Development of a bladder filled with purulent material in defunctionalised bladder, i.e. due to supravesical diversion or from anuric renal failure.
Incidence is hard to define – about 5 – 20 % of defunctionalised bladders.
Pathogenesis
Accumulation of exfoliated urothelial cells that liquefies and becomes infected.
The loss of normal antegrade urine flow prevents the normal excretion of shedding urothelial cells.
Often patients are immunosuppressed due to ESRF but also diabetes etc, predisposing to infection.
Risk factors
- More common in females
- Often presents first 6 – 12 months after diversion
- Radiation
- Previous infections including fistulas
- Previous proteus infections
- Previous bladder outlet obstruction or stricture
- Previous ISC/repeated instrumentation
Irrigation of the bladder peri-operatively around time of diversion with saline, antibiotics or diluted betadine has been described.
Clinical presentation
Can be varied and a challenging diagnosis.
Suprapubic or vague lower abdominal pain associated with low grade fever most common presentation.
Malodorous or purulent urethral discharge. Drainage of purulent material on catheterisation is a key diagnostic feature.
Less common symptoms – penile pain, nausea, lethargy, anorexia, weight loss.
Examination may reveal suprapubic tenderness and fever.
Ultrasound and CT may show a full bladder with thickened bladder wall (in a patient thought to be anuric).
Common organisms are the usual urinary bugs.
Management of pyocystis
Manage sepsis as usual following CCrISP algorithm, broad spectrum IV antibiotics (consider previous cultures), fluid resuscitation.
Catheter drainage.
Bladder irrigation can be used to ensure all infection drained – not too fast for risk of spreading bacteraemia.
Prophylactic irrigation once or twice weekly may be needed going forward to prevent recurrence of pyocystis.
Surgical management with simple cystectomy can be performed to prevent recurrence.
Spence-Allan procedure – creating an iatrogenic vesico-vaginal fistula to drain bladder secretions – only in sexually inactive women.