132
DIETRICK AND ASSOCIATES
There are a number of surgical and anesthetic techniques described to minimize blood loss during surgery in patients who refuse blood transfusions, including extreme hemodilution,7 autotransfusion,8 controlled hypotension,9 artificial plasma ex panders,10 artificial oxygen-carrying molecules11 and acute lim ited normovolemic hemodilution.12 While these techniques are useful to decrease the loss of red cells and maintain blood pressure, they do not increase the hematocrit and are only marginally helpful in a patient with pre-existing severe anemia. Recombinant human erythropoietin is an acidic glycoprotein with an estimated molecular weight of 34,000.5 Recombinant human erythropoietin increases red cell production by stimu lating the proliferation, differentiation and maturation of the erythroid precursors.13 There are 2 major erythroid precursors, burst-forming unit-erythroid and colony-forming unit-eryth roid.3 The burst-forming unit-erythroid precursor is found ear lier in the synthetic pathway and is also affected by a number of other hematopoietic growth factors, including interleukin-1 and GM-CSF. Recombinant human erythropoietin acts on its target cells through a receptor-mediated mechanism that is not completely understood.3 However, it has been shown that re combinant human erythropoietin can induce the synthesis of membrane and cytoskeletal proteins, heme and hemoglobin in erythroid precursors.6 Recombinant human erythropoietin was first used to treat the anemia associated with end stage renal disease, where it has become a mainstay of treatment.14 More than 95% of the patients with end stage renal disease benefit from recombinant human erythropoietin therapy with an increased hematocrit, freedom from transfusions and an enhanced sense of well being.14 The other current and potential indications for recom binant human erythropoietin treatment include refractory ane mia,2· 14 sickle cell disease15 and anemia of prematurity,16 and in patients undertaking autologous blood donation for elective surgery.17 Patients with anemia of chronic disease or secondary to malignancy may also benefit from recombinant human erythropoietin therapy.4• 18 The toxicity of recombinant human erythropoietin in clinical trials of end stage renal disease patients has been relatively mild. The most important side effect reported was an increase in or new presentation of hypertension, which is postulated to result from an increase in blood viscosity with an accompanying elevation in peripheral resistance.3• 14 However, in normal pa tients treated with recombinant human erythropoietin no clin ically significant hypertension has been reported.4 Recombi nant human erythropoietin antibodies have not been found in any patient.14 In our patient no adverse effects were noted while on recom binant human erythropoietin and the clinical response to this form of treatment was excellent, allowing us to perform exten sive reconstruction safely. Our case illustrates a new approach to the challenge presented by the Jehovah's Witness patient who requires an operation. We recommend that recombinant
human erythropoietin therapy be considered in any patient requiring an elective operation who refuses blood transfusions. REFERENCES
1. Dixon, J. L. and Smalley, M. G.: Jehovah's Witnesses. The sur gical/ethical challenge. J.A.M.A., 246: 2471, 1981. 2. Ponticelli, C. and Casati, S.: Correction of anaemia with recombi nant human erythropoietin. Nephron, 52: 201, 1989. 3. Zanjani, E. D. and Ascensao, J. L.: Erythropoietin. Transfusion, 29: 46, 1989. 4. Erslev, A. J., Wilson, J. and Caro, J.: Erythropoietin titers in anemic, nonuremic patients. J. Lab. Clin. Med., 109: 429, 1987. 5. Flaharty, K. K., Caro, J.,Erslev, A., Whalen, J. J., Morris,E. M., Bjornsson, T. D. and Vlasses, P. H.: Pharmacokinetics and erytlrropoietic response to human recombinant erythropoietin in healthy men. Clin. Pharm. Ther., 47: 557, 1990. 6. Spivak, J. L.: The mechanism of action of erythropoietin. Int. J. Cell Cloning, 4: 139, 1986. 7. Trouwborst, A., Hagenouw, R. R. P. M., Jeekel, J. and Ong, G. L.: Hypervolaemic haemodilution in an anaemic Jehovah's Witness. Brit. J. Anaesth., 64: 646, 1990. 8. Byrne, M. P.: Abdominal aortic aneurysm surgery in the Jehovah's Witness. Use of autotransfusion. Ill. Med. J., 150: 87, 1976. 9. Cunningham, A. J. A.: Controlled hypotension to minimize blood loss of anaemic Jehovah's Witness patient undergoing total hip and shoulder replacement. Brit. J. Anaesth., 54: 895, 1982. 10. Puri, V. K., Paidipaty, B. and White, L.: Hydroxyethyl starch for resuscitation of patients with hypovolemia and shock. Crit. Care Med., 9: 833, 1981. 11. Tremper, K. K. and Cullen, B. F.: U.S. clinical studies of the treatment of anemia with fluosol-DA 20%. Artif. Organs, 8: 19, 1984. 12. Grubbs, P.E., Jr., Marini, C. P. and Fleischer, A.: Acute hemodi lution in an anemic Jehovah's Witness during extensive abdom inal wall resection and reconstruction. Ann. Plast. Surg., 22: 448, 1989. 13. Schwenk, M. H. and Halstenson, C. E.: Recombinant human erythropoietin. D.I.C.P., 23: 528, 1989. 14. Eschbach, J. W.,Egrie, J. C., Downing, M. R., Browne, J. K. and Adamson, J. W.: Correction of the anemia of end-stage renal disease with recombinant human erythropoietin. Results of a combined phase I and II clinical trial. NewEngl. J. Med., 316: 73, 1987. 15. Sherwood, J. B., Goldwasser, E., Chilcote, R., Carmichael, L. D. and Nagel, R. L.: Sickle cell anemia patients have low erythro poietin levels for their degree of anemia. Blood, 67: 46, 1986. 16. Shannon, K. M.: Anemia of prematurity: progress and prospects. Amer. J. Ped. Hematol. Oncol., 12: 14, 1990. 17. Goodnough, L. T., Rudnick, S., Price, T. H., Ballas, S. K., Collins, M. L., Crowley, J. P., Kosmin, M., Kruskall, M. S., Lenes, B. A., Menitove, J.E., Silberstein, L.E., Smith, K. J., Wallas, C. H., Abels, R. and Von Tress, M.: Increased preoperative collection of autologous blood with recombinant human erythropoietin therapy. NewEngl. J. Med., 321: 1163, 1989. 18. Ludwig, H., Fritz,E., Kotzmann, H., Hocker, P., Gisslinger, H. and Barnas, U.:Erythropoietin treatment of anemia associated with multiple myeloma. NewEngl. J. Med., 322: 1693, 1990.
0022-5347/92/1471-0132$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 147, 132-134, January 1992 Printed in U.S.A.
INTRAVESICAL MIGRATION OF INTRAUTERINE DEVICE DANIEL D. DIETRICK,* MUTA M. ISSA, JOHN N. KABALIN
AND
JAMES B. BASSETT
From the Departments of Urology, Stanford University Hospital, Stanford and Palo Alto Medical Clinic, Palo Alto, California
ABSTRACT
Intrauterine devices have been plagued by many early and late complications, including uterine perforation and migration into adjacent structures. To our knowledge only 18 cases have been reported in the literature of migration of an intrauterine device into the bladder. We report on a
INTRAVESICAL MIGRATION OF INTRAUTER1:l\fE DEVICE
133
38-year-old woman in whom an intrauterine device eroded from the c1terus 3 years after µs,CAv•0H." The device remained asymptomatic in the pelvis for an additional 13 years before the patient presented with urinary symptoms. The literature is reviewed. KEY WORDS: bladder, trauma, intrauterine devices, foreign body migration Intrauterine devices have been plagued by many complica tions since their introduction, including uterine perforation, septic abortion and migration into adjacent organs. The Dalkon shield intrauterine device was finally removed from the market in the early 1970s due to its unusually high association with complications. To our knowledge only 18 cases of migration into the bladder have been reported in the literature. We report a case in which 16 years elapsed between insertion and removal of an intrauterine device in the bladder. CASE REPORT
A 38-year-old woman presented with a 2-month history of pelvic pressure, suprapubic pain, urinary urgency and terminal hematuria. Urinalysis revealed 15 to 25 leukocytes and 20 to 25 erythrocytes per high power field, and a urine culture was sterile. Further history revealed that a Dalkon shield intrauter ine device had been placed 16 years ago. However, 13 years before the current evaluation she had undergone emergency hysterectomy and bilateral salpingo-oophorectomy after a pel vic abscess and sepsis developed when the intrauterine device perforated the uterus. The device was not recovered at opera tion and it remained in the pelvis as confirmed by postoperative radiography. The patient remained asymptomatic and no fur ther intervention was done at that time. At examination a tender area in the anterior vaginal wall was noted. A plain radiograph of the pelvis showed a 5.5 cm. calcified mass in the pelvis. Computerized tomography con firmed the presence of a calcified mass at the posterior bladder wall, possibly intramural, without surrounding air or fluid collection. Cystoscopy revealed a large, freely mobile calculus in the bladder with no mucosa! erythema or edema. Cystolith otomy was performed, and the bladder mucosa and bladder wall showed no defects. The disk-shaped calculus measured 5.2 X 4.5 x 1.5 cm. and had a rough surface. Upon fracturing the stone the intact Dalkon shield intrauterine device was con tained entirely within the calculus (see figure). The patient tolerated the procedure well and was discharged from the hospital 5 days postoperatively. DISCUSSION
Since introduction of the intrauterine device there have been many reports of complications, including infections, sponta neous abortions and uterine nl'rt,,r�,t, Although erosion of an intrauterine device into au,1m;ca, structures is an exception ally rare complication, intrauterine devices have been found in the peritoneum, omentum, appendix and colon. Including our case a total of 19 cases of intravesica! perforation by an intra uterine device has been reported in the literature.1-18 Although perforation of the uterus by an intrauterine device is often a silent phenomenon erosion into the bladder usually causes voiding symptoms. Patients typically present with irritative voiding symptoms (11 cases), recurrent urinary tract infections (8) and/or hematuria (5). A constant, dull abdominal pain occurred in 7 cases and menouria (vesical menstruation) was noted in 1. These symptoms can develop many years after the device is inserted. Among the 19 cases reported the duration of symptoms before diagnosis ranged from 3 months to 5 years, and the interval between insertion and removal of the device ranged from 6 months to 16 years. In half of the 8 cases reported since 1986, including our case, erosion from the uterus and into the bladder took 10 years or longer. Our case demonstrates that Accepted for publication April 19, 1991. * Requests for reprints: Department of Urology, S287, Stanford University Hospital, Stanford, California 94305.
Calculus removed at cystolithotomy reveals intact Dalkon shield an intrauterine device may erode into the bladder and become symptomatic as long as 16 years after placement and 13 years after it was free within the pelvis. To our knowledge this is the longest duration reported in the literature to date" The intrauterine device most commonly associated with mi gration has been the Lippes loop (6 cases). Of these cases 5 occurred before 1977, whereas after 1978, 4 of the 5 cases reported involved the Dalkon shield intrauterine device. Once an intrauterine device has eroded into the bladder it usually becomes either partially or totally incrusted with calculus (12 cases). However, the degree of calculus formation is variable and independent of the duration in the bladder. Vecsey reported calculus formation as early as 6 months after penetration, 17 while Kiilholma et al reported no calculus formation around the small portion of a Nova-T intrauterine device that was within the bladder for 3 years. 18 The Dalkon shield device was finally withdrawn from the market in the early 1970s because of its unusually high associ ation with complicated pregnancies and mid trimester septic abortions. However, despite its removal from the market more than a decade and a half ago, the Dalkon shield and other intrauterine devices remain a source of uncommon but severe pelvic pathology. Vesical calculi in men more than 50 years old usually result from factors , "" ""·' ,,. urinary prostatic hypertrophy or bladder diverticu urethral lum. Vesical calculi are unusual in women and the presence of intravesical stones should raise the suspicion of the presence of a foreign body. Erosion of an intrauterine device into the bladder should be considered whenever a woman with an un retrieved intrauterine device presents with irritative voiding symptoms, pelvic pain and/or hematuria. REFERENCES
1. Rubin, A.: Complications due to Lippe's loop. Report of a death and other complications seen over an 18-month period at Bar gawanath Hospital. S. Afr. J. Obst. Gynaec., 10: 45, 1972. 2. Ansari, A. H.: Diagnosis and management of intrauterine device with missing tail. Obst. Gynec., 44: 727, 1974. 3. Saronwala, K. C., Singh, R. and Dass, H.: Lippes loop perforation of the uterus and urinary bladder with stone formation. Obst. Gynec., 44: 424, 1974. 4. Hefnawi, F., Hosni, M., El-Sheikha, Z., Serour, G. I. and Hasseeb, F.: Perforation of the uterine wall by the Lippes loop in postpar tum women. In: Analysis of Intrauterine Contraception. Edited
134 5. 6. 7. 8. 9.
10. 11.
QUINT AND ASSOCIATES
by F. Hefnawi and S. J. Segal. New York: American Elsevier Co., Inc., pp. 469-476, 1975. Weekes, L. R.: Complications of intrauterine contraceptive devices. J. Natl. Med. Ass., 67: 1, 1975. Iglesias, J., Corbalan, G., Galan, G. and Gayan, P.: Perforation of uterus and bladder by Lippes loop. Rev. Chi!. Obst. Ginec., 42: 149, 1977. Buchsbaum, H. J. and Schmidt, J. D.: Gynecological and Obstetric Urology. Philadelphia: W. B. Saunders Co., p. 88, 1978. Neutz, E., Silber, A. and Merendino, V. J.: Dalkon Shield perfora tion of the uterus and urinary bladder with calculus formation: case report. Amer. J. Obst. Gynec., 130: 848, 1978. Junceda Avello, E., Gonzalez Torga, L., Lasheras Villanueva, J. and Gonzalez Bernaldo de Quiros, A.: Perforacion Uterina y migracion vesical de un dispositivo intrauterino observacion casuistica. Acta Ginec61., 30: 79, 1977. Ruiz, M., Soto, E., Rioseco,-E. and Campod6nico, I.: Intravesical intrauterine Copper-T device. Echographic diagnosis. Rev. Chi!. Obst. Ginec., 44: 84, 1979. Woods, M. and Wise, H. M., Jr.: An unusual cause of cystolithiasis:
a migrant intrauterine device. J. Urol., 124: 720, 1980. 12. Goldstein, M. S.: Personal communication. Cited by Zakin, D.: Perforation of the bladder by the intrauterine device. Obst. Gynec. Surv., 39: 59, 1984. 13. Schwartzwald, D., Mooppan, U. M. M., Tancer, M. L., Gomez Leon, G. and Kim, H.: Vesicouterine fistula with menouria: a complication from an intrauterine contraceptive device. J. Urol., 136: 1066, 1986. 14. Thomalla, J. V.: Perforation of urinary bladder by intrauterine device. Urology, 27: 260, 1986. 15. Hillie, K. E., Ystgaard, B. and Due, J.: Perforation of the urinary bladder. A complication of the spiral IUD. Tidsskr. Nor. Laege foren, 107: 545, 1987. 16. Sasidharan, K. and Chally, R.: Intravesical migration of Lippes loop with stone formation. Brit. J. Urol., 61: 363, 1988. 17. Vecsey, D.: Intrauterine device-a rare foreign body in the urinary bladder. Med. Klin., 83: 575, 1988. 18. Kiilholma, P., Makinen, J. and Vuori, J.: Bladder perforation: uncommon complication with a misplaced IUD. Adv. Contra cept., 5: 47, 1989.
0022-534 7/91/1471-0134$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 147, 134-137, January 1992
Printed in U.S.A.
EMPHYSEMATOUS CYSTITIS: A REVIEW OF THE SPECTRUM OF DISEASE HOWARD J. QUINT, GEORGE W. DRACH, WILLIAM D. RAPPAPORT AND C. J. HOFFMANN From the Department of Surgery, Sections of Urology and Surgery, University of Arizona, Tucson, Arizona
ABSTRACT
Emphysematous cystitis is an uncommon condition in which pockets of gas are formed in and around the bladder wall by gas-forming organisms. Persons with diabetes, neurogenic bladder and chronic urinary infection are predisposed to the disease. Severity of illness ranges from an asymp tomatic condition to life-threatening cystitis. We present 2 cases of emphysematous cystitis. One case was an incidental finding on evaluation of abdominal discomfort with resolution upon removal of predisposing factors. The other patient presented with an acute abdomen that progressed to severe necrotizing cystitis ultimately requiring cystectomy. The initial involvement of the urologist as a consultant is emphasized. A complete review of the literature describes the incidence, various presentations, associated diseases and organisms, pathogenesis, and available methods for diagnosis and treatment reported for this disease. Successful management depends on early diagnosis with correction of underlying causes, administration of appropriate antibiotics, establishment of adequate bladder drainage and surgical excision of involved tissue when required. Early detection and prompt treatment are encouraged. KEY WORDS: cystitis, bladder diseases
Emphysematous cystitis (cystitis emphysematosa) is a rare condition in which bacteria produce gas in the bladder wall and lumen. It is associated with diabetes mellitus, glucosuria and chronic urinary tract infections.1 Emphysematous cystitis has been described by some as a benign and reversible condition not affecting the prognosis of the patient.1-3 Others have de scribed it as a disease with a grim prognosis and an often fatal outcome.4· 5 We report on 2 patients with emphysematous cystitis: 1 with minor symptoms and complete recovery, and 1 who had pro gression resulting in cystectomy. Our experience demonstrates that the disease represents a spectrum of illness with variable prognosis. A review of the literature reveals that this disease may have subtle clinical findings, may be difficult to diagnose, requires early management of predisposing factors and may have a wide range of sequelae. By reviewing the variety of presentations, clinical courses and potential outcomes de scribed in this disease we hope to encourage early recognition and prompt management of this unusual condition. Accepted for publication April 26, 1991.
CASE REPORTS
Case 1. A 59-year-old woman required back surgery to correct spinal stenosis associated with lower extremity weakness. She had no voiding complaints but had recently been treated for an Escherichia coli urinary tract infection. Because of poor nutri tion from gastric outlet obstruction she was admitted to the general surgery service for preoperative total parenteral nutri tion. While all measured serum glucose levels were less than 300 mg./dl. (normal 70 to 110) and glucosuria was never docu mented, 1 urinalysis was positive for ketones. On total paren teral nutrition day 20 crampy abdominal pain developed. Ex amination revealed mild abdominal distension and diffuse ten derness. Abdominal radiographs revealed extraperitoneal pelvic gas (fig. 1). Urological consultation was obtained. Computerized tomography (CT) demonstrated gas within and surrounding the bladder wall (fig. 2). Urine culture yielded Klebsiella. Symp toms resolved after appropriate antibiotic therapy. Case 2. A 63-year-old woman with a history of an atonic bladder, and chronic laxative and alcohol abuse presented to
DIETRICK AND ASSOCIATES
There are a number of surgical and anesthetic techniques described to minimize blood loss during surgery in patients who refuse blood transfusions, including extreme hemodilution,7 autotransfusion,8 controlled hypotension,9 artificial plasma ex panders,10 artificial oxygen-carrying molecules11 and acute lim ited normovolemic hemodilution.12 While these techniques are useful to decrease the loss of red cells and maintain blood pressure, they do not increase the hematocrit and are only marginally helpful in a patient with pre-existing severe anemia. Recombinant human erythropoietin is an acidic glycoprotein with an estimated molecular weight of 34,000.5 Recombinant human erythropoietin increases red cell production by stimu lating the proliferation, differentiation and maturation of the erythroid precursors.13 There are 2 major erythroid precursors, burst-forming unit-erythroid and colony-forming unit-eryth roid.3 The burst-forming unit-erythroid precursor is found ear lier in the synthetic pathway and is also affected by a number of other hematopoietic growth factors, including interleukin-1 and GM-CSF. Recombinant human erythropoietin acts on its target cells through a receptor-mediated mechanism that is not completely understood.3 However, it has been shown that re combinant human erythropoietin can induce the synthesis of membrane and cytoskeletal proteins, heme and hemoglobin in erythroid precursors.6 Recombinant human erythropoietin was first used to treat the anemia associated with end stage renal disease, where it has become a mainstay of treatment.14 More than 95% of the patients with end stage renal disease benefit from recombinant human erythropoietin therapy with an increased hematocrit, freedom from transfusions and an enhanced sense of well being.14 The other current and potential indications for recom binant human erythropoietin treatment include refractory ane mia,2· 14 sickle cell disease15 and anemia of prematurity,16 and in patients undertaking autologous blood donation for elective surgery.17 Patients with anemia of chronic disease or secondary to malignancy may also benefit from recombinant human erythropoietin therapy.4• 18 The toxicity of recombinant human erythropoietin in clinical trials of end stage renal disease patients has been relatively mild. The most important side effect reported was an increase in or new presentation of hypertension, which is postulated to result from an increase in blood viscosity with an accompanying elevation in peripheral resistance.3• 14 However, in normal pa tients treated with recombinant human erythropoietin no clin ically significant hypertension has been reported.4 Recombi nant human erythropoietin antibodies have not been found in any patient.14 In our patient no adverse effects were noted while on recom binant human erythropoietin and the clinical response to this form of treatment was excellent, allowing us to perform exten sive reconstruction safely. Our case illustrates a new approach to the challenge presented by the Jehovah's Witness patient who requires an operation. We recommend that recombinant
human erythropoietin therapy be considered in any patient requiring an elective operation who refuses blood transfusions. REFERENCES
1. Dixon, J. L. and Smalley, M. G.: Jehovah's Witnesses. The sur gical/ethical challenge. J.A.M.A., 246: 2471, 1981. 2. Ponticelli, C. and Casati, S.: Correction of anaemia with recombi nant human erythropoietin. Nephron, 52: 201, 1989. 3. Zanjani, E. D. and Ascensao, J. L.: Erythropoietin. Transfusion, 29: 46, 1989. 4. Erslev, A. J., Wilson, J. and Caro, J.: Erythropoietin titers in anemic, nonuremic patients. J. Lab. Clin. Med., 109: 429, 1987. 5. Flaharty, K. K., Caro, J.,Erslev, A., Whalen, J. J., Morris,E. M., Bjornsson, T. D. and Vlasses, P. H.: Pharmacokinetics and erytlrropoietic response to human recombinant erythropoietin in healthy men. Clin. Pharm. Ther., 47: 557, 1990. 6. Spivak, J. L.: The mechanism of action of erythropoietin. Int. J. Cell Cloning, 4: 139, 1986. 7. Trouwborst, A., Hagenouw, R. R. P. M., Jeekel, J. and Ong, G. L.: Hypervolaemic haemodilution in an anaemic Jehovah's Witness. Brit. J. Anaesth., 64: 646, 1990. 8. Byrne, M. P.: Abdominal aortic aneurysm surgery in the Jehovah's Witness. Use of autotransfusion. Ill. Med. J., 150: 87, 1976. 9. Cunningham, A. J. A.: Controlled hypotension to minimize blood loss of anaemic Jehovah's Witness patient undergoing total hip and shoulder replacement. Brit. J. Anaesth., 54: 895, 1982. 10. Puri, V. K., Paidipaty, B. and White, L.: Hydroxyethyl starch for resuscitation of patients with hypovolemia and shock. Crit. Care Med., 9: 833, 1981. 11. Tremper, K. K. and Cullen, B. F.: U.S. clinical studies of the treatment of anemia with fluosol-DA 20%. Artif. Organs, 8: 19, 1984. 12. Grubbs, P.E., Jr., Marini, C. P. and Fleischer, A.: Acute hemodi lution in an anemic Jehovah's Witness during extensive abdom inal wall resection and reconstruction. Ann. Plast. Surg., 22: 448, 1989. 13. Schwenk, M. H. and Halstenson, C. E.: Recombinant human erythropoietin. D.I.C.P., 23: 528, 1989. 14. Eschbach, J. W.,Egrie, J. C., Downing, M. R., Browne, J. K. and Adamson, J. W.: Correction of the anemia of end-stage renal disease with recombinant human erythropoietin. Results of a combined phase I and II clinical trial. NewEngl. J. Med., 316: 73, 1987. 15. Sherwood, J. B., Goldwasser, E., Chilcote, R., Carmichael, L. D. and Nagel, R. L.: Sickle cell anemia patients have low erythro poietin levels for their degree of anemia. Blood, 67: 46, 1986. 16. Shannon, K. M.: Anemia of prematurity: progress and prospects. Amer. J. Ped. Hematol. Oncol., 12: 14, 1990. 17. Goodnough, L. T., Rudnick, S., Price, T. H., Ballas, S. K., Collins, M. L., Crowley, J. P., Kosmin, M., Kruskall, M. S., Lenes, B. A., Menitove, J.E., Silberstein, L.E., Smith, K. J., Wallas, C. H., Abels, R. and Von Tress, M.: Increased preoperative collection of autologous blood with recombinant human erythropoietin therapy. NewEngl. J. Med., 321: 1163, 1989. 18. Ludwig, H., Fritz,E., Kotzmann, H., Hocker, P., Gisslinger, H. and Barnas, U.:Erythropoietin treatment of anemia associated with multiple myeloma. NewEngl. J. Med., 322: 1693, 1990.
0022-5347/92/1471-0132$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 147, 132-134, January 1992 Printed in U.S.A.
INTRAVESICAL MIGRATION OF INTRAUTERINE DEVICE DANIEL D. DIETRICK,* MUTA M. ISSA, JOHN N. KABALIN
AND
JAMES B. BASSETT
From the Departments of Urology, Stanford University Hospital, Stanford and Palo Alto Medical Clinic, Palo Alto, California
ABSTRACT
Intrauterine devices have been plagued by many early and late complications, including uterine perforation and migration into adjacent structures. To our knowledge only 18 cases have been reported in the literature of migration of an intrauterine device into the bladder. We report on a
INTRAVESICAL MIGRATION OF INTRAUTER1:l\fE DEVICE
133
38-year-old woman in whom an intrauterine device eroded from the c1terus 3 years after µs,CAv•0H." The device remained asymptomatic in the pelvis for an additional 13 years before the patient presented with urinary symptoms. The literature is reviewed. KEY WORDS: bladder, trauma, intrauterine devices, foreign body migration Intrauterine devices have been plagued by many complica tions since their introduction, including uterine perforation, septic abortion and migration into adjacent organs. The Dalkon shield intrauterine device was finally removed from the market in the early 1970s due to its unusually high association with complications. To our knowledge only 18 cases of migration into the bladder have been reported in the literature. We report a case in which 16 years elapsed between insertion and removal of an intrauterine device in the bladder. CASE REPORT
A 38-year-old woman presented with a 2-month history of pelvic pressure, suprapubic pain, urinary urgency and terminal hematuria. Urinalysis revealed 15 to 25 leukocytes and 20 to 25 erythrocytes per high power field, and a urine culture was sterile. Further history revealed that a Dalkon shield intrauter ine device had been placed 16 years ago. However, 13 years before the current evaluation she had undergone emergency hysterectomy and bilateral salpingo-oophorectomy after a pel vic abscess and sepsis developed when the intrauterine device perforated the uterus. The device was not recovered at opera tion and it remained in the pelvis as confirmed by postoperative radiography. The patient remained asymptomatic and no fur ther intervention was done at that time. At examination a tender area in the anterior vaginal wall was noted. A plain radiograph of the pelvis showed a 5.5 cm. calcified mass in the pelvis. Computerized tomography con firmed the presence of a calcified mass at the posterior bladder wall, possibly intramural, without surrounding air or fluid collection. Cystoscopy revealed a large, freely mobile calculus in the bladder with no mucosa! erythema or edema. Cystolith otomy was performed, and the bladder mucosa and bladder wall showed no defects. The disk-shaped calculus measured 5.2 X 4.5 x 1.5 cm. and had a rough surface. Upon fracturing the stone the intact Dalkon shield intrauterine device was con tained entirely within the calculus (see figure). The patient tolerated the procedure well and was discharged from the hospital 5 days postoperatively. DISCUSSION
Since introduction of the intrauterine device there have been many reports of complications, including infections, sponta neous abortions and uterine nl'rt,,r�,t, Although erosion of an intrauterine device into au,1m;ca, structures is an exception ally rare complication, intrauterine devices have been found in the peritoneum, omentum, appendix and colon. Including our case a total of 19 cases of intravesica! perforation by an intra uterine device has been reported in the literature.1-18 Although perforation of the uterus by an intrauterine device is often a silent phenomenon erosion into the bladder usually causes voiding symptoms. Patients typically present with irritative voiding symptoms (11 cases), recurrent urinary tract infections (8) and/or hematuria (5). A constant, dull abdominal pain occurred in 7 cases and menouria (vesical menstruation) was noted in 1. These symptoms can develop many years after the device is inserted. Among the 19 cases reported the duration of symptoms before diagnosis ranged from 3 months to 5 years, and the interval between insertion and removal of the device ranged from 6 months to 16 years. In half of the 8 cases reported since 1986, including our case, erosion from the uterus and into the bladder took 10 years or longer. Our case demonstrates that Accepted for publication April 19, 1991. * Requests for reprints: Department of Urology, S287, Stanford University Hospital, Stanford, California 94305.
Calculus removed at cystolithotomy reveals intact Dalkon shield an intrauterine device may erode into the bladder and become symptomatic as long as 16 years after placement and 13 years after it was free within the pelvis. To our knowledge this is the longest duration reported in the literature to date" The intrauterine device most commonly associated with mi gration has been the Lippes loop (6 cases). Of these cases 5 occurred before 1977, whereas after 1978, 4 of the 5 cases reported involved the Dalkon shield intrauterine device. Once an intrauterine device has eroded into the bladder it usually becomes either partially or totally incrusted with calculus (12 cases). However, the degree of calculus formation is variable and independent of the duration in the bladder. Vecsey reported calculus formation as early as 6 months after penetration, 17 while Kiilholma et al reported no calculus formation around the small portion of a Nova-T intrauterine device that was within the bladder for 3 years. 18 The Dalkon shield device was finally withdrawn from the market in the early 1970s because of its unusually high associ ation with complicated pregnancies and mid trimester septic abortions. However, despite its removal from the market more than a decade and a half ago, the Dalkon shield and other intrauterine devices remain a source of uncommon but severe pelvic pathology. Vesical calculi in men more than 50 years old usually result from factors , "" ""·' ,,. urinary prostatic hypertrophy or bladder diverticu urethral lum. Vesical calculi are unusual in women and the presence of intravesical stones should raise the suspicion of the presence of a foreign body. Erosion of an intrauterine device into the bladder should be considered whenever a woman with an un retrieved intrauterine device presents with irritative voiding symptoms, pelvic pain and/or hematuria. REFERENCES
1. Rubin, A.: Complications due to Lippe's loop. Report of a death and other complications seen over an 18-month period at Bar gawanath Hospital. S. Afr. J. Obst. Gynaec., 10: 45, 1972. 2. Ansari, A. H.: Diagnosis and management of intrauterine device with missing tail. Obst. Gynec., 44: 727, 1974. 3. Saronwala, K. C., Singh, R. and Dass, H.: Lippes loop perforation of the uterus and urinary bladder with stone formation. Obst. Gynec., 44: 424, 1974. 4. Hefnawi, F., Hosni, M., El-Sheikha, Z., Serour, G. I. and Hasseeb, F.: Perforation of the uterine wall by the Lippes loop in postpar tum women. In: Analysis of Intrauterine Contraception. Edited
134 5. 6. 7. 8. 9.
10. 11.
QUINT AND ASSOCIATES
by F. Hefnawi and S. J. Segal. New York: American Elsevier Co., Inc., pp. 469-476, 1975. Weekes, L. R.: Complications of intrauterine contraceptive devices. J. Natl. Med. Ass., 67: 1, 1975. Iglesias, J., Corbalan, G., Galan, G. and Gayan, P.: Perforation of uterus and bladder by Lippes loop. Rev. Chi!. Obst. Ginec., 42: 149, 1977. Buchsbaum, H. J. and Schmidt, J. D.: Gynecological and Obstetric Urology. Philadelphia: W. B. Saunders Co., p. 88, 1978. Neutz, E., Silber, A. and Merendino, V. J.: Dalkon Shield perfora tion of the uterus and urinary bladder with calculus formation: case report. Amer. J. Obst. Gynec., 130: 848, 1978. Junceda Avello, E., Gonzalez Torga, L., Lasheras Villanueva, J. and Gonzalez Bernaldo de Quiros, A.: Perforacion Uterina y migracion vesical de un dispositivo intrauterino observacion casuistica. Acta Ginec61., 30: 79, 1977. Ruiz, M., Soto, E., Rioseco,-E. and Campod6nico, I.: Intravesical intrauterine Copper-T device. Echographic diagnosis. Rev. Chi!. Obst. Ginec., 44: 84, 1979. Woods, M. and Wise, H. M., Jr.: An unusual cause of cystolithiasis:
a migrant intrauterine device. J. Urol., 124: 720, 1980. 12. Goldstein, M. S.: Personal communication. Cited by Zakin, D.: Perforation of the bladder by the intrauterine device. Obst. Gynec. Surv., 39: 59, 1984. 13. Schwartzwald, D., Mooppan, U. M. M., Tancer, M. L., Gomez Leon, G. and Kim, H.: Vesicouterine fistula with menouria: a complication from an intrauterine contraceptive device. J. Urol., 136: 1066, 1986. 14. Thomalla, J. V.: Perforation of urinary bladder by intrauterine device. Urology, 27: 260, 1986. 15. Hillie, K. E., Ystgaard, B. and Due, J.: Perforation of the urinary bladder. A complication of the spiral IUD. Tidsskr. Nor. Laege foren, 107: 545, 1987. 16. Sasidharan, K. and Chally, R.: Intravesical migration of Lippes loop with stone formation. Brit. J. Urol., 61: 363, 1988. 17. Vecsey, D.: Intrauterine device-a rare foreign body in the urinary bladder. Med. Klin., 83: 575, 1988. 18. Kiilholma, P., Makinen, J. and Vuori, J.: Bladder perforation: uncommon complication with a misplaced IUD. Adv. Contra cept., 5: 47, 1989.
0022-534 7/91/1471-0134$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 147, 134-137, January 1992
Printed in U.S.A.
EMPHYSEMATOUS CYSTITIS: A REVIEW OF THE SPECTRUM OF DISEASE HOWARD J. QUINT, GEORGE W. DRACH, WILLIAM D. RAPPAPORT AND C. J. HOFFMANN From the Department of Surgery, Sections of Urology and Surgery, University of Arizona, Tucson, Arizona
ABSTRACT
Emphysematous cystitis is an uncommon condition in which pockets of gas are formed in and around the bladder wall by gas-forming organisms. Persons with diabetes, neurogenic bladder and chronic urinary infection are predisposed to the disease. Severity of illness ranges from an asymp tomatic condition to life-threatening cystitis. We present 2 cases of emphysematous cystitis. One case was an incidental finding on evaluation of abdominal discomfort with resolution upon removal of predisposing factors. The other patient presented with an acute abdomen that progressed to severe necrotizing cystitis ultimately requiring cystectomy. The initial involvement of the urologist as a consultant is emphasized. A complete review of the literature describes the incidence, various presentations, associated diseases and organisms, pathogenesis, and available methods for diagnosis and treatment reported for this disease. Successful management depends on early diagnosis with correction of underlying causes, administration of appropriate antibiotics, establishment of adequate bladder drainage and surgical excision of involved tissue when required. Early detection and prompt treatment are encouraged. KEY WORDS: cystitis, bladder diseases
Emphysematous cystitis (cystitis emphysematosa) is a rare condition in which bacteria produce gas in the bladder wall and lumen. It is associated with diabetes mellitus, glucosuria and chronic urinary tract infections.1 Emphysematous cystitis has been described by some as a benign and reversible condition not affecting the prognosis of the patient.1-3 Others have de scribed it as a disease with a grim prognosis and an often fatal outcome.4· 5 We report on 2 patients with emphysematous cystitis: 1 with minor symptoms and complete recovery, and 1 who had pro gression resulting in cystectomy. Our experience demonstrates that the disease represents a spectrum of illness with variable prognosis. A review of the literature reveals that this disease may have subtle clinical findings, may be difficult to diagnose, requires early management of predisposing factors and may have a wide range of sequelae. By reviewing the variety of presentations, clinical courses and potential outcomes de scribed in this disease we hope to encourage early recognition and prompt management of this unusual condition. Accepted for publication April 26, 1991.
CASE REPORTS
Case 1. A 59-year-old woman required back surgery to correct spinal stenosis associated with lower extremity weakness. She had no voiding complaints but had recently been treated for an Escherichia coli urinary tract infection. Because of poor nutri tion from gastric outlet obstruction she was admitted to the general surgery service for preoperative total parenteral nutri tion. While all measured serum glucose levels were less than 300 mg./dl. (normal 70 to 110) and glucosuria was never docu mented, 1 urinalysis was positive for ketones. On total paren teral nutrition day 20 crampy abdominal pain developed. Ex amination revealed mild abdominal distension and diffuse ten derness. Abdominal radiographs revealed extraperitoneal pelvic gas (fig. 1). Urological consultation was obtained. Computerized tomography (CT) demonstrated gas within and surrounding the bladder wall (fig. 2). Urine culture yielded Klebsiella. Symp toms resolved after appropriate antibiotic therapy. Case 2. A 63-year-old woman with a history of an atonic bladder, and chronic laxative and alcohol abuse presented to
