Lower urinary tract symptoms and sexual dysfunction in men with multiple sclerosis

OBJECTIVES: To assess the prevalence and interrelationship between lower urinary tract symptoms and sexual dysfunction in men with multiple sclerosis (MS). METHODS: In a cross-sectional study, we evaluated 41 men (mean age 41.1±9.9 years) with MS from February 2011 to March 2013, who were invited to participate irrespective of the presence of lower urinary tract symptoms or sexual dysfunction. Neurological impairment was assessed with the Expanded Disability Status Scale; lower urinary tract symptoms were evaluated with the International Continence Society male short-form questionnaire, and sexual dysfunction was evaluated with the International Index of Erectile Function. All patients underwent transabdominal urinary tract sonography and urine culture. RESULTS: The mean disease duration was 10.5±7.3 years. Neurological evaluation showed a median Expanded Disability Status Scale score of 3 [2-6]. The median International Continence Society male short-form questionnaire score was 17 [10-25]. The median International Index of Erectile Function score was 29 [15-46]. Twenty-nine patients (74.4%) had sexual dysfunction as defined by an International Index of Erectile Function score <45. Voiding dysfunction and sexual dysfunction increased with the degree of neurological impairment (r=0.02 [0.02 to 0.36] p=0.03 and r=-0.41 [-0.65 to -0.11] p=0.008, respectively). Lower urinary tract symptoms and sexual dysfunction also displayed a significant correlation (r=-0.31 [-0.56 to -0.01] p=0.04). CONCLUSIONS: Most male patients with MS have lower urinary tract symptoms and sexual dysfunction. The severity of the neurological disease is a predictive factor for the occurrence of voiding and sexual dysfunctions.

Evaluation of urodynamic parameters after sling surgery in men with post-prostatectomy urinary incontinence

ABSTRACT Objective: To evaluate urodynamic alterations after sub-urethral sling surgery (SSU) in patients with post-prostatectomy urinary incontinence (PPUI). Materials and Methods: We evaluated data of 22 patients submitted to radical prosta- tectomy (RP) or transurethral resection of prostate (TURP) that presented post-surgical urinary incontinence and were treated with SSU implant in a pilot study previously performed in our institution. Methods: Those patients with PPUI were evaluated by urodynamic exam (UD) before and after surgery, and the parameters were compared, including uroflow, cystometry and micturition study. Exclusion criteria included patients without pre-operatory urodynamic study, those with urethral stenosis, those not healed of prostate cancer, pa- tients without clinical conditions to be submitted to urodynamic study and those with severe neurological diseases or that refused to sign the consent form. Results were analyzed statistically by Fisher, Wilcoxon or Mann-Whitney tests. Results: During free uroflow, none parameters showed any statistical significant differ- ences. During cystometry, there were also no statistical differences and the same was observed at pressure versus flow study; the exception was at maximal flow detrusor pressure (PdetQmax), that was lower at post-operatory (p=0.028). In relation to the presence of urinary dysfunctions associated to PPUI, we observed a significant reduc- tion of detrusor overactivity (p=0.035) in relation to pre-operatory period. Conclusion: SSU surgery significantly reduced detrusor overactivity and PdetQMax; however, there were no alterations of other evaluated urodynamic parameters.

Argus T® versus advance® sling for postprostatectomy urinary incontinence: a randomized clinical trial

ABSTRACT Objective To compare the results of two slings, Argus T® and Advance®, for the treatment of postprostatectomy urinary incontinence (PPUI). Material and Methods: From December 2010 to December 2011, 22 patients with PPUI were randomized as follows: 11 (mean age 62.09(±5.30)) underwent treatment with Advance® and 11 (mean age 62.55(±8.54)) with Argus T®. All patients were evaluated preoperatively with urodynamic testing, quality of life questionnaire (ICIQ-SF), voiding diary and 24-hour pad test. Exclusion criteria were: neurological diseases, severe detrusor overactivity and urethral stenosis. Evaluation was performed at 6, 12 and 18 months after the surgery. After implantation of the Argus T® sling, patients who experienced urine leakage equal to or greater than the initial volume underwent adjustment of the sling tension. Results were statistically analyzed using the Fisher’s test, Kolmogorov-Smirnov test, Friedman’s non-parametric test or the Mann-Whitney test. Results Significant improvement of the 24-hour pad test was observed with the Argus T® sling (p=0.038) , With regard to the other parameters, there was no significant difference between the two groups. Removal of the Argus T® device due to perineal pain was performed in one patient (9%). Despite non uniform results, both devices were considered useful to improve quality of life (ICIQ-SF): Argus T® (p=0.018) and Advance® (p=0.017). Conclusions Better results were observed in the 24h pad test and in levels of satisfaction with the Argus T® device. Both slings contributed to improve quality of life (ICIQ-SF), with acceptable side effects.

Long-term results of a clinical trial comparing isolated vaginal stimulation with combined treatment for women with stress incontinence / Resultados a longo prazo de um estudo clínico comparando estimulação vaginal isolada com tratamento combinado para mulheres com incontinência urinária de esforço

Objective To determine the efficacy of stress urinary incontinence treatments adding pelvic floor muscle training to vaginal electrical stimulation. Methods Forty-eight women with stress urinary incontinence were randomized into 2 groups: 24 underwent isolated vaginal electrical stimulation, and 24 vaginal electrical stimulation plus pelvic floor muscle training. History, physical examination, voiding diary, perineum strength test, and urodynamic study were assessed. Comparisons were made for adherence to treatment, muscle strength improvement, urinary symptoms, and degree of satisfaction immediately, 12 and 96 months after treatment. Results Patients’ degree of satisfaction on vaginal electrical stimulation, and on vaginal electrical stimulation plus pelvic floor muscle training immediately, 12 and 96 months post treatment, were, respectively: 88.2% versus 88.9% 64.7% versus 61.1% and 42.9% versus 28.6% (p>0.05). Conclusion Vaginal electrical stimulation associated to pelvic floor muscle training did not show better results than vaginal electrical stimulation alone. .

Objetivo Determinar a eficácia da eletroestimulação vaginal combinada com treinamento muscular do assoalho pélvico para o tratamento da incontinência urinária de esforço. Métodos Um total de 48 mulheres com incontinência urinária de esforço foi randomizado em 2 grupos, sendo 24 submetidas a eletroestimulação vaginal isolada e 24 a eletroestimulação vaginal e treinamento muscular do assoalho pélvico. Foram avaliados anamnese, exame físico, diário miccional, força perineal e urodinâmica. Compararam-se a adesão ao tratamento, a melhora da força muscular perineal e dos sintomas urinários, e o grau de satisfação imediatamente, 12 e 96 meses após o tratamento. Resultados O grau de satisfação das pacientes no grupo da eletroestimulação isolada e do segundo grupo, imediatamente, com 12 e com 96 meses foi, respectivamente, 88,2% versus 88,9% 64,7% versus 61,1% e 42,9% versus 28,6% (p>0,05). Conclusão A eletroestimulação vaginal associada ao treinamento muscular do assoalho pélvico não foi mais eficaz do que a eletroestimulação isolada. .

Bladder involvement in systemic lupus erythematosus / Envolvimento vesical no lúpus eritematoso sistêmico

Objective: To study bladder involvement in systemic lupus erythematosus patients through clinical and laboratorial evaluation, ultrasonography, radiological and endoscopic examination. Methods: Thirty-nine patients, either outpatients or inpatients at the Department of Rheumatology of Hospital das Clínicas da Faculdade de Medicina from Universidade de São Paulo were evaluated as to clinical and laboratorial data. All patients were submitted to ultrasonographic evaluation of the upper urinary tract, radiological and endoscopic examinations of the middle and lower urinary tracts. Results: Mean age of patients varied between 13 and 62 years (median = 29 years). Thirty-six were females and three were males. The disease varied from 6 months to 22 years (median three years and one month). Clinical and laboratory activity of the disease was present in 30 patients. Twenty-two patients had the diagnosis of lupus established for three years or more. Twenty-five patients were asymptomatic and all had received corticosteroids for treatment at least once. Twenty-three received antimalarial drugs; ten received cytostatics, and seven patients received non-steroid anti-inflammatory drugs. Upper urinary tract ultrasonography was normal in all cases but one with staghorn calculus associated with neurogenic bladder secondary to neurological involvement by the disease. Vesicoureteral reflux was observed in two cases. Other two patients had significant post-voiding residual urine, both with neurogenic bladder secondary to nervous system involvement by lupus. The average bladder maximum capacity in an awaken patient was 342 mL, and was decreased in 18.9% of cases. This subgroup of patients presented a greater frequency of urinary symptoms and greater use of cytostatic drugs (Z > Z5%). A pathognomonic cystoscopic pattern of bladder involvement in systemic lupus erythematosus could not be established. Cystoscopic aspects similar to those seen in the initial or minor forms of interstitial cystitis were present in 43.2% of patients. This finding was more frequent when cytostatic drugs were used for treating the disease. Conclusions: There was bladder involvement in systemic lupus erythematosus, even in asymptomatic patients, demonstrated by the occurrence of cystoscopic abnormalities or by reduced bladder maximum capacity associated with the presence of suprapubic pain, urinary irritation symptoms and the use of cytostatic drugs.

Objetivo: Estudar o envolvimento vesical em pacientes com lúpus eritematoso sistêmico (LES) por meio de avaliações clínica, laboratorial, ultrassonográfica e de estudos radiológico e endoscópico. Métodos: Trinta e nove pacientes ambulatoriais ou internados no Serviço de Reumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo foram avaliados clínica e laboratorialmente. Todos foram submetidos à avaliação do trato urinário superior por meio da ultrassonografia, e a exames radiológicos e endoscópicos para a avaliação dos tratos médio e inferior. Resultados: A idade dos pacientes variou de 13 a 62 anos (mediana = 29 anos). Trinta e seis pacientes eram do sexo feminino e três do sexo masculino. O tempo de doença variou de seis meses a 22 anos (mediana = três anos e um mês). Trinta pacientes apresentavam atividade da doença na ocasião do estudo. O diagnóstico de lúpus havia sido estabelecido havia três anos ou mais em 22 pacientes. Vinte e cinco pacientes eram assintomáticos em relação às queixas urinárias e todos haviam feito uso de corticoides em alguma fase do tratamento. Vinte e três receberam antimaláricos; dez, citostáticos e sete anti-inflamatórios não-hormonais. A ultrassonografia do trato urinário superior foi normal em todos os casos, exceto um que apresentou cálculo coraliforme associado à bexiga neurogênica devido a envolvimento neurológico pelo lúpus. Refluxo vésico-ureteral foi demonstrado em dois pacientes e, em outros dois casos, observava-se grande resíduo pós-miccional secundário à lesão neurológica pela doença de base. A média da capacidade vesical máxima com paciente desperto foi de 342 ml e, em 18,9% dos casos este parâmetro estava diminuído. Este subgrupo apresentou maior incidência de manifestações urinárias e maior frequência de emprego de citostáticos (Z > Z5%). Não se caracterizou padrão diacrítico de participação vesical na doença. Em 43,2% dos pacientes, detectaram-se aspectos cistoscópicos semelhantes aos descritos para a forma precoce ou menor de cistite intersticial, guardando dependência apenas com o emprego de citostáticos no tratamento do lúpus eritematoso sistêmico. Conclusões: Demonstrou-se o envolvimento vesical no lúpus eritematoso sistêmico, mesmo em pacientes assintomáticos e que se manifestou pela ocorrência de alterações cistoscópicas e pela diminuição da capacidade vesical máxima em paciente desperto, estando esta associada à presença de dor suprapúbica à repleção vesical e manifestações irritativas urinárias, bem como ao uso de citostáticos.

Histological aspects of the bladder in systemic lupus erythematosus / Aspectos histopatológicos da bexiga no lúpus eritematoso sistêmico

Objectives: to study pathological data from bladders of systemic lupus erythematosus patients, correlate them to clinical events and the use of therapeutic drugs, and compare them to bladder histopathological findings in individuals not affected by systemic lupus erythematosus. Methods: thirty-nine out or inpatients of the Department of Rheumatology at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, diagnosed with systemic lupus erythematosus were clinically and cystoscopically evaluated. Bladder biopsy was also performed. As a normal parameter, bladders taken from 20 corpses collected at the Death Verification Department of São Paulo city, without autolysis or evidence of urinary tract or autoimmune disease were also histologically studied. This group was considered as a Control Group. A correlation among clinical, cystoscopic and histopathological data was carried out. Results: the patients mean age was 29 years (range 13-62). Thirty-six were females and three were males. Twenty-five patients were asymptomatic during the study period. In the Control Group the age range was 20-65 years. Nineteen were females (95%) and one was male (5%). Cystoscopic examination of the group with systemic lupus erythematosus showed interstitial pattern in 16 cases (41.0%) and normal in 15 (38.5%). The bladder was normal in four patients (10.3%). Chronic unspecific cystitis was observed in 18 (46.2%) patients. In the remaining, several alterations were found, including bladder vasculitis in seven patients (17.9%). The mean number of mast cells in the bladder area was 2.223/mm2. In the Control Group, unspecific cystitis was found in three cases (15.0%). No other abnormalities were found. The mean number of mast cells in this group was 0.777/mm2 (±2.7). Chronic unspecific cystitis, bladder vasculitis and the mean number of mast cells were compared with each other and no statistical differences were found (p > 0.05). There were statistically significant differences between the two groups regarding chronic unspecific cystitis and bladder vasculitis (Z = 2.078 > Z5% = 1.645 and Z = 1.777 > Z5% = 1.645) and also mean number of mast cells (Z = 2.387 > Z5% = 1.673). There were statistically significant differences between the proportion of mast cell infiltrate and presence of suprapubic pain as well as use of antimalarial drugs. The other analysis did not show statistically significant differences. There was no statistical evidence of dependence among the events: cystoscopy with interstitial pattern and chronic unspecific cystitis (p > 0.237); cystoscopy with interstitial pattern and bladder vasculitis(p > 0.325); cystoscopy with interstitial pattern and mast cell infiltrate (p > 0.277). Conclusions: the bladder in systemic lupus erythematosus may be involved even in the absence of clinical manifestations. The involvement of the bladder in systemic lupus erythematosus was characterized mainly by the finding of chronic unspecific cystitis, bladder vasculitis and mast cell infiltrate. The presence of chronic unspecific cystitis was significantly greater in patients with the disease than in the Control Group, and the same occurred with bladder vasculitis. The number of mast cells/mm2 was higher than normal in patients with systemic lupus erythematosus. This finding was associated to suprapubic pain upon bladder repletion and to use of antimalarial drugs.

Isolated anterior urethral trauma in man after coitus:a case report / Trauma isolado de uretra anterior masculina após coito: relato de caso

Penile fracture with or without urethral injury after coitus presents with severe pain and immediate penile detumescence accompanied by a cracking sound. Hematuria or voiding difficulty are common findings and suggest associated urethral injury. The objective of this report is to describe an unusual complication of coital trauma diagnosed based on clinical findings. The isolated urethral injury is rare but is one of the causes of male coital trauma and may be suspected when patients present urethral bleeding.

Fratura de pênis com ou sem lesão de uretra é a principal lesão ocorrida durante o ato sexual e se apresenta com dor intensa, rápido intumescimento e estalido. Hematúria ou dificuldade miccional são sintomas incomuns, que sugerem lesão de uretra associada. O objetivo do trabalho foi relatar essa rara complicação de lesão isolada de uretra durante o intercurso sexual cujo diagnóstico se acha baseado em achados clínicos. A lesão isolada de uretra, embora rara, pode ocorrer durante o intercurso sexual e deve ser suspeitada na presença de uretrorragia.

Female urethral diverticulum associated witha large urinary calculus / Divertículo de uretra feminina associado a grande cálculo urinário

The diverticula of female urethra are very uncommon, but more frequently found between the third and fifth decade of life. Diverticula area mostly relate to repeated urinary infections of the periurethral glands or urethras trauma. The diverticula may cause infection, calculus formation and rarely endometriosis or cancer. A case of a 65-year old Caucasian female with vaginal mass over six months is herein reported. There was no urinary loss, urethral secretion or urinary symptoms. A cystourethrography showed diverticula with calculus inside. The patient was submitted to surgery and dismissed from the hospital on the first postoperative day. The pathologic examination revealed no malignancy. In six months of follow-up, the patient was continent with no complaints.

Os divertículos de uretra feminina são incomuns, porém mais frequentes entre a terceira e a quinta década de vida. A maioria dos divertículos de uretra está relacionada a infecções recorrentes das glândulas periuretrais ou traumatismo uretral. Os divertículos podem ser sítio de infecções, formação de cálculos e, mais raramente, endometriose ou neoplasia. Relata-se o caso de paciente de 65 anos, branca, com queixa de nódulo em parede vaginal notado há seis meses. Negava incontinência urinária, derrame uretral e sintomas urinários de armazenamento ou de esvaziamento. A uretrocistografia miccional revelou divertículo uretral associado a cálculo. Submetida à cirurgia, teve alta hospitalar no primeiro dia pós-operatório. O resultado do exame anatomopatológico não evidenciou malignidade. Após seis meses de seguimento, a paciente encontra-se sem queixas urinárias ou vaginais e com continência urinária preservada.

What is the best choice for chronic urinary retention: indwelling catheter or clean intermittent catheterization? / Qual a melhor escolha para a retenção urinária crônica: sondagem vesical de demora ou cateterismo intermitente limpo?

Objective: The aim of this study was to analyze the advantages and disadvantages of clean intermittent catheterization, comparing to indwelling urinary catheter, in the treatment of chronic urinary retention. Methods: This literature review was carried out in order to highlight the best evidences for the choice between treatments. The extensive literature review was made through PubMed and Cochrane National Library. We selected the main articles published between 1950 and 2007, using urinary retention, indwelling urinary catheter, and clean intermittent catheterization as keywords. Results: Twenty five papers were selected, including three meta-analyses evaluating the long-term complications of clean intermittent catheterization, prophylactic intervention, and catheter types. Most articles discussed complications in patients with neurologic dysfunctions. Conclusion: Clean intermittent catheterization is better than indwelling catheter, as it is related to lower complication rates, both short and long-term. Indwelling catheterization was associated with decreased vesical compliance and bladder calculi, among others.

Objetivo: O objetivo do estudo foi analisar quais as vantagens e desvantagens do uso do cateterismo intermitente limpo, se comparado à sonda vesical de demora, no tratamento dos pacientes com retenção urinária crônica. Métodos: O estudo foi feito por meio da revisão da literatura, com o objetivo de destacar as melhores evidências para a realização de um ou de outro tratamento. A pesquisa bibliográfica foi realizada no PubMed e na Cochrane Library. As palavras-chave utilizadas foram retenção urinária, cateteres de demora e cateterismo intermitente limpo, e os artigos foram selecionados no período compreendido entre 1950 e 2007. Resultados: Dos 25 artigos selecionados, foram incluídas três metanálises, que avaliaram as complicações em longo prazo do uso do cateterismo intermitente limpo, medidas profiláticas para manuseio do cateter e tipos de cateter utilizados. A grande maioria dos artigos selecionados se referiu ao tratamento e manuseio das complicações em pacientes com disfunções neurológicas. Conclusões: O cateterismo intermitente demonstrou ser superior à sondagem de demora, pois está associado a uma menor taxa de complicações a curto e a longo prazo, como, por exemplo, cálculos vesicais, redução da complacência vesical, dentre outras.

Busca ativa de casos de leishmaniose cutânea em humanos e cães em área periférica do município de Campo Mourão - PR, Brasil / Active search of cutaneous leishmaniasis in humans and canines in the peripherical area of Campo Mourão - PR - Brazil

Foi realizada uma busca ativa de casos de leishmaniose cutânea em humanos e cães, em área periférica da cidade de Campo Mourão - PR. No período de 01 a 30 de junho de 2004, uma equipe multidisciplinar visitou todas as residências e estabelecimentos comerciais situadas até 150m da margem superior e inferior do rio 119, que delimita o município. Todos os casos humanos suspeitos de Leishmaniose Tegumentar Americana (LTA) foram encaminhados para o Posto de Saúde de referência para receberem os devidos tratamentos e orientação profilática. Foram encontrados 6 (seis) casos de pessoas suspeitas de LTA, sendo que 04 (quatro) resultaram em diagnóstico negativo e 02 (dois) em diagnóstico positivo. Nenhum cão apresentou lesão suspeita de LTA.

An active search was done to identify cases of leishmaniasis in humans and dogs in a peripherical area of Campo Mourão, PR, Brazil. From the first to thirtieth June of 2004, a multidisciplinary professional team visited all residences located within 150 meters from the superior and inferior margins of the river 119, which delimits the city. All human cases of American Tegumentary Leishmaniasis (ATL) were directed to reference health care center for the appropriated treatment and prophylactic orientation. Six cases of persons suspected of ATL were found; four patients resulted in a negative diagnosis while two cases were positive. No dogs demonstrated lesions that were suggestive of ATL.

Comparison of vaginal wall sling and modified vaginal wall sling for stress urinary incontinence

CONTEXT: There are several controversies about which is the best form of surgical treatment for stress urinary incontinence in women. The vaginal wall sling in its original and modified form were presented by Raz as new options for treatment of these conditions, but there is a lack of comparative clinical trials using both techniques. OBJECTIVE: To compare the effectiveness of the original and the modified vaginal wall sling. DESIGN: A comparative, prospective, non-randomized clinical trial. SETTING: Public and private health care units (Urology Division, Faculty of Medicine of the ABC Foundation, and Universidade Federal de São Paulo / Escola Paulista de Medicina). PARTICIPANTS: Twenty patients with anatomical and intrinsic sphincter deficiency stress urinary incontinence were surgically treated for evaluating the initial results of the vaginal wall sling, from February 5, 1994, to June 27, 1996. INTERVENTIONS: The patients were divided into two groups. Group A (n = 10) were treated with the original vaginal wall sling. Group B (n = 10) were treated with the modified vaginal wall sling. Both groups were statistically similar according to clinical and urodynamic parameters. MAIN MEASUREMENTS: Cure and complication rates. RESULTS: Follow-up ranged from 19 to 43 months (median = 28) for group A. The overall cure rate was 70 percent. Fifty percent of the patients had urinary retention of 7 to 35 days. There were no major complications. Follow-up ranged from 14 to 26 months (median = 18) for Group B. The cure rate was 80 percent. Two patients had urinary retention of 7 and 55 days. There were no major complications. CONCLUSIONS: The vaginal wall sling is as effective as the modified vaginal wall sling but has a higher rate of urinary retention.

Cirurgia de burch laparoscópica em Instituiçäo pública: estudo comparativo de custos / Laparoscopic burch suegery in public health care: cost comparative study

Foi realizado um estudo dos custos da cirurgia de Burch por via laparoscópica, em comparaçäo com a cirurgia aberta, com objetivo de verificar possíveis implicaçöes econômicas para as instituiçöes públicas no Brasil. Foram analisados de maneira retrospectiva os prontuários de 20 pacientes operados para correçäo de incontinência urinária de esforço pela técnica de Burch, consecutivamente, de dezembro de 1994 a janeiro de 1996. Dez foram submetidos a cirurgia vídeo laparoscópica (CVL) e 10 a cirurgia de Burch aberta (CBA). Os gastos de enfermaria e centro cirúrgico de cada modalidade foram avaliados e comparados com o valor pago pelo sistema único de saúde (SUS) para este procedimento cirúrgico. A duraçäo da internaçäo foi similar em ambos os grupos; a duraçäo da cirurgia foi em média 4 horas para CVL e 2 horas para CBA. O custo da CVL (R$ 292,00) foi significativamente maior (p<0,05) que o da CBA (R$ 190,32), sendo esta diferença observada principalmente nos custos intra-operatórios. Concluímos que CVL aumenta o custo hospitalar devido ao aumento dos custos de centro cirúrgico, no entanto, com valores compatíveis com os pagos pelo SUS. Somente quando a CVL for realizada com um período de internaçäo mais curto, já que permite recuperaçäo mais rápida da paciente, os custos globais poderäo ser reduzidos e näo haverá ônus adicional para o sistema público

Tratamento vídeo laparoscópico da fibrose retroperitoneal / Laparoscopic video treatment of retroperitoneal fibrosis

A fibrose retroperitoneal é uma doença classicamente tratada através da ureterolise por via aberta. Descrevemos o tratamento desta entidade por videolaparoscopia com nova abordagem através de 4 punçöes abdominais. A ureterolise laparoscópica é um método viável e menos invasivo que pode ser realizado em centros com disponibilidade de material e experiência básica em técnicas urológicas de cirurgia vídeo-assistida

Coágulo vesical gigante retido: alternativas terapêuticas / Management of massive bladder clot

A retenção urinária secundária a obstrução por coágulos é comum na rotina urológica. A conduta inicial é a irrigação vesical contínua havendo resolução na maior parte dos casos. Relatamos caso de um coágulo gigante duro-elástico que se formou em 10 dias e que, após tentativas de irrigação, evacuação através de cistoscopia e secção com alça do ressectoscópio, não permitiu limpeza da bexiga. Optamos por cistostomia, a qual levou a importante morbidade. Revisamos também as opções terapêuticas para estes casos, lembrando adicionalmente o uso de fibrinolíticos