Friday, March 29, 2013

MICTURITION SYNCOPE: A RARE CASE


A 23 year old patient came with history of syncope while passsing urine three times in a period of 2 months.The first episode happened when he got up during the sleep.

The other two episodes happened without any provokative factors.

His routine biochemical and hematological tests were normal.ECG and ECHO tests were too normal.His VMA levels in urine were normal.

His USG KUB and uroflowometry were within the normal limits.

Finally he was given reassurance and advised some life style modifying factors.

To sit while urinating 
To sit on the edge of the bed for a while before getting up and going to the toilet 
To avoid micturition while feeling sleepy. 

Review of the literature:

Micturition syncope fainting shortly after or during urination.
The patients can have concomitant nausea; vomiting and can feel dizzy before loss of consciousness. Some people can have syncope following or during vomiting, defecation or coughing (About 61% with micturition syndrome also suffered from other kinds of syncope).

It is more common in male. It is responsible for 2.4 to 8.4 percent of all syncope. The events often occur at night or after awaking. A combination of postural hypotension and straining is always found in such cases. Defecation syncope is a relatively rare disorder that occurs typically in middle-aged or older individuals and affects women more often than men. More than one third of patients with defecation syncope die within 2 years of complications of their underlying diseases.

The mechanism of micturition syncope is still unknown but believed that it is related to vasovagal syncope.
During micturition there is increased vagal tone as a result from straining (Valsalva maneuver) which results in bradycardia leads to syncope due to decreased cerebral blood flow. As clinician we should rule out cardiac causes, anemia and while does the patient strain at urination (whether he has underlying stricture disease,
PROSTATOMEGALY especially on alpha blockers).

A rare tumor –pheochromocytoma of the bladder can lead to such condition. In all cases it would be safer to do imaging of the bladder, check for urine VMA as a routine.
  • Diagnosis mainly relies on patient history but other investigation like ECG, echocardiogram, TMT /Holter monitoring and blood tests need to rule out other diseases.
  • There is no specific treatment for micturition syncope. General advice to men who have a micturition syncope includes: 
  • To sit while urinating

  • To sit on the edge of the bed for a while before getting up and going to the toilet
  • To avoid micturition while feeling sleepy
  • If it is happening again and again and interfering with the life of the patient then beta blockers can be administered.
  • Some urologists prescribe SSRI /antidepressants in such conditions .it may offer some help.
  • If any sinus block is present cardiology intervention in the form of pace makers may be needed in rare cases.



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