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456

Letters

Radiology

mean in the test group (patients with spinal cord injuries) with that for the control group for mean ejection fraction:

and the Environment

David Magaram, in his recent letter [1], has made an interesting, environmentally friendly suggestion that appears to solve two problems at once. When I was working at a municipal public hospital, we often had shortages of various kinds. At least some of these were

(SD, 19.72 vs 1 1 .88; coefficient

overcome because of ingenuity. The radiology department’s supply of paper for letters consisted entirely of the sheets used for interleaving X-ray films in boxes. The film boxes themselves were used in a number of ways. Films for teaching files were placed in these boxes,

patients

which were then labeled in accordance Some of the boxes were used for dispatch section of the department. boxes came from the nursing staff of the boxes

by the patients’

bedsides,

with the standardized separating

X-ray

films

criteria. in the

Frequent requests for these the wards, who used to hang

as receptaclesfor

clinical

papers.

Unused X-ray films that got accidentally exposed to light or stored films that had not been used before their expiration date were not thrown away. Instead they were immersed in a solution of chemical fixer and then washed and dried. The unusable films were transformed

into usable

written

data on a view

transparent

sheets,

box. These

suitable

were

for communicating

also ideal “slides”

for

handwritten text and hand-drawn diagrams used in overhead projections with epidiascopes. Though partly because of scarcities, we were being environmen-

with spinal

cord injury

be of great

interest,

provid-

quotient

of ejected

volume

in

is lower than that in control subjects: this to the lower resting volume in the

49% vs 62%. They attribute patients with spinal cord injury.

However,

divided

ejection

by resting

fraction

volume,

is the

so a lower

resting volume would, on the contrary, increase the ejection fraction. A much more plausible reason for their finding would be the lower ejected

volume:

1 i ml in the test group

We think it is misleading al. do in their

Figure

vs 17 ml in the control

to represent

2 (in [1]).

group.

the data as Nino-Murcia

If gallbladder

volume

(their

et

data)

is

plotted as a function of time, it appears that the T#{189}, the time required for the gallbladder to empty half its volume, is markedly prolonged in patients with spinal cord injuries as compared with control subjects: 50 vs 34 mm (Fig. 1 this letter). Because only mean data are reported by Nino-Murcia et al., not the results for individual patients, standard ,

deviation

and statistical

significance

cannot

be generated.

However,

these results seem to agree with our previous data ([2, 3]; ChassinKaplan SL et al., paper presented at the annual meeting of the

30

REFERENCE

25

DL. Radiology and the environment

would

ing each of the subgroups has a sufficient number of patients. Nino-Murcia et al. find that the gallbladder ejection fraction

tally friendly all the same. I would like to hear from other radiologists about similar waste-reducing experiences. Hemant Morpana Bombay 400006, India

1 . Magararn

of variability,

lysis of the data after stratification

compared

3.6 vs 2.1 0.40 vs 0.19). Reana-

Gallbladder

volume

(ml)

(letter). AiR 1991;156:863 20 15

Gallbladder Cord Injury

Contractility

in Patients

with Spinal

We question the methods, results, and conclusions of Nino-Murcia et al. in their article “Gallbladder Contractility in Patients with Spinal Cord Injuries: A Sonographic Investigation” [1]. Their study design has several flaws, which makes their interpretation of the data ambiguous. The authors’ test group was not stratified according to relative completeness,

naI

10

duration,

or level of spinal cord injury, all of which may

obscure differences based on the degree of autonomic The lack of stratification is shown by the large standard

dysfunction. error of the

cord injury

5 0 0

5

10

15

20

25

30

35

40

45

50

55

60

minutes Fig. 1.-Graph shows gallbladder contractility in control subjects and in patients with spInal cord Injuries (based on data from Ninl-Murcia et aI. [1]).

AJR:i58,

February

American tying

Spinal Injury Association,

is impaired

in patients

May 1988) that gallbladder

with high spinal

cord injury. Michael

emp-

D. Apstein

Harvard University Veterans

Affairs

Medical

West Roxbury,

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457

LETTERS

1992

Kaplan Milne Irvine

Norah

University Veterans

of California,

Affairs

completely comparing

Center

MA 02132

Susan

Medical

Long Beach,

or 10.5 ml, or essentially the end volume of a fully contracted gallbladder. In other words, T#{189} for normal controls means the time it takes to empty 82.4% of the ejectable gallbladder volume, whereas T#{189} for patients with spinal cord injuries means the time it takes to

Center

CA 90822

empty apples

the ejectable and oranges.

volume of the gallbladder. That is This is why we chose to normalize

the kinetics ordinate scale by expressing gallbladder volumes as a percentage of the total ejectable volume. When this procedure is used, T#{189} is meaningful and, more to the point, identical for both patients and controls. In summary, we stand by our conclusions. Matilde Nino-Murcia Inder Perkash

REFERENCES

Stanford

2. 3.

1990;154:521-524 Williams W, Apstein M, Chassin 5, et al. Gallbladder injury patients. J NucI Med 1987;28:P596 Milne N, Segal JL, Rypins EB, et al. Biliary kinetics (SCI). J NucI Med 1987;28:P688

motility

University

Veterans

Affairs

University cord

School

CA 94305

Medical

Center

Palo Alto, CA 94304 Paul J. Chang

in spinal cord

in spinal

Medical

Stanford,

1 . Nino-Murcia M, Burton D, Chang P, et al. Gallbladder contractility in patients with spinal cord injuries: a sonographic investigation. AJR

of Iowa

injury

Hospital

and

Clinics

Iowa City, IA 52242 REFERENCES 1 . Nino-Murcia contractility

Reply

Apstein, Kaplan, and Milne have made three criticisms ofour article [1]. First, they observe that none of our patients were stratified according to the completeness, duration, or level of the injury. Dr. Milne was the coauthor of a previous letter to the editor [2], to which we have already responded [3]. We emphasize once again reanalyzed our data after stratification. The results confirm

that we our ob-

servation that gallbladder contractility does not differ significantly in patients with spinal cord injuries as compared with control subjects. Their

second

the quotient lower

criticism

is that inasmuch

as the ejection

fraction

is

of the ejected volume divided by the resting volume,

resting

volume

allegedly

would

increase

the ejection

a

fraction.

The conclusion wrongly assumes that the ejected volume will remain constant. This can never be the case if the resting volume is smaller and the end volume is the same: The ejected volume will also be smaller. For example, assume that the resting volume of a normal control gallbladder is 1 0 ml and that its end volume, after contraction,

is 5 ml. The ejection fraction is then (1 0 5)/i 0, or 50%. Let us then suppose that the resting volume of the gallbladder in a patient with a spinal cord injury is smaller, say 8 ml, but that its end volume is also 5 ml. The ejection fraction is then (8 5)/8, or 37.5%. What this -

-

exampie

illustrates,

then,

is that the ejection

fraction

is smaller

with

a lower resting volume. The example also illustrates gallbladder

contractility

underlying

physiologic

that describing in terms of the ejection fraction obscures the

fact: The observed

smaller

ejection

fraction

is

not due to impaired contractility but to a smaller initial resting volume. The calculated smaller ejection volume is not of primary importance, and certainly does not characterize the process. It is secondary to what is primarily a simple arithmetic relationship. The third criticism is that if gallbladder volume is plotted as a function

of time, it appears

that T,

the time required

for the gallblad-

M, Burton D, Chang P, Stone J, Perkash I. Gallbladder in patients with spinal cord injuries: a sonographic investiga-

tion. AJR 1990;154:521-524 Segal JL, Milne N. Gallbladder (Ietter).AJR 1991;i57:4i2

2.

3. Nino-Murcia, function

function in patients with spinal cord injury

Perkash I, Chang P. Reply. To: Segal JL, Milne N. Gallbladder with spinal cord injury (letter). AiR 1991;157:412-413

in patients

Insulinomas: MR Imaging Motion Suppression

with STIR

Sequences

and

Insulinomas are often a diagnostic challenge, because they are usually less than 2 cm in size at the time of dinical presentation. Diagnostic sensitivity has ranged from 43% to 78% with CT scanning,

60% to 90% with angiography, and 8i% to 90% for pancreatic selective venous sampling [1 , 2]. Although MR imaging has shown low sensitivity for the detection offunctional islet cell tumors, a recent study [3] showed that gastrinomas were markedly hyperintense to adjacent tissues on short TI inversion recovery (STIR) images. We

assessed the usefulness of STIR imaging for the detection of insulinomas. Two women and one man 26-45 years old with possible insulinoma were referred for MR imaging. All had normal findings on contrastenhanced CT scans. MR imaging was performed at 1 .5 T (GE Signa, Milwaukee, WI), and glucagon (0.5 mg) was given IV after the initial localizing MR sequence. Pulse sequences included axial Ti -weighted (233-500/i 6-20 [TRITE]), T2-weighted (2000/20, 80), and STIR (i 700-2000/30-43, TI i 40) images. Slice thickness was 5 or 6 mm, with a 50% interslice gap. Respiratory compensation of phase-encoding steps was used for all sequences.

MR correctly surgical

confirmation

with reordering

showed the insulinoma in both patients who had of their tumors. Both of these lesions were

1 cm in size at surgery. T2-weighted images, slightly about

They were hypointense

isointense to pancreas on on Ti -weighted images,

der to empty half its volume, is markedly prolonged in patients with spinal cord injuries as opposed to control subjects. Our response is as follows: The graph Apstein et al. provide is misleading, because they have not normalized the ordinate scale. Basically, the absolute gallbladder volume cannot be used as the reference scale for both patients and control subjects. This is a basic tenet of kinetics methodology. Thus, for example, half the resting volume for a control patient is (28/2) or 14 ml, which represents a gallbladder that still has about 17.6% of its total ejectable volume remaining. Half of the

third patient, in whom insulinoma ultimately was excluded on the basis of clinical findings, no insulinoma was seen on MR images. Although angiography and pancreatic selective venous sampling may help in detecting small insulinomas that are not shown on CT, a noninvasive alternative would be preferred. Although Frucht et al. [3] found a sensitivity of only 24% for MR detection of intrapancreatic gastrinomas, the STIR technique was not used for some patients in

resting

their series. Frucht et al. also did not use respiratory

volume

for a patient

with a spinal cord

injury

would

be (2i/2),

and markedly

hyperintense

on STIR images

(Figs. 1 and 2). In the

compensation

LETTERS

458

AJA:158, February 1992

areas of lung parenchyma subtended by these fissures are not referred to as lobes. Likewise, lobes that have incomplete or virtually nonexistent

fissures

do not lose their lobar identity. Ferris Hall Beth Israel Hospital

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Harvard

Medical Boston,

School

MA

02215

REFERENCES 1 . Mata J, C#{225}ceres J, Alegret X, Coscojuela P, De Marcos JA. Imaging the azygos lobe: normal anatomy and variations. AJR 1991;156:931-937 2. Glossary of terms for thoracic radiology: recommendations of the nomenclature committee of the Fleischner Society. AJR 1984;143:509-517 Fig. 1.-Insulinorna of head of pancreas in 41-year-old man. STIR MR Image (1700/30, TI 140) shows a 1-cm lesion (arrow) that is hyperintense to surroundIng rim of normal pancreatic tissue.

Fig. 2.-lnsulinoma Image (2000/43, adjacent normal

of pancreatic body in 45-year-old woman. STIR MR TI 140) shows 1-cm lesion (arrow) that is hyperintense to pancreas (arrowheads). Incidental hemangiomas (H) are

present In liver.

and glucagon, respiration

thereby,

increasing

and peristalsis,

improves

the number

respectively.

delineation

of the pancreas

of(i)

supression

combination

motion

of artifacts

Administration

during techniques

due to

of glucagon

MR imaging

[4]. The

Reply

We thank Dr. Hall for his interest in our paper [1]. The expression azygos lobe is a time-honored term that has been used by prominent anatomists and radiologists [2-4]. We have used it to avoid semantic variations that may confuse or mislead the reader. We agree with Dr. Hall that azygos fissure or anomalous azygos vein and fissure are more appropriate terms, as the azygos fissure does not limit a real anatomic structure. J. M. Mata

J. C#{225}ceres

and (2) high contrast Hospital

associated with STIR imaging allowed us to detect small insulinomas and would likely improve detection of other islet cell tumors of the pancreas. Ruben

Yale University School of Medicine New Haven, CT 06510 REFERENCES 1. Rossi P, Baert A, Passariello A, Simonetti G, Pavone P, Tempesta P. CT of functioning tumors of the pancreas. AJR 1985;i44:57-60 2. Gunther RW, Klose KJ, RuCkert K, Bayer J, Kuhn FP, Klotter HJ. Localizatin of small islet cell tumors: preoperative and intraoperative ultrasound, computed tomography, arteriography, digital subtraction angiography, and pancreatic venous sampling. Gastrointest Radiol 1985;10:i45-152 3. Frucht H, Doppman JL, Norton JA, et al. Gastrinomas: comparison of MA imaging with CT, angiography, and US. Radiology 1989;171 :713-717 4. Tscholakoff D, Hricak H, Thoeni A, Winkler ML, Margulis AR. MR imaging in the diagnosis of pancreatic disease. AiR 1987;i48:703-709

Lobe:

Mata et al. [1] on their lobe. However, I take semantic

REFERENCES 1 . Mata J, C#{225}ceres J, Alegret X, Coscojuela P, De Marcos JA. Imaging of the azygos lobe: normal anatomy and variations. AJR 1991;i56:931-937 2. Stibbe EP. The accessory pulmonary lobe of the vena azygos. J Anat 1919;53:305-313 3. Boyden EA. Developmental anomalies of the lungs. Am J Surg

1955;89:79-89 4. Felson B. The azygos Roentgenol

lobe: variations

in health

and

disease.

Semin

1989;24:56-66

Pneumothorax

and Thoracentesis

I read with interest the paper by Raptopoulos

et al. [i], who found

a sharp decrease in the prevalence of pneumothorax when sonography rather than clinical examination was used for guidance during thoracentesis. I report a simple way to reduce even further the prevalence of pneumothorax. For many years, I have been doing sonographically guided thora-

A Nonentity?

I commend

Universidad Aut#{244}noma 08025 Barcelona, Spain

Kier

Barbara Kinder

The Azygos

de Sant Pau

lucid

article

on imaging

the

centesis

with

a

16- or 18-gauge

Jelco IV catheter

placement

unit

azygos exception to their use, and the use by many other authors, of the term azygos lobe. I think that a more appropriate term would be azygos fissure or anomalous azygos vein and fissure. The Fleischner Society defines a lobe of the lung as “one of the

(Citikon, Tampa, FL). Sonography is used to localize the pleural fluid precisely before the needle-cannula unit is inserted. Continuous aspiration through an attached 2-mI syringe is maintained during placement of the unit, and as soon as fluid is obtained, the cannula is advanced, and the needle is withdrawn. Extension tubing and a three-

principal

way stopcock are attached to the cannula, and the fluid is aspirated by using a 50-mi syringe. The cannula is blunt, so therapeutic thora-

divisions

of the lungs (usually

three on the right and two on

the left) that are separated in whole or in part by pleural fissures” [2]. This definition is similar to those found in standard medical dictionaries

and clearly

on the basis offissures. accessory

fissure,

the basal segments fissures

(as illustrated

does not intend

Commonly,

fissures

that a lobe be defined

radiologists

separating

solely

identify a right inferior

the superior

of the lower lobes, or assorted

segments

from

supernumerary

by Mata et al. in their Fig. 1 7A). However,

the

centesis can be performed safely without fear of penetrating the expanding lung. Using this technique, I have performed hundreds of thoracenteses (usually aspirating all the fluid possible) and have had only one pneumothorax, which presumably was produced during the initial placement of the needle-cannula unit. Substituting a cannula for a

AJR:158,

1992

February

needle thus increases sonographically

guided

further the safety advantage thoracentesis.

provided

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by using

Patrick

J. Bryan

San Antonio Community

Hospital

Upland,

CA 91786

REFERENCE i

.

459

LETTERS

Raptopoulos V, David LM, Lee G, Umali C, Lew A, Irwin AS. Factors affecting the development ofpneumothorax associated with thoracentesis. AJR 1991;156:917-920

Erosion of Spinous We describe foreign

body

Process

After Surgery

a case of erosion of a spinous

process

caused by a

reaction

to a compress left behind dunng surgery. A 45-year-old man was admitted because he had had right-sided sciatic pain for 2 months. Seven years before he had had surgery for a herniated disk at L5-Si (median approach of L5-Si , clearing of

the left paraspinal gutter, cleaning out of the disk). the lumbar spine showed erosion of the left side process of the fourth lumbar vertebra (Fig. 1A); the of L5 appeared to be eroded on frontal views but

Radiographs of of the spinous superior border was normal on

Reply

Dr. Bryan’s guidance and

experience

with using a combination technique

a needle-catheter

of sonographic

to perform

thoracentesis

is worth noticing because his record is outstanding. However, to attribute his success to the use of the cannula may be conjectural. The needle-catheter unit makes good sense, but in a prospective randomized study done at the University of Massachusetts, my colleagues and I showed that use of this method was not associated with a decrease in the prevalence of pneumothorax when compared

with use of the needle-only subsequent

study

[2]

technique

in which

the

[i].

use

Dr.

Bryan

refers

of needle-catheter

to a

systems

was not investigated

any further. In addition, Dr. Bryan’s assumption is related to puncture of the lung may not be accurate. If so, the occurrence of pneumothorax after

that pneumothorax

completely percutaneous lung biopsy (lung puncture is obligatory) would have been high. Instead, pneumothorax may be related to the inability of

the lung to reexpand

as fast as the pleural cavity is emptied.

Accord-

ingly, our data have shown that excluding sonographic guidance, the size of the needle (or cannula) used and the amount of fluid aspirated are the only other factors that affect the development of pneumothorex associated with thoracentesis: the smaller the better for both needle and fluid [2]. Regardless, what is the clinical usefulness of aspirating the pleural cavity dry? If this is needed, we suggest that it be done in stages. thoracenteses,

whereas

may be statistically

significant,

clinical

Similarly,

importance.

18% rate of pneumothorax sonographic

guidance

views.

CT showed

irregular

erosion

of the spinous

we had five in 1 88 [2]. This difference

thought

to be the cause

but it is small and thus of doubtful

surgery

showed that to a compress

of the pain. Examination the erosion was caused

in “hundreds”

clinicians

in patients than

of sonograpically

would

argue

having thoracentesis

they

would

expect

that

our

without

on the

reaction

earlier

surgery

,

for this deficiency

the ability of trainees physicians.

by providing

special

does not equal the abilities

nstructions

had migrated

guidance may be most helpful for those in training. As for Dr. Bryan and others with similar experience, it would be imprudent to suggest that they change the techniques they use for thoracentesis.

Raptopoulos

Beth Israel Hospital

Medical School Boston,

MA 02215

REFERENCES 1 . Grogan DR, Irwin AS, Channick A, et al. Complications associated with thoracentesis: a prospective, randomized study comparing three different methods. Arch Intern Med 1990;i50:873-877 2. Raptopoulos V. Davis LM, Lee G, Wiali C, Lew A, Irwin AS. Factors affecting the development of pneumothorax associated with thoracentesis. AJR 1991;156:917-920

during the

B. Fouquet P. Goupille P. Cotty J. P. VaPat Trousseau Hospital 37044 Tours, France

[1],

Sonographic

Harvard

gutter

upward.

basis

of experienced

Vassilios

of the area during by a foreign body

left in the left paraspinal

that probably

of their own experiences. These anecdotal accounts illustrate that complex factors related to individual dexterity, although difficult to measure, cannot be downplayed. Thoracentesis is a common procedure, and in most teaching hospitals it is performed and learned by physicians in, and usually with the least, training. Although we tried to control

process,

1B)that did not enhance after IV administration and a herniated disk at L5-Si which was

many

is higher

lateral

an adjacent mass(Fig. of contrast material,

Dr. Bryan had one pneumothorax guided

of spinous process caused by a foreign body reaction. shows erosion of left side of spinous process of fourth lumbar vertebra (arrows). B, cr scan shows marked erosion of spinous process of fourth lumbar vertebra and an adjacent soft-tissue mass. Fig. 1.-Erosion A, Radiograph

Grid

for

CT-Guided

Percutaneous

Fine-Needle

Aspiration fine-needle aspirations are done by introducing a after the patient is scanned with a grid in place on the skin. The grid is often improvised, resulting in some inaccuracy in placement of the needle and considerable compromise Many CT-guided

needle from a point chosen

so

far as convenience and ease of application I have found that the wires of a common,

of the grid. inexpensive

egg slicer

The cost of the slicer is small-a little more than $1 -and the grid is easily detached from the base of the apparatus. The grid’s frame and wires are stainless steel, so it is (Fig.

i)

provide

an excellent

grid.

easily sterilized. CT scanning is done twice: with and without the grid in position. The grid is placed with the wires parallel to the long axis of the patient. The cross-sectional plane of entry is indicated by the pencil

460

LETTERS

AJA:i58,

1992

February

Fig. 1.-Retained surgical sponge 14 years after thoracot-

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omy. A, Chest radiograph shows cxtrapleural mass adjacent to left

hemldiaphragm. B and C, TI-weighted (500/25, B) and T2-weighted (200/90, C) MR images show that mass Is above diaphragm.

‘I

.

A

B

Fig. 1.-Grid for CT-guided percutaneous fine-needle aspiration. A, Grid consists of frame and wires (6.5 mm apart) from an egg slicer. B, CT scan shows needle placed Into posterior lung mass by using grid

for guidance.

beam

-240

of the CT gantry. A window width of 1200 H, centered on H, provides a clear image of the fine wires of the grid and of

the outer frame along each side. Choosing

the best site of entry along

the grid, relative to the lesion to be sampled, placement

allows highly accurate

of the needle.

Milton E. Tobias Brenthurst Clinic 2000, South Africa

Johannesburg

MR Appearance A 19-year-old

of a Retained

man was referred

Surgical

to National

Sponge

REFERENCES

Himeji Hospital

for

evaluation of a mass detected on a chest radiograph made during a routine examination. When he was 5 years old, he had had a pulmonary abscess resected at another hospital. Currently, the chest radiograph and a CT scan showed a mass adjacent to the left hemidiaphragm (Fig. iA). MR images showed that the mass was

separated from the stomach by the diaphragm, making a diaphragmatic hernia unlikely. The mass was hypointense relative to the spleen and slightly more intense than muscle on Ti- and T2-weighted images.

An area of high

intensity

was

present

in the center

1 . Kokubo T, ltai Y, Ohtomo K, Yoshikawa K, ho M, Atomi Y. Retained surgical sponges: CT and US appearance. Radiology 1987;165:4i5-418 2. Choi BI, Kim SH, Vu ES, Chung HS, Han MC, Kim CW. Retained surgical sponge: diagnosis with CT and sonography. AiR 1988;150: 1047-1050 3. Terrier F, Revel D, Hricak H, Feduska N. MRI of a retained sponge in a dog. Magn Reson Imaging 1985;3:283-286 4. Nabors MW, McCray ME, Clemente RJ, et al. Identification surgical sponge using magnetic resonance imaging. 1986;18:496-498

of a retained Neurosurgery

of the

lesion (Figs. 1B and 1C). Because of the patient’s previous thoracic surgery, the diagnosis was pulmonary granuloma. Thoracotomy showed a mass that was separate from both the lungs and the diaphragm. surgical

Pathologic sponge

inflammation.

examination

encapsulated

Extensive

central

showed

by an area

necrosis

that

the mass

was

a

granulomatous

of intense

was apparent.

Surgical sponges retained after thoracotomy or laparotomy cause acute and chronic inflammatory reactions and extensive fibrosis. The CT, MA, and sonographic findings have been reported in several cases [1 -4], but the diagnosis is usually difficult. In our case, the findings on MR correlated well with the findings on pathologic examination.

The area of reduced

intensity

in the periphery

of the mass

was caused by chronic inflammation, and the area of high intensity in the center was caused by necrosis. MR was useful for excluding diaphragmatic hernia as a possible diagnosis. Kazunan lshii Kazunori Maeda National Himeji Hospital

Kobe University,

Hyogo, 670 Japan Michio Kono School of Medicine Kobe, 650 Japan and colleagues

Psychogenic in a Child

Urinary Retention

An 1 1-year-old ned

because

encopresis. gocele.

(Hinman

Syndrome)

child with a history of urinary dribbling

of recurrent

tract

urinary

infections,

was exam-

enuresis,

and

The child had no history of spina bifida or myelomenin-

Neurologic

testing

showed

no bladder

sphincter

dyssynergia.

Renal sonograms showed mild hydronephrosis. Voiding cystourethrograms showed a huge, trabeculated bladder with bilateral grade IV reflux without urethral valves or ectopic ureteral implantation (Fig 1 A). Cystourethroscopic

findings were normal. Cranial and spinal MR

images were normal. Several years later, renal sonograms bilateral hydronephrosis significant family stress. identification that were pursuit of sex-changing clearly

precipitated

Psychogenic cause (Hinman

the

showed

progressive

severe

(Fig. i B). Psychologic evaluation revealed The mother had difficulties with gender manifested by cross-dressing and active

surgery. child’s

The mixture

voluntary

urinary

of familial

problems

retention.

urinary retention, or urinary retention syndrome) was reported by Braasch

without organic and Thompson

AJR:158,

February

LETTERS

1992

in

461

1935

[1] as a clinical

entity

in adults.

Later

Baldwin

and van

Gelderen [2] described six cases in children that were associated with constipation. Hinman syndrome typically occurs in females; only a few cases in males have been reported [i , 2]. Chapman [3]

this behavior as self-punishment in response to a patient’s hostile feelings. Whatever the mechanism, it is important to recognize such possibilities in patients who have chronic bladder obstruction and obstructive renal atrophy without anatomic cause.

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described

Raymond Kathleen

K. Tu

A. Scanlan

University of Wisconsin Madison, WI 53792

REFERENCES

Fig. 1.-Psychogenic

urinary retention

A, Voiding cystourethrogram bladder. Note normal urethra.

shows

(Hinman

syndrome). large, trabeculated (arrows),

atonic

B, Sonogram of left kidney shows marked, progressive pelvic dilatation (arrows) as compared with normal findings on previous sonograms.

1 . Braasch WF, Thompson GJ. Treatment of atonic bladder. Gynecol Surg 1935;61 :379-384 2. Baldwin IM, van Geldem HH. Urinary retention without organic cause in children. Br J Urol 1983;55:200-202 3. Chapman AU. Psychogenic urinary retention in women. Psychosom Med 1958;2i :119

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