient with this disease, urodynamic assessment should be done in order to have an idea about bladder functions; a choice should be made among bladder neck resection, urinary diversion and AIC.