P. Gleich

Self-inflicted foreign bodies involving lower urinary tract and male genitals

A great variety of self-inflicted foreign bodies have been removed from the lower urinary tract and male external genitalia. These foreign bodies were inserted or applied for autoerotic, psychiatric, therapeutic, or no definite reasons by the patient. Most patients were too ashamed to admit they had inserted or applied any object and usually presented when a complication had occurred from the foreign body such as difficulty voiding, hematuria, pain or swelling, extravasation, or abscess formation. Inspection and palpation diagnosed foreign bodies involving the male external genitalia in 3 patients and anterior urethra in 6. Radiographic studies with and without contrast medium and endoscopy were required to diagnose foreign bodies in the posterior urethra and bladder in 9 patients, and the exact location, shape, and orientation of the foreign bodies in all sites, radiolucent objects, and the complications of mucosal laceration and extravasation. All 16 foreign bodies in the anterior urethra (below urogenital diaphragm) were removed by endoscopic manipulation in the 6 patients. Nine foreign bodies in the posterior urethra or bladder (above the urogenital diaphragm) were removed by endoscopic manipulation in 2 females and 2 males, while suprapubic cystostomy was required in 1 female and 4 males. The 3 foreign bodies applied to the external genitalia of 3 males were removed carefully to avoid injury to the underlying skin. Foreign bodies lying below the urogenital diaphragm were palpable and readily removed endoscopically while foreign bodies above the urogenital diaphragm required greater endoscopic manipulation or open surgical procedures.

Management of urinary calculi in pregnancy

When a calculus is present in the upper urinary tract during pregnancy, the upper tract dilatation seen on radiography and ultrasonography can be due to the calculus or to the pregnancy. This makes the decision on management difficult unless there are associated clinical findings of pain or sepsis. The records of 24 pregnant patients with proved urinary calculi were reviewed. The stone passed spontaneously in 18 patients, and procedures to remove the stone were required in 6 for pain and/or sepsis. With an upper urinary tract calculus and dilatation during pregnancy the deciding factors for intervention were the clinical findings of pain and/or sepsis and not the dilatation alone.

Clinical Indications for Radiographic Evaluation of Blunt Renal Trauma

The evaluation of patients with blunt renal trauma has become controversial. We tested the hypothesis that renal contusion can be diagnosed clinically and that these patients do not require radiographic evaluation. To evaluate the association of microhematuria without shock and with renal contusion, we reviewed the medical records of 831 patients with hematuria following blunt renal trauma. Microscopic hematuria without shock was noted in 160 of 241 patients without and 334 of 590 with associated injuries. Of the former 160 patients 159 had renal contusion and 1 had a renal laceration, while of the latter 334 patients 329 had renal contusion, 3 had renal laceration, 1 had renal rupture and 1 had a pedicle injury. Most patients with microscopic hematuria and no shock after blunt renal trauma had a renal contusion, especially those with no associated injury. All of the patients with renal contusions experienced no complications from nonoperative management. However, avoiding a radiographic evaluation in patients with blunt renal trauma plus microhematuria and no shock would miss a few cases of severe renal injury.

Testicular Trauma: Potential Impact on Reproductive Function

PURPOSE The long-term effects of testicular trauma on reproductive function are unknown. In an effort to define the relationship between testicular injury and fertility in humans, we identified patients with a history of testicular trauma and assessed parameters commonly associated with fertility. MATERIALS AND METHODS We reviewed 15 patients 23 to 59 years old who underwent immediate exploration after testicular trauma between 1972 and 1991. Of the patients 11 were contacted and 8 returned for prospective followup. Reproductive and sexual histories, physical examination, measurements of serum hormones and antisperm antibodies, semen analysis and scrotal ultrasound were done. RESULTS Of the 8 patients 1 (13%) achieved and 7 (87%) did not attempt conception. Hormonal status was normal in all 8 patients. Six men had objective evidence of subfertility by semen analysis only, although none had severe oligospermia or asthenospermia and only 1 had severe teratospermia. Five of 9 traumatized testes were atrophic. Interestingly, only 1 patient had antisperm antibodies, the levels of which were probably low enough to be clinically insignificant. CONCLUSIONS There was definite evidence of subfertility as assessed by abnormal semen analyses and atrophic testes following testicular trauma. However, the subfertility did not appear to be immune mediated nor did the patients present with infertility. Since only 1 patient had severely compromised fertility according to semen analysis we conclude that early repair can help preserve hormonal function as well as fertility.

A 22-Year Followup of Ileal Conduits in Children with a Neurogenic Bladder

Previously, the ileal conduit had been used in children for diversion of urine from the neurogenic bladder to prevent deterioration of the upper urinary tracts and to manage urinary incontinence. Long-term results after ileal conduits in children have revealed upper tract deterioration and a high complication rate. The complications and renal deterioration rates in 139 children with ileal conduits followed up to 22 years were evaluated. Of 224 complications 114 required surgical correction. Upper urinary tract deterioration occurred in 16.5 per cent of 50 children followed for 10 or more years (mean 13.3 years). The ileal conduit has been replaced by clean intermittent catheterization, ureteral reimplantation for reflux, the artificial sphincter and undiversion in the management of neurogenic bladders in children. Long-term followup will be necessary to compare the results of these procedures to the known long-term results of the ileal conduit to determine the appropriate role of the ileal conduit in the management of children with neurogenic bladders.

Clean Intermittent Catheterization in the Management of the Neurogenic Bladder in Children

Clean intermittent catheterization has been successful in the management of urinary incontinence and upper tract changes associated with a neurogenic bladder. The results of clean intermittent catheterization controlling urinary incontinence, ureteral reflux, upper tract dilatation and urinary infection in 84 children with a neurogenic bladder were evaluated for up to 3 years of followup. Of the children 41 (49 per cent) were totally incontinent and 14 (17 per cent) were slightly damp. Preexisting ureteral reflux deteriorated in 25 per cent of the patients, ceased in 35 per cent and was unchanged in 40 per cent, while pre-existing upper tract dilatation improved in 12.5 per cent and was unchanged in 87.5 per cent. On clean intermittent catheterization and antibacterial medication 90 per cent of the children had sterile urine and 7.5 per cent had 10(5) or more colonies per ml. Complications occurred on 54 occasions but were minor in nature and were corrected easily. Half of the parents, schools and children found clean intermittent catheterization very acceptable or acceptable but a quarter of the parents and patients found it unacceptable or slightly unacceptable, or were undecided. Initial management of urinary complications associated with neurogenic bladder in children has changed to the clean intermittent catheterization program, with greatly improved results compared to Credés expression of the bladder, an indwelling urethral catheter or urinary diversion. However, the clean intermittent catheterization regimen was not effective completely, not without complications and not accepted completely by parents, schools and children.

Intractable Hematuria and Formalin

Massive hematuria, which is most frequently caused by radiation for pelvic malignancies, after treatment with cyclophosphamide or secondary to aggressive anticoagulation, represents a vexing problem for the practicing urologist. The existence of numerous therapeutic approaches results from the lack of an effective therapeutic modality. Lately, formalin seems to offer a new hope for the treatment of intractable hematuria. Analysis of published results after treatment with formalin revealed generally excellent results regarding control of hematuria. Nevertheless, the complication rate of formalin application is surprisingly high, including vesicoureteral reflux and hydroureteronephrosis as local reactions and systemically tubular necrosis with anuria. Our series of patients is presented with a detailed description of a patient who was afflicted with a vesicovaginal fistula following formalin instillation. Formalin can serve as excellent therapy for massive hematuria. If attention is paid to the concentration and to the technical details of its instillation the noxious side effects can be minimized or prevented in the majority of cases.

Renal pedicle injury in patients with multiple injuries.

In a study of 41 patients seen over 24 years, renal pedicle injuries were associated with life-threatening multiple system injuries and the immediate surgical management of these associated injuries by general surgeons took precedence over that of the renal pedicle injury. The result was the delayed diagnosis of the renal pedicle injury with loss of function of the kidney. In an effort to improve the renal salvage rate aggressive management of renal pedicle injuries with immediate radiologic evaluation and early surgical treatment was instituted in 1969. The records of 41 renal pedicle injuries from 1959 to 1983 were evaluated. Blunt external trauma was the cause in 76%. All 41 patients had multiple system injuries, averaging 3.7 associated injuries per patient, with 35 (85%) having a laparotomy for intra-abdominal injuries and an overall mortality rate of 44%. Conservative management was followed in 13 patients, with injury to the renal artery in nine and a branch of the renal artery in four, with a renal loss/delayed nephrectomy rate of nine of nine (100%) renal artery injuries. Immediate surgical management was performed in 23 patients, with injury to the renal artery in nine, the renal artery and renal vein in four, a branch of the renal artery in two, and the renal vein in eight, with a renal salvage rate of seven of 21 (33%) renal artery and/or vein injuries. Five patients died on admission or on the operating room table. A significant renal salvage rate resulted from immediate radiologic evaluation and early surgical treatment of renal artery/vein injuries compared to zero salvage rate with conservative management.

Management of the Neurogenic Bladder in 413 Children

During the last 10 years the management of the neurogenic bladder in children has changed from indwelling urethral catheterization or urinary diversion to intermittent catheterization or artificial sphincter implantation. Neurogenic bladder dysfunction in 413 children was caused by myelomeningocele in 323, traumatic paraplegia in 47, spastic quadriplegia in 11, sacral agenesis in 18 and spinal cord disease in 14. Management included indwelling urethral catheterization in 27 children, urinary diversion in 193, intermittent catheterization in 84, an artificial sphincter in 11 and undiversion in 6. No single treatment was completely effective or without significant complications.

Incidence of urinary tract complications with myelomeningocele

Children born with myelomeningocele face the morbidity of urinary tract complications after they have survived the neurologic complications of the first years of life. The incidence of urinary tract complications was evaluated in 258 children before any operation or intermittent catheter management was performed. In 119 children under one year of age the incidence of urinary tract infection of more than 10(5) colonies was 23 per cent, reflux was 22 per cent, and upper tract dilatation was 6 per cent. In children of all ages the incidence of urinary tract infection of more than 10(5) colonies was 26 per cent, reflux 34 per cent, upper tract dilatation 18 per cent, and urinary incontinence 87 per cent. In 11 children with complete denervation of the pelvic floor muscles reflux developed in 2 (18%) and upper tract dilatation in 1 (9%). In 13 children with slight or moderate denervation of the pelvic floor muscles reflux developed in 5 (38%) and upper tract dilatation in 7 (54%). The development of upper tract changes with myelomeningocele was mainly related to some innervation of the pelvic floor muscles (including periurethral striated muscle) with incoordinate detrusor/sphincter activity. These changes mainly occurred in the first two to four years of life.