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While hydrodistention is generally believed to be safe and is often used as a treatment for interstitial cystitis, an article "Bladder Necrosis Following Hydrodistention in Patients with Interstitial Cystitis" released in the January 2007 Journal of Urology describes a rare and devastating complication, an almost total "necrosis" of the bladder wall that occurred in three patients. Necrosis (aka tissue death) occurs when blood supply is insufficient.
Who? One man and two women between the ages of 29 and 46 had a long history of IC symptoms and had previously experienced hydrodistention with "some therapeutic response."
How was it discovered? In these incidents, both women reported severe abdominal pain immediately after the procedure. The man reported pain after his foley catheter was removed. The pain was severe requiring narcotic pain medication. Additional examinations revealed debris in the bladder. Surgical exploration discovered that the necrosis had occurred through the full thickness of the bladder wall (sparing the trigone), leaving fragile gray tissue behind. The pathology report suggested that tissue death occurred due to an obstruction or destruction of vessels supplying blood to the tissue.
How was it treated? For the two patients who underwent surgical exploration, all gray tissue was removed until healthy bleeding tissue was found. Each patient then underwent an augmentation cystoplasty. The man, unfortunately, refused further treatment and was lost to follow up.
Are complications common? The complications from hydrodistention procedures are poorly documented in the journals. According to this article, the most common are gross hematuria (bleeding) and bladder perforation. The authors state that "Bladder perforation occurs in 2 to 8% of cases and it is more likely to occur with prolonged distention and/or after biopsies." This article is the first case report of almost total bladder necrosis though one additional article revealed a case where a small area of necrosis was found after hydrodistention.
Why did it occur?? The authors report that necrosis is an unsual and rare complication and that the cause is "unknown." They suggest that the hydrodistention may have obstructed blood flow in local blood vessels of the bladder. Apparently some animal studies have shown that blood flow can decrease depending upon the volume of water used in the procedure and pressure that occurs. The authors further note that two of patients also had a chlorpactin instillation which may have contributed.
Conclusion: IC patients are often frightened by the concept of having a hydrodistention. Luckily, a hydrodistention is now less frequently used to diagnose IC/PBS in favor of other less traumatic methods such as the PUF questionnaire. But it does have an important use. A hydrodistention is required if a physician would like to conduct a biopsy. Hydrodistention clearly has some risks. At a minimum, this article suggests that combining a chlorpactin treatment with a hydrodistention, especially if the bladder has sustained any injuries during the procedure, may be unwise. The use of higher volumes and pressures during the procedure may also be a risk factor.
Dr. Deborah Lightner of the Mayo Clinic provided an official editorial comment from the Journal of Urology at the end of the article that captures our viewpoint as well. She says "Given the lack of placebo controlled trials of cystodistention or of chlorpactin for PBS, it behooves the surgeon to first do no harm." She and the authors reiterate that distention is no longer diagnostic for IC/PBS and is rarely therapeutic in the long run. Makes sense to us!
Source: Zabihi, N. et al. Bladder Necrosis Following Hydrodistention in Patients With Interstitial Cystitis, Jurol, Vol. 177, 149-152, January 2007
Who? One man and two women between the ages of 29 and 46 had a long history of IC symptoms and had previously experienced hydrodistention with "some therapeutic response."
How was it discovered? In these incidents, both women reported severe abdominal pain immediately after the procedure. The man reported pain after his foley catheter was removed. The pain was severe requiring narcotic pain medication. Additional examinations revealed debris in the bladder. Surgical exploration discovered that the necrosis had occurred through the full thickness of the bladder wall (sparing the trigone), leaving fragile gray tissue behind. The pathology report suggested that tissue death occurred due to an obstruction or destruction of vessels supplying blood to the tissue.
How was it treated? For the two patients who underwent surgical exploration, all gray tissue was removed until healthy bleeding tissue was found. Each patient then underwent an augmentation cystoplasty. The man, unfortunately, refused further treatment and was lost to follow up.
Are complications common? The complications from hydrodistention procedures are poorly documented in the journals. According to this article, the most common are gross hematuria (bleeding) and bladder perforation. The authors state that "Bladder perforation occurs in 2 to 8% of cases and it is more likely to occur with prolonged distention and/or after biopsies." This article is the first case report of almost total bladder necrosis though one additional article revealed a case where a small area of necrosis was found after hydrodistention.
Why did it occur?? The authors report that necrosis is an unsual and rare complication and that the cause is "unknown." They suggest that the hydrodistention may have obstructed blood flow in local blood vessels of the bladder. Apparently some animal studies have shown that blood flow can decrease depending upon the volume of water used in the procedure and pressure that occurs. The authors further note that two of patients also had a chlorpactin instillation which may have contributed.
Conclusion: IC patients are often frightened by the concept of having a hydrodistention. Luckily, a hydrodistention is now less frequently used to diagnose IC/PBS in favor of other less traumatic methods such as the PUF questionnaire. But it does have an important use. A hydrodistention is required if a physician would like to conduct a biopsy. Hydrodistention clearly has some risks. At a minimum, this article suggests that combining a chlorpactin treatment with a hydrodistention, especially if the bladder has sustained any injuries during the procedure, may be unwise. The use of higher volumes and pressures during the procedure may also be a risk factor.
Dr. Deborah Lightner of the Mayo Clinic provided an official editorial comment from the Journal of Urology at the end of the article that captures our viewpoint as well. She says "Given the lack of placebo controlled trials of cystodistention or of chlorpactin for PBS, it behooves the surgeon to first do no harm." She and the authors reiterate that distention is no longer diagnostic for IC/PBS and is rarely therapeutic in the long run. Makes sense to us!
Source: Zabihi, N. et al. Bladder Necrosis Following Hydrodistention in Patients With Interstitial Cystitis, Jurol, Vol. 177, 149-152, January 2007
) things to think about. My uro (I had at the time) when I watched him do the inoffice distention, as soon as the water going into my bladder went from a steady stream to a dribble he stopped it. I was starting to feel pretty uncomfortable but he got the reading. When I was under, as soon as the dribble became drops he immediately stopped. (I am hoping, at least that was what I was told..) when the water came out, he could see the "terminal pinking"...(as I said, he really didn't like to "pin this awful disease" on anyone so he was playing conservative) From where he could see the bladder irritated, he took biopsys. (ouch) But he told me in the hospital he didn't think I had it. I'm just trying to figure out how he would have gotten it would it not have been for the distention, and I do know some people have had relief from distention. (I for one would not want to undergo that again...but I do think I was cared for, but what do I know, I was unconscious!!!) That uro did refer me to a very good female urologist who has become my buddy, although we disagree on some aspects of treatment. (The fact that she let's me disagree without getting her panties in a wad has made me respect her 100% more)
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