Herpes zoster induced acute urinary retention in the immunocompetent female

Abstract

We present a rare case of acute urinary retention complicated by constipation secondary to a unilateral herpes zoster reactivation in the S2-4 dermatomes of an immunocompetent female. Diagnosis was confirmed by clinical examination, negative cystoscopy and positive viral polymerase chain reaction (PCR) for herpes zoster virus. The patient was commenced on a course of oral acyclovir, the bowel symptoms resolved, and the patient was discharged with a urinary catheter in situ for an outpatient trial without catheter for 2 weeks to be followed by a course of intermittent self catheterisation pending resolution of symptoms.

BACKGROUND

Acute urinary retention secondary to herpes zoster infection is wholly treatable and emphasises the importance of a full history and examination of patients who present with retention in the emergency setting. This case serves as an important aide memoir for the general practitioner, emergency physician and urologist.

CASE PRESENTATION

A 67-year-old retired publican presented to the accident and emergency department complaining of a week’s history of incomplete voiding, increasing urgency, frequency, nocturia and a progressively worsening stream with no dysuria. Her symptoms were exacerbated by a 3 day history of constipation and 1 day history of complete inability to void urine. She had no significant past medical history, did not suffer from any dermatological conditions and had not been bothered by lower urinary tract symptoms before this episode.

On examination: she was afebrile; cardiovascular and respiratory examinations were unremarkable; abdominal examination revealed a tender bladder palpable to the umbilicus; and general examination revealed a unilateral rash consisting of multiple grouped vesicles in the distribution of the left S2–4 dermatomes (fig 1). Many of the vesicles had burst and were exuding pus. The patient had suffered chicken pox as a child but had not experienced a secondary reactivation throughout her adult life. On further questioning, she admitted to a painful, burning rash which had rapidly erupted 1 day previously that she had been treating with topical calamine lotion with limited effect.

Figure 1. Rash on the left buttock in the S2–4 dermatomal distribution (healing phase).

INVESTIGATIONS

Negative urinalysis was confirmed by negative urine culture; cystoscopy was negative and excluded a structural cause for retention. Human immunodeficiency virus and hepatitis serology was negative and immunocompetence was confirmed by a normal full blood count. Viral polymerase chain reaction (PCR) of the vesicular exudate was positive for herpes zoster virus.

DIFFERENTIAL DIAGNOSIS

Acute urinary retention in women is uncommon. Established causes include postoperative urethral stricture, bladder calculi, pelvic malignancy, clot retention, extrinsic compression (for example, prolapse of a pelvic organ), diabetic cystopathy, multiple sclerosis, psychogenic primary disorders of sphincter relaxation (Fowler’s syndrome), and reactivation of herpes zoster virus.

TREATMENT

Urethral catheterisation was performed in the emergency setting with a 14 Ch Foley catheter yielding a residual volume of 1700 ml straw urine. Once a clinical diagnosis of herpes zoster reactivation was made the patient was commenced on 800 mg of oral aciclovir five times daily for 1 week according to local microbiology advice.

OUTCOME AND FOLLOW-UP

The constipation resolved spontaneously following 2 days of oral acyclovir. The patient was discharged with a urinary catheter in situ to complete the course of antiviral medication; she returned as an outpatient for a trial without catheter for 2 weeks, to be followed by a course of intermittent self catheterisation (ISC) in the community until the urinary symptoms resolved.

DISCUSSION

Davidsohn first recorded the urological manifestations of herpes zoster in 1890.^1–3 Since then fewer than 150 cases have been reported worldwide.^3–5 Herpes zoster infection is characterised by a vesicular rash affecting one or more dermatomes associated with an inflammatory reaction (haemorrhage, nerve cell necrosis and mononuclear infiltration) caused by a reactivation of the zoster virus following primary infection.⁶ Cutaneous reactivation is usually unilateral; however, there are three syndromes of zoster associated bladder dysfunction: zoster cystitis, zoster retention and zoster myelitis.^2,4 In a recent case series of 423 patients who were admitted with a diagnosis of herpes zoster at a single centre in Taiwan, 4.02% were shown to suffer from a zoster associated voiding dysfunction, increasing to 8.81% when those with cranial nerve involvement were excluded.² Zoster cystitis is the mildest form of the disease, characterised by a triad of dysuria, frequency and haematuria that may be associated with a herpetic hemi-cystitis on cystoscopy.⁷ The cutaneous rash is usually simultaneous with the cystitis syndrome (60%) and is closely associated with thoracolumbar reactivation (60%) and a positive bacterial urine culture (70%).⁴

Zoster cystitis is thought to correlate pathologically with virus spread along the autonomic nerves to the bladder causing local erythema, oedema and vesicle formation.⁶ Zoster retention (as reported here) is usually an acute presentation that is frequently accompanied by severe constipation and is closely associated with sacral reactivation (50–78%).^4,6 The unilateral infection spreads from the dorsal root ganglion into the sacral motor neurones, roots or peripheral nerves causing interruption of the bilateral detrusor reflex to manifest clinically as an atonic bladder.^2,7 Detrusor areflexia may be demonstrated on cystometrography and is likely to persist for 4–6 weeks.⁵ In zoster retention the course of the voiding dysfunction is thought to be independent of rash severity.⁴ Zoster myelitis is a rare manifestation that presents as a spastic bladder with overflow incontinence secondary to a virally induced transverse myelitis with involvement of the ascending tracts.²

In cases of zoster retention most authors advocate symptomatic management of the condition with the use of oral antiviral medication, urethral catheterisation in the acute setting, and a course of ISC in the community. Urodynamic investigations should be considered if symptoms fail to improve 6–8 weeks from onset to exclude a true neurogenic cause.^2,4,5 Although rare, we stress the importance of a full history and examination of patients presenting with new onset urological disturbance in the absence of an apparent cause, and urge clinicians to consider herpes zoster reactivation in this clinical context, especially where evidence of a concurrent vesicular rash is present. We hope that this case will serve as an important aide memoir for the general practitioner, emergency physician and urologist alike.

LEARNING POINTS

The authors believe this case:

• Is a well-demonstrated reminder of an important clinical association.

• Emphasises the importance of a full history and examination in patients who present with an otherwise unexplained episode of acute urinary retention.

• Will serve as an important aide memoir for general practitioners, emergency physicians and urologists alike.