Is there a relationship between bladder outlet obstruction due to benign prostatic hyperplasia and pulmonary thromboembolism? "Beyond the Abstract," by Roger W. Byard, MD

BERKELEY, CA (UroToday.com) - Pulmonary thromboembolism continues to be a significant cause of morbidity and mortality in Western countries.

Most often arising in the deep veins of the leg, and less often within pelvic veins, there are a number of predisposing factors which act as part of Virchow’s triad to increase the risk of clotting either by i) slowing blood flow, ii) creating endothelial damage, or iii) causing hypercoagulability. Practically, the two most important components of the triad are blood stasis and hypercoagulability.[1,2] All ages are at risk.[3]

Hypercoagulable states may be inherited, as in the thrombophilias factor V Leiden, protein C and protein S deficiencies, or acquired, associated with disseminated malignancies or infections. Blood stasis may result from immobility arising from stroke with extremity paralysis, limb immobilization following injury or surgery, or from external compression of pelvic or femoral veins.[4] It is this latter mechanism that may link some cases of prostatic hyperplasia to deep venous thrombosis,[1,2] as it is well recognized that a range of benign pelvic masses may cause lower limb venous stasis with the attendant risk of thrombosis and embolic sequelae.[2]

Although the current study did not show any significant increase in incidence of prostatic hyperplasia and bladder enlargement in 60 cases of fatal pulmonary thromboembolism compared to controls1, isolated reports have documented obstruction to pelvic venous return from external pressure arising from massively distended bladders.[5, 6, 7, 8, 9, 10] This was related most often to benign prostatic hyperplasia with bladder outlet obstruction, and less often to neurogenic bladder. Significant pressure on pelvic veins occurs when the bladder volume exceeds 300mls.[5] While it is possible that the occurrence of benign prostatic hyperplasia, bladder enlargement, and pulmonary thromboembolism is purely coincidental, related to the increasing incidence of these phenomena with age, it may also be that pelvic venous flattening from an enlarged bladder may act as a risk modifier. That is, the risk of deep venous thrombosis in individuals who have significant comorbidities that predispose to thrombosis may be increased if there is additional compression of the pelvic veins. Conditions that increase the risk of deep venous thrombosis and pulmonary thromboembolism include cardiorespiratory diseases such as congestive cardiac failure, ischemic heart disease, cardiomegaly, interstitial lung disease and chronic obstructive pulmonary disease, disseminated malignancy, general debility, sepsis, and obesity.[4, 11, 12] It should be noted that the current study did not stratify cases for these conditions.

Thus, while the risk of a thromboembolic event was not found to be significantly altered in cases of simple benign prostatic hyperplasia with bladder enlargement, this may not be the case if other comorbidities are present. The possibility of an additive effect in terms of risk should be considered, and additional studies with larger cohorts controlling for underlying disease states may provide further useful information.

References:

  1. Rosenfeld H, Byard RW. Is there a relationship between bladder outlet obstruction due to benign prostatic hyperplasia and pulmonary thromboembolism? J Forensic Science 2012;57:663-4.
  2. Rosenfeld H, Byard RW. Lower extremity deep venous thrombosis with fatal pulmonary thromboembolism caused by benign pelvic space occupying lesions – an overview. J Forensic Sci 2012;57:665-8.
  3. Byard RW, Cutz E. Sudden and unexpected death in infancy and childhood due to pulmonary thromboembolism. Arch Pathol Lab Med 1990;114:142-4.
  4. Previtali E, Bucciarelli P, Passamonti SM, Martinelli I. Risk factors for venous and arterial thrombosis. Blood Transfus 2011;9:120-38.
  5. Meinardi JR, Kremer J, van der Meer J. Deep vein thrombosis associated with distension of the urinary bladder due to benign prostatic hypertrophy - a case report. Neth J Med 2004;62:137-8.
  6. Andrew WK. An unusual cause of deep venous thrombosis of the lower limb. S Afr Med J 2000;90:42.
  7. Palma L, Peterson MC, Ingebretsen R. Iliac vein compression syndrome from urinary bladder distension due to prostatism. South Med J. 1995;88:959-60.
  8. Evans JM, Owens TP Jr, Zerbe DM, Rohren CH. Venous obstruction due to a distended urinary bladder. Mayo Clin Proc. 1995;70:1077-9.
  9. Ito M, Hatta K, Miyakawa K, Arai H. Pulmonary embolism from persistent dilatation of the bladder secondary to anticholinergic side effects. Gen Hosp Psychiatry 2009;31:187-9.
  10. Vaidyanathan S, Hughes P, Soni BM, Oo T, Singh G, Parsons KF et al. Occlusion of left common iliac vein by a distended urinary bladder in a male with paraplegia due to spinal cord injury. Spinal Cord. 2001;39:394-8.
  11. Rosenfeld H, Tsokos M, Byard RW. The association between body mass index and pulmonary thromboembolism in an autopsy population. J Forensic Science DOI: 10.1111/j.1556-4029.2012.02140.x
  12. Byard RW. The complex spectrum of forensic issues arising from obesity. Forensic Sci Med Pathol DOI: 10.1007/s12024-012-9322-5.

 


Written by:
Roger W. Byard, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Address for Correspondence:
Discipline of Anatomy and Pathology,
Level 3 Medical School North Building,
The University of Adelaide, Frome Road,
Adelaide 5005, Australia
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Is there a relationship between bladder outlet obstruction due to benign prostatic hyperplasia and pulmonary thromboembolism? - Abstract

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