<p>Sir,</p> <p>Thyroid dysfunction is a common problem, especially among women. Thyrotoxicosis is characterized by exaggerated responses to catecholamines, while in hypothyroidism, narrowing of adaptive responses is observed. It is, therefore, not surprising to see gastrointestinal and lower urinary tract symptoms (LUTS) in patients with thyroid dysfunction.</p> <p>Unfortunately, published articles addressing voiding dysfunction in hyper-and hypothyroidism are scarce, most of them being case reports. In June 2012, we searched PubMed, Google Scholar, EMBASE, and Ovid for articles about these issues. The obtained results are as follows.</p> <p>Most hypothyroid patients are middle-aged women. They may develop retention of urine and renal failure. <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup>This retention could be the presenting symptom or may be found incidentally in a patient who has other signs and symptoms of hypothyroidism like myxedema, malaise, a change in the tone of voice, and mental confusion. <sup> <xref ref-type="bibr" rid="ref2">2</xref> </sup>Paralytic ileus (colonic pseudo-obstruction) has been reported in association with bladder atony in the setting of hypothyroidism. <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref2">2</xref> </sup>Uremia may ensue as the result of urinary retention or acute kidney injury. <sup> <xref ref-type="bibr" rid="ref3">3</xref> </sup>In less severe cases, only a reduction in the voiding frequency and urine volume is observed without bothering the patient. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup></p> <p>Hyperthyroidism is also more common among women. Patients may exhibit both irritative and obstructive LUTS. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>Of the LUT symptoms, urinary frequency is the most common. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>Other storage symptoms include urgency, urge incontinence, nocturia, and enuresis (either primary or secondary). <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>Of the voiding symptoms, incomplete emptying and straining have been reported. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>Patients rarely complain of urgency, frequency, and enuresis; therefore, they should be asked about these symptoms in moderate to severe cases of hyperthyroidism. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup></p> <p>Urodynamic study has been performed in a few cases and the findings include: Diminished flow rate, increased post-void residue, increased pelvic floor activity during voiding, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>early first sensation, and detrusor overactivity. <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>Bladder capacity has been reported to be normal, decreased, <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>or increased. <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>In a study, although the peak flow rate was significantly less than the control group, it was still in the normal range. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>Chung and colleagues followed up some 11,000 female hyperthyroid patients for 3 years and found that the risk of developing urinary incontinence in them was more than in the healthy, control group (hazard ratio = 1.54). <sup> <xref ref-type="bibr" rid="ref7">7</xref> </sup></p> <p>Bladder involvement may be the presenting symptom or may appear a few months after the onset of the thyroid disease and is responsive to proper medical therapy. However, complete improvement may take several weeks to a few months.</p> <p>To better define the manifestations of bladder involvement in thyroid dysfunction, larger cohort of patients with thyroid problems should be evaluated for LUTS and urodynamic study be performed when indicated. Also, the incidence of thyroid dysfunction in patients presenting with LUTS should be determined.</p> </sec> </body> <back> <ref-list> <ref id="ref1"> <label>1</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Hansen</surname> <given-names>MV</given-names> </name> <name> <surname>Engberg</surname> <given-names>A</given-names> </name> </person-group> <article-title>Uremia as a complication to urinary retention due to hypothyreosis.Case report</article-title> <source>Scand J Urol Nephrol</source> <year>1988</year> <volume>22</volume> <fpage>351</fpage> <lpage>3</lpage> </nlm-citation> </ref> <ref id="ref2"> <label>2</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Nathan</surname> <given-names>AW</given-names> </name> <name> <surname>Havard</surname> <given-names>CW</given-names> </name> </person-group> <article-title>Paralytic ileus and urinary retention due to hypothyroidism</article-title> <source>Br Med J (Clin Res Ed)</source> <year>1982</year> <volume>285</volume> <fpage>477</fpage> </nlm-citation> </ref> <ref id="ref3"> <label>3</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Rodrigo</surname> <given-names>C</given-names> </name> <name> <surname>Gamakaranage</surname> <given-names>CS</given-names> </name> <name> <surname>Epa</surname> <given-names>DS</given-names> </name> <name> <surname>Gnanathasan</surname> <given-names>A</given-names> </name> <name> <surname>Rajapakse</surname> <given-names>S</given-names> </name> </person-group> <article-title>Hypothyroidism causing paralytic ileus and acute kidney injury: Case report</article-title> <source>Thyroid Res</source> <year>2011</year> <volume>4</volume> <fpage>7</fpage> </nlm-citation> </ref> <ref id="ref4"> <label>4</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Andersen</surname> <given-names>LF</given-names> </name> <name> <surname>Agner</surname> <given-names>T</given-names> </name> <name> <surname>Walter</surname> <given-names>S</given-names> </name> <name> <surname>Hansen</surname> <given-names>JM</given-names> </name> </person-group> <article-title>Micturition pattern in hyperthyroidism and hypothyroidism</article-title> <source>Urology</source> <year>1987</year> <volume>29</volume> <fpage>223</fpage> <lpage>4</lpage> </nlm-citation> </ref> <ref id="ref5"> <label>5</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Ho</surname> <given-names>CH</given-names> </name> <name> <surname>Chang</surname> <given-names>TC</given-names> </name> <name> <surname>Guo</surname> <given-names>YJ</given-names> </name> <name> <surname>Chen</surname> <given-names>SC</given-names> </name> <name> <surname>Yu</surname> <given-names>HJ</given-names> </name> <name> <surname>Huang</surname> <given-names>KH</given-names> </name> </person-group> <article-title>Lower urinary tract symptoms and urinary flow rates in female patients with hyperthyroidism</article-title> <source>Urology</source> <year>2011</year> <volume>77</volume> <fpage>50</fpage> <lpage>4</lpage> </nlm-citation> </ref> <ref id="ref6"> <label>6</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Goswami</surname> <given-names>R</given-names> </name> <name> <surname>Seth</surname> <given-names>A</given-names> </name> <name> <surname>Goswami</surname> <given-names>AK</given-names> </name> <name> <surname>Kochupillai</surname> <given-names>N</given-names> </name> </person-group> <article-title>Prevalence of enuresis and other bladder symptoms in patients with active Graves′ disease</article-title> <source>Br J Urol</source> <year>1997</year> <volume>80</volume> <fpage>563</fpage> <lpage>6</lpage> </nlm-citation> </ref> <ref id="ref7"> <label>7</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Chung</surname> <given-names>SD</given-names> </name> <name> <surname>Chen</surname> <given-names>YK</given-names> </name> <name> <surname>Chen</surname> <given-names>YH</given-names> </name> <name> <surname>Lin</surname> <given-names>HC</given-names> </name> </person-group> <article-title>Hyperthyroidism and female urinary incontinence: A population-based cohort study</article-title> <source>Clin Endocrinol (Oxf)</source> <year>2011</year> <volume>75</volume> <fpage>704</fpage> <lpage>8</lpage> </nlm-citation> </ref> <ref id="ref8"> <label>8</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"></person-group> <article-title></article-title> <source></source> <year></year> <volume></volume> <fpage></fpage> </nlm-citation> </ref> </ref-list> </back> </article>

JRMS

J Res Med Sci

Journal of Research in Medical Sciences

1735-1995 1735-7136

Medknow Publications Pvt Ltd

India

JRMS-18-167

23914221

Letter to Editor

Bladder involvement in thyroid dysfunction

Alizadeh

Farshid

Zargham

Mahtab

Nouri-Mahdavi

Kia

Khorrami

Mohammad H

Izadpanahi

Mohammad H

Sichani

Mehrdad M

Department of Urology, Isfahan Urology and Kidney Transplantation Research Center, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran Department of Urology, Isfahan Urology and Kidney Transplantation Research Center, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran Department of Urology, Isfahan Urology and Kidney Transplantation Research Center, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran Department of Urology, Isfahan Urology and Kidney Transplantation Research Center, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran Department of Urology, Isfahan Urology and Kidney Transplantation Research Center, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran Department of Urology, Isfahan Urology and Kidney Transplantation Research Center, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran

Address for correspondence:Mahtab Zargham, Urology Department Office, Al Zahra Hospital, Shohadaye Soffeh Blvd., Isfahan, Iran mah_zargham@yahoo.com

February 2013

18 2 167 167

2013

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

<p>Sir,</p> <p>Thyroid dysfunction is a common problem, especially among women. Thyrotoxicosis is characterized by exaggerated responses to catecholamines, while in hypothyroidism, narrowing of adaptive responses is observed. It is, therefore, not surprising to see gastrointestinal and lower urinary tract symptoms (LUTS) in patients with thyroid dysfunction.</p> <p>Unfortunately, published articles addressing voiding dysfunction in hyper-and hypothyroidism are scarce, most of them being case reports. In June 2012, we searched PubMed, Google Scholar, EMBASE, and Ovid for articles about these issues. The obtained results are as follows.</p> <p>Most hypothyroid patients are middle-aged women. They may develop retention of urine and renal failure. <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup>This retention could be the presenting symptom or may be found incidentally in a patient who has other signs and symptoms of hypothyroidism like myxedema, malaise, a change in the tone of voice, and mental confusion. <sup> <xref ref-type="bibr" rid="ref2">2</xref> </sup>Paralytic ileus (colonic pseudo-obstruction) has been reported in association with bladder atony in the setting of hypothyroidism. <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref2">2</xref> </sup>Uremia may ensue as the result of urinary retention or acute kidney injury. <sup> <xref ref-type="bibr" rid="ref3">3</xref> </sup>In less severe cases, only a reduction in the voiding frequency and urine volume is observed without bothering the patient. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup></p> <p>Hyperthyroidism is also more common among women. Patients may exhibit both irritative and obstructive LUTS. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>Of the LUT symptoms, urinary frequency is the most common. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>Other storage symptoms include urgency, urge incontinence, nocturia, and enuresis (either primary or secondary). <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>Of the voiding symptoms, incomplete emptying and straining have been reported. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>Patients rarely complain of urgency, frequency, and enuresis; therefore, they should be asked about these symptoms in moderate to severe cases of hyperthyroidism. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup></p> <p>Urodynamic study has been performed in a few cases and the findings include: Diminished flow rate, increased post-void residue, increased pelvic floor activity during voiding, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>early first sensation, and detrusor overactivity. <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>Bladder capacity has been reported to be normal, decreased, <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>or increased. <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>In a study, although the peak flow rate was significantly less than the control group, it was still in the normal range. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>Chung and colleagues followed up some 11,000 female hyperthyroid patients for 3 years and found that the risk of developing urinary incontinence in them was more than in the healthy, control group (hazard ratio = 1.54). <sup> <xref ref-type="bibr" rid="ref7">7</xref> </sup></p> <p>Bladder involvement may be the presenting symptom or may appear a few months after the onset of the thyroid disease and is responsive to proper medical therapy. However, complete improvement may take several weeks to a few months.</p> <p>To better define the manifestations of bladder involvement in thyroid dysfunction, larger cohort of patients with thyroid problems should be evaluated for LUTS and urodynamic study be performed when indicated. Also, the incidence of thyroid dysfunction in patients presenting with LUTS should be determined.</p> </sec> </body> <back> <ref-list> <ref id="ref1"> <label>1</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Hansen</surname> <given-names>MV</given-names> </name> <name> <surname>Engberg</surname> <given-names>A</given-names> </name> </person-group> <article-title>Uremia as a complication to urinary retention due to hypothyreosis.Case report</article-title> <source>Scand J Urol Nephrol</source> <year>1988</year> <volume>22</volume> <fpage>351</fpage> <lpage>3</lpage> </nlm-citation> </ref> <ref id="ref2"> <label>2</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Nathan</surname> <given-names>AW</given-names> </name> <name> <surname>Havard</surname> <given-names>CW</given-names> </name> </person-group> <article-title>Paralytic ileus and urinary retention due to hypothyroidism</article-title> <source>Br Med J (Clin Res Ed)</source> <year>1982</year> <volume>285</volume> <fpage>477</fpage> </nlm-citation> </ref> <ref id="ref3"> <label>3</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Rodrigo</surname> <given-names>C</given-names> </name> <name> <surname>Gamakaranage</surname> <given-names>CS</given-names> </name> <name> <surname>Epa</surname> <given-names>DS</given-names> </name> <name> <surname>Gnanathasan</surname> <given-names>A</given-names> </name> <name> <surname>Rajapakse</surname> <given-names>S</given-names> </name> </person-group> <article-title>Hypothyroidism causing paralytic ileus and acute kidney injury: Case report</article-title> <source>Thyroid Res</source> <year>2011</year> <volume>4</volume> <fpage>7</fpage> </nlm-citation> </ref> <ref id="ref4"> <label>4</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Andersen</surname> <given-names>LF</given-names> </name> <name> <surname>Agner</surname> <given-names>T</given-names> </name> <name> <surname>Walter</surname> <given-names>S</given-names> </name> <name> <surname>Hansen</surname> <given-names>JM</given-names> </name> </person-group> <article-title>Micturition pattern in hyperthyroidism and hypothyroidism</article-title> <source>Urology</source> <year>1987</year> <volume>29</volume> <fpage>223</fpage> <lpage>4</lpage> </nlm-citation> </ref> <ref id="ref5"> <label>5</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Ho</surname> <given-names>CH</given-names> </name> <name> <surname>Chang</surname> <given-names>TC</given-names> </name> <name> <surname>Guo</surname> <given-names>YJ</given-names> </name> <name> <surname>Chen</surname> <given-names>SC</given-names> </name> <name> <surname>Yu</surname> <given-names>HJ</given-names> </name> <name> <surname>Huang</surname> <given-names>KH</given-names> </name> </person-group> <article-title>Lower urinary tract symptoms and urinary flow rates in female patients with hyperthyroidism</article-title> <source>Urology</source> <year>2011</year> <volume>77</volume> <fpage>50</fpage> <lpage>4</lpage> </nlm-citation> </ref> <ref id="ref6"> <label>6</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Goswami</surname> <given-names>R</given-names> </name> <name> <surname>Seth</surname> <given-names>A</given-names> </name> <name> <surname>Goswami</surname> <given-names>AK</given-names> </name> <name> <surname>Kochupillai</surname> <given-names>N</given-names> </name> </person-group> <article-title>Prevalence of enuresis and other bladder symptoms in patients with active Graves′ disease</article-title> <source>Br J Urol</source> <year>1997</year> <volume>80</volume> <fpage>563</fpage> <lpage>6</lpage> </nlm-citation> </ref> <ref id="ref7"> <label>7</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Chung</surname> <given-names>SD</given-names> </name> <name> <surname>Chen</surname> <given-names>YK</given-names> </name> <name> <surname>Chen</surname> <given-names>YH</given-names> </name> <name> <surname>Lin</surname> <given-names>HC</given-names> </name> </person-group> <article-title>Hyperthyroidism and female urinary incontinence: A population-based cohort study</article-title> <source>Clin Endocrinol (Oxf)</source> <year>2011</year> <volume>75</volume> <fpage>704</fpage> <lpage>8</lpage> </nlm-citation> </ref> <ref id="ref8"> <label>8</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"></person-group> <article-title></article-title> <source></source> <year></year> <volume></volume> <fpage></fpage> </nlm-citation> </ref> </ref-list> </back> </article>