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Journal of The Association of Physicians of India Vol.

63 July 2015

63

Herpes Zoster Infection Presenting with Urinary


Retention and Constipation
VM Bhalerao1, BS Gedam2, AK Mukharjee2
Abstract

antibiotics, and bladder training


exercises.

Herpes zoster is a sporadic disease that results from the reactivation of


latent Varicella zoster virus infection (VZV) from the dorsal root ganglion.
We report a case of herpes zoster of lumbosacral region presenting as
acute retention of urine and constipation, an uncommon presentation.

The patient improved after 10


days. His catheter was removed
and he started passing urine and
anal sphincter tone became normal.

Introduction

aricella zoster virus (VZV)


causes two distinct entities
i.e. chicken pox and herpes zoster,
chickenpox is usually a benign
illness during the childhood while
herpes zoster present as dermatome
rash associated with severe pain
and burning sensation. The virus
remain dormant in the dorsal root
ganglion for many years and may
get reactivated. The commonest
dermatome affected are thoracic
(42.4%), cranial (28.2%), lumbar
(7.8%) and sacral (4.8%).1 The
common clinical presentation is
severe pain followed by vesicular
rash in the affected dermatome.
I t l a s t f o r 7 t o 1 0 d a y s . We
report a case of herpes zoster of
lumbosacral nerves (L1-L2) and
(S2-S4) presenting as acute urinary
retention and constipation.

Case Report
A 75 year old man non-diabetic,
non-hypertensive was admitted
with the complaints of urinary
retention and constipation since
last 24 hours. There was no history
of urinary complaints in the past.
There was history of rash and
burning sensation on his lower
back and lower abdomen on
the right side, 8 days prior to
admission. He was diagnosed as
a case of herpes zoster infection at
government medical college and
was put on symptomatic treatment.
Otherwise there was no significant

past medical history. There was no


history of chickenpox.
On examination he was afebrile,
BP 120/80 mm Hg. There was no
edema feet. There was vesicular
rash over the lumbar and sacral
dermatomes (L1-L2 and S2-S4)
on right side (Figure 1). His
n e u r o l o g i c a l e x a m i n a t i o n wa s
normal, there was no weakness
i n t h e l o we r l i m b s , n o n u c h a l
rigidity and reflexes were normal.
His bladder was palpable up to
umbilicus. Other systems were
normal.
H i s i n ve s t i g a t i o n s r e ve a l e d
Hb-10.2 gm%, TLC- 8600/cmm,
DLC- normal, blood sugar- 86 mg/
dl. His kidney function tests and
liver function tests were normal.
His HIV and AA were non-reactive.
His MRI of lumbosacral spine was
normal, USG abdomen showed no
evidence of obstructive uropathy
and CT brain was normal. CSF
examination done to rule out aseptic
m e n i n g i t i s wa s a c e l l u l a r w i t h
normal proteins. His cystoscopy
was normal.
Considering his typical rash
over the lumbosacral dermatome
he was diagnosed as case of VZV
infection causing urinary retention
and constipation. He underwent
Foleys catheterization. He was also
treated with acyclovir for 10 days,

Discussion
The most common presentations
were paresthesias, pain and
itching. 2 In a study conducted
on 205 patients of herpes Abdul
et al found that only 4.8% had
sacral involvement while 42% had
thoracic involvement. 1
There are three syndromes
of zoster associated bladder
dysfunction. They are zoster
cystitis, zoster retention of urine
and zoster myelitis. Retention is
caused by spread of infection from
dorsal root ganglion into the sacral
motor neurons, roots or peripheral
nerves causing interruption of
bilateral detrusor reflex to manifest
as atonic bladder. 2
Involvement of the sacral nerve
roots (S2-S4) in herpes zoster is
uncommon. The virus involves
not only the ipsilateral nerve root
ganglion but also the meninges
and contralateral root involvement
partially. Thus herpes zoster may
cause bilateral pelvic nerve root
involvement eventhough the skin
eruption is unilateral. 3
Symptoms of sacral and lumbar
radiculopathy in herpes cause
dull or tingling pain in the lower
back, buttocks or anogenital area,
sciatica-like pain down the thighs,
weakness of the lower limb and
inability to walk on tip toes. In

Associate Professor, 2Lecturer, Department of Medicine, S.D.K.S.D.C. and Hospital, Nagpur, Maharashtra
Received: 04.12.2014; Revised: 03.04.2014; Accepted: 26.05.2014

64

Journal of The Association of Physicians of India Vol. 63 July 2015

constipation which fully recovered


after 3 weeks. Urodynamic
investigations should be considered
if symptoms fail to improve within
6-8 weeks of onset.
In conclusion patients
presenting with lumbosacral
herpes zoster should be warned
about possible urinary and bowel
symptoms and monitored carefully.

References

Fig. 1: Rash over lumbosacral dermatomes

rare cases urinary retention (5%),


constipation and transient paralysis
occur. 4
Urinary retention in herpes
zoster can also occur due to aseptic
meningitis, but in our patient there
was no evidence of fever, nuchal
rigidity, headache, weakness in the
lower limbs. His CSF examination
was normal.

We demonstrated a rare case


of acute urinary retention and
constipation secondary to herpes
zoster infection of the lumbosacral
nerve roots It is speculated that
n e u r o p a t h i c b l a d d e r d e ve l o p s
because of involvement of
detrusor reflex. VZV infection
in our case also resulted in anal
sphincter dysfunction resulting in

1.

Abdul EN, Pavithranm K. Herpes zoster


A clinical study of 205 patients. Indian J
Dermatol 2011; 56:529-32.

2.

Biddlestone J, Suraparaju L, Shah N. Herpes


zoster induced acute urinary retention in
the immunocompetant female. BMJ Case
Rep 2009 bcr-07, 2008, 0452.

3.

Sakakibara R, Yamanishi T, Uchiyama T,


Hattori T. Acute urinary retention due to
benign inflammatory nervous diseases. J
Neurol 2006; 253:1103-1110.

4.

Oates JK, Green House PR. Retention of


urine in anogenital herpatic infection.
Lancet 1978; 1:691-692.