DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Urinary retention with incontinence, rule out hypotonic bladder, rule out sensory paralytic neuropathic bladder.
POSTOPERATIVE DIAGNOSES:
1. Possible hypotonic bladder or sensory paralytic bladder.
2. No urinary incontinence with a high residual of 600 mL.
3. Normal-appearing bladder mucosa.
PROCEDURE PERFORMED:
1. Cystometric study.
2. Cystoscopy.
3. Urethral dilatation.
4. Pelvic examination.
SURGEON: John Doe, MD
SEDATION: Local anesthesia.
DESCRIPTION OF PROCEDURE: The patient was brought to the cystoscopy suite and the procedure was carried out under local anesthesia. The patient was complaining of low back pain and sacral pain, hence she was allowed to place her legs in the Allen stirrups on the regular operating room table so that the legs were placed according to her pain tolerance. Her genitals were prepped with Betadine and draped in the usual fashion with sterile drapes. There was no urinary incontinence noted and a Bard cystometric apparatus was used. A red rubber catheter was inserted into the bladder. There was residual urine of 600 mL, amber yellow urine, sent for culture and sensitivity.
The fiberoptic probe was inserted through the red rubber catheter and sterile water was run in at a constant rate. The first desire to urinate was not really felt until about 678 mL when the bladder pressure was about 11 cm. There was no definite urge to void. Encouraged the patient to void when the bladder capacity was about 726 mL, and with straining the bladder, pressure reached 22 cm. With vigorous straining and Valsalva at 738 mL, the bladder pressure was 35 cm. There were no uninhibited contractions, and there was no urinary leak around the catheter.
At this time, the catheter was removed. The patient was made to cough. There was no leak of urine in the supine position with coughing. It appears that she has sensory impaired neuropathic bladder rather than hypotonicity as the bladder pressure could be achieved to 22 cm. By the patient attempting to void and by straining, it reached up to 35 cm.
At this time, the urethra was anesthetized with 20 mL of 2% lidocaine jelly, and after about 5 minutes, a 21 French ACMI cystoscope was inserted into the bladder. The bladder was examined with 70 degree lens followed by Foroblique lens. The bladder mucosa was normal. There was 0 to 1+ trabeculation. No diverticula, no calculi, and no tumors noted. Ureteral orifices were small and normally located. Effluxes were clear. There was no cystocele. There was no gross evidence of urinary tract infection. Urethral mucosa was normal. Urethra was somewhat tight and snug around the scope, and hence the urethra was dilated with Walther female urethral dilators from 24 to 30 French. The bladder was emptied and vaginal examination was performed, and this revealed normal urethrovesical angle. No cystocele noted. The uterus was small and atrophic. No masses in the parametrium. The patient tolerated the procedure well. She was transferred to her room in good condition.
In summary, the patient seems to have a sensory impaired neuropathic bladder. The bladder pressure appears to be reasonably low normal range. The bladder mucosa was normal. No cystocele and no urinary leaks. The plan would be to encourage the patient for timed voiding q.3 hours during the day and q.4 hours at night irrespective of her bladder sensation, as the bladder sensations are unreliable. We will continue the Flomax and measure the postvoid residual. If that is over 200 mL, will keep Foley in for additional 5 to 7 days, by which time the Flomax might work effectively in helping her to urinate with low residuals. This was explained to the patient in detail and importance of timed voiding q.3 hours during the day and q.4 hours at night irrespective of her bladder sensations, which cannot be relied upon, were all thoroughly explained to the patient.
