Urinary bladder retention secondary to intranasal administration of oxymetazoline “Afrin” for intra-arterial chemotherapy

Abstract

Selective ophthalmic artery infusion of chemotherapy (SOAIC) has emerged as the standard of care for retinoblastoma (RB). Intranasal oxymetazoline (INO), Afrin, is often intraoperatively administered adjunctively to optimize flow to the orbit. There has been one report to date that suggests the adjunctive use of INO has led to systemic side effects. To our knowledge, this is the first documented case of INO causing urinary retention in a patient undergoing SOAIC, and the recommended treatment.

Case presentation

A young boy underwent SOAIC for RB. A “generous amount” of INO was administered via both nostrils after intubation. The patient underwent SOAIC twice without incident. After the third session, the mother of the patient noted he had issues with voiding over the next 24 h that eventually resolved on their own. He would cry and lay on this stomach stating he had to pee but could not when he tried.

The same experience was noted after SOAIC #4; however, the patient was unable to obtain relief from his symptoms and was taken to the emergency room where a postvoid residual of >200 mL was noted. The symptoms resolved on their own. Prior to session #5, the parents brought this to the attention of the team. After completion of the procedure, the patient underwent straight catheterization and was kept for a period of observation. After awakening, the patient immediately complained of the inability to urinate and was found to have a post void residual of 100 mL. Upon returning home, the patient continued to have voiding issues and was subsequently prescribed Tamsulosin (0.4 mg) daily. Approximately 2 h after administration he was able to urinate normally. The patient required 3 days of treatment.

Discussion

Adverse events from adjunctive techniques used to optimize outcomes of SOAIC for the treatment of RB are rare. There has been one reported case in which cerebral vasoconstriction was triggered by INO during IAC treatment. Abruzzo et al. described a 19-month-old patient that developed systemic hypertension and cerebral vasoconstriction shortly after intranasal oxymetazoline was administered.^1–3 While intranasal oxymetazoline was administered to our patient, the patient did not receive other drugs described in this work and the adverse events observed were substantially different.

After the third SOAIC procedure, our patient had trouble voiding. In subsequent SOAIC sessions, the patient's symptoms increased in severity. The progression of symptoms was thought to be because of increasing sensitivity after multiple exposures to INO. We suspect that oxymetazoline's affinity for adrenergic receptors played a role in our patient's voiding dysfunction. Oxymetazoline is an a-adrenergic agonist with greater activity at the a2 than the a1 adrenergic receptor. ⁴ Moreover, a1-adrenoceptors play a prominent functional role in the neck of the bladder and hence the regulation of bladder outlet resistance while ⁵ a2-adrenoceptors are expressed in the bladder, urethra, and prostate.

To treat the newly observed symptom of urinary retention, our patient was prescribed tamsulosin (Flomax). Tamsulosin hydrochloride is an a1-adrenoceptor blocking agent that exhibits selectivity for a1a-receptors. Tamsulosin decreases bladder outlet resistance at the bladder neck and improves urine flow rates. ⁶ Classically, alpha-blockers are the first-line treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia in adult men. However, there has been evidence that suggests tamsulosin can be used in the treatment of non-neurogenic dysfunctional voiding in children. Vanderbrick et al. investigated the safety and efficacy of tamsulosin in the treatment of dysfunctional voiding in pediatric populations. They found that most children with impaired bladder emptying showed improved symptoms during tamsulosin therapy with no clinically significant alterations in systemic blood pressure. The study also found an initial dose of 0.4 mg was safe for the pediatric population. ⁷ Our patient was prescribed 0.4 mg of Tamsulosin daily and parents were instructed to break open the capsule and pour the contents into yogurt or apple sauce.

There are documented cases of other nasal decongestants causing similar symptoms in both adult and pediatric patients. Pseudoephedrine, a widely used sympathomimetic nasal decongestant, was found to commonly cause voiding dysfunction in adult male patients while Ephedrine, a sympathomimetic commonly used in the treatment of bronchial asthma, was found to cause urinary retention in pediatric patients.^8–10 Moreover, in a retrospective study that examined acute urinary retention in children, it was found that adverse drug events accounted for 13% of cases and male children were 3 times more likely to experience these symptoms, reflecting the proximal anatomic relationship between the bladder and the prostatic urethra in prepubertal males. ⁹ With this in mind, practitioners performing SOAIC should be aware if patients experience this symptom, especially if other adjunctive agents such as topical phenylephrine are administered during this procedure.

Conclusion

Although adverse events following INO administration during SOAIC procedures for RB are rare, increased awareness of adverse effects can help with prevention and/or treatment. We provide a medical treatment option for patients who may experience bladder retention secondary to INO administration or other topical sympathomimetic agents for SOAIC. There is a need for more research pertaining to the pharmacokinetics, dosing, as well as the adverse effects and benefit, of common adjunctive agents being used in SOAIC.