Description

A middle-aged man presented with increased abdominal girth over 6–9 months, associated with pain in the right upper quadrant and flanks. History was significant for a non-seminomatous testicular cancer in his teens with left orchiectomy, aortic node dissection and 1 week of chemotherapy. On examination, the abdomen was grossly distended and non-tender, with positive fluid wave and dullness to percussion. At an outside facility, laboratory values were within normal limits, including tumour markers, and ultrasound demonstrated what was believed to be a large amount of ascites and possible pancreatic mass. CT clarified this as a slightly complex-appearing cystic mass filling the entire abdomen and pelvis. He underwent an aspiration of 5 litres, and cytology of the fluid demonstrated spermatocytes. At our institution, MRI showed a markedly distended urinary bladder, measuring 29 × 26 × 12 cm (figures 1 and 2). At cystoscopy, 7 litres of urine was drained and he has since initiated self-intermittent catheterisation. Urodynamic study with cystoscopy at 3-month follow-up showed an atonic and very floppy trabeculated bladder without any prostatic obstruction. A diagnosis of idiopathic neurogenic bladder has been made.

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Figure 1

MRI coronal view showing the urinary bladder occupying the entire abdominal cavity.

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Figure 2

MRI transverse view at the level of L3 showing (A) the urinary bladder compacting intra-abdominal structures, (B) the ascending colon, (C) the descending colon and (D) compressed small bowel.

Neurogenic bladder can be caused by any number of conditions that disrupt the coordinated interaction of motor and sensory inputs of both the autonomic and somatic nervous systems. Causes include multiple sclerosis, spinal cord injury, diabetes mellitus, Parkinson's disease, amyotrophic lateral sclerosis or iatrogenic injury from spinal or pelvic surgery.1 Of note, chemotherapy with vincristine has been known to cause bladder neuropathy due to neurotoxicity and could have played a role in our patient, although this cause is extremely rare and unlikely given the delayed onset of bladder dysfunction from time of chemotherapy.2 In addition, our patient's previous chemotherapeutic regimen is remote and unclear.