LETTERS
TO
THE
EDITOR
CONSTIPATION: A CAUSE OF URINARY TRACT OBSTRUCTION AND INFECTION I was interested in the “Prostatoanal To the Editor: Syndrome” described by Puigvert, in the October issue (vol. 6, page 530) of UROLOGY. I have believed that there is a close relationship between bowel dysfunction and urinary tract disorders. I believe that constipation is a cause of urinary tract obstruction and, therefore, infection. Degree of constipation will dictate degree of obstruction and subsequent symptomatology. Because of the anatomic relationship of the organs, the pressure of rectal distention may obstruct the urethra, either directly or by angulation at the urethrovesical junction (Figs. 1 and 2). Elevation of the bladder floor by extrinsic bowel pressure can also obstruct one or both intravesical ureters, with resulting hydroureter and/or hydronephrosis. Urologists frequently see, via cystoscopic examination, a raised bladder floor caused by rectal pressure. The bladder in these cases is intrinsically normal. After bowel evacuation its appearance returns to normal. Urethral obstruction can vary with degree of constipation, resulting in residual urine of varying amounts. People with chronic constipation would therefore be most susceptible to recurrent urinary tract infection because of persistent residual urine.
Since patients do not associate these conditions, they do not volunteer the information to urologists. Therefore, physicians should interrogate their patients about their bowel habits as part of the urologic examination. They should treat constipation as a cause of urinary tract obstruction and infection. Experience has shown there is a marked decrease in recurrence of urinary tract infections, as well as urinary complaints, when bowel habits are regular and bowel problems corrected. Although this is most common in females, the male is also affected. It is more common in the young and in the elderly. Marks’ in 1964 coined a phrase “urethrorectal syndrome,” which describes the relationship of rectal pressure and the urge to urinate. Many patients over fifty years of age who complain of frequency and urgency of urination have an associated urge to defecate, which is utilized to relieve pressure. Many men with prostatitis complain of rectal fullness and urethral discharges with the passage of hard, constipated stool. Bowel symptoms are concomitant with prostatitis and benign prostatic hypertrophy. This is similar to Puigvert’s “prostatoanal syndrome.” Ravich, Lerman, and Schell’ previously reported that fecal impaction in a child can cause urinary retention, by causing marked angulation of the urethra
,Uterus
B
Bladder /
9
/ The urethra is shorter than in the mate
FIGURE 1. Sagittal view of female: pressure at (A) can elevate trigone and distort vesicourethral axis at junction, causing either partial or complete obstruction, depending on degree of pressure. Angulation of ureters with obstruction may also occur.
236
FIGURE 2. Sagittal view of male: increased pressures at (A) can cause prostatic symptoms, and at (B) distortion of vesicourethral axis and proportionate obstruction.
UROLOGY
/ FEBRUARY1976
/ VOLUMEVII,
NUMBER2
by extrinsic pressure. Removal of the fecal impaction relieved urinary retention and brought the urinary tract back to normal. Chronic constipation, causing persistent urethral obstruction, may result in an obstructed bladder, with or without trabeculation, with no evidence of intrinsic urethral or bladder neck pathology. Fecal impaction, a relatively common condition in the elderly and in psychiatric patients, was reported by La1 and Brown3 to have caused urinary obstruction in 2 patients. In one they reported bilateral megaloureter, pyonephrosis, and death. There is no question that urologic investigation in elderly patients with bowel problems will reveal mild-to-moderate urinary obstruction despite the lack of urinary complaints. Urinary retention is seen not infrequently in the elderly male with fecal impaction which is relieved by cleansing enemas after catheterization. Constipation should be considered a cause of urinary tract obstruction and of recurrent urinary tract infections. All physicians should include investigation of bowel habits with examinations for urinary tract infections. If there is a bowel disorder, successful correction may prevent further urinary tract infections and relieve urinary obstruction. Lawrence Ravich, M.D. 4277 Hempstead Turnpike Bethpage, New York 11714 References 1. MARKS, M. M.: Urethrorectal syndrome, Dis. Colon Rectum 7: 55 (1964). 2. RAVICH, L., LERMAN, P. H., and SCHELL, N. B.: Urinary retention due to fecal impaction, N.Y. State J. Med. 63: 3289 (1963). 3. LAL, S., and BROWN, G. N.: Unusual complications of fecal impaction in 2 patients, Am. J. Proctol. 18: 226 (1967).
ROLE OF PUBIC HAIR IN URINARY TRACT INFECTIONS As a practicing urologist in both the To the Editor: Middle East and now in the United States, I have noticed there are “occasional” urinary tract infections in the Middle Eastern women compared to “frequent” recurring infections in women in the United States. A striking difference is the customary “shaving” or “epilation” of the pubic genital hair of married women in the Middle East. Many urologists from different countries in the Middle East concur that there is less infection in women in these countries because they shave or epilate the pubic-genital hair. Many pioneer researchers exhausted all possible sources for recurring and relapsing urinary tract infection and found possible introital and rectal
UROLOGY
/
FEBRUARY 1976 /
VOLUME VII, NUMBER 2
contamination. It is surprising that although surgeons order routine shaves in preparing for a surgical procedure because of the high risk of infection carried by hair, to my knowledge no research has been done in this field. I hope someone who has the facilities will do this research. Realizing the possible objection to shaving her pubic hair by the average American woman, I have been instructing my female patients who have resistant and recurrent urinary tract infections to apply antibiotic ointment not only to the introital area but also to the pubic genital hair. These patients have been more comfortable because they had less infections. Han M. Ha&y, M.D. 203 North Vine Street Harrisburg, Illinois 62946
ACUTE RENAL ARTERY THROMBOSIS AND KIDNEY SALVAGE To the Editor: I would like to comment on “Acute Renal Artery Thrombosis Following Blunt Trauma,” by Lt. Col. J. W. McAninch, in the July issue (vol. 6, page 74) of UROLOGY. Although I agree with his management of the case, I do want to suggest that in those cases when nephrectomy is performed and the kidney is thought to be viable, it should be flushed with Collins, Sacks, or modified Ringer’s solution and placed on ice or perfused. Should the patient experience renal shutdown one might consider reimplanting the kidney in the iliac fossa at a later time. Should this not be necessary the kidney could then be used for homotransplantation. We recently received a kidney for perfusion from a hospital. It had been removed from a patient who had been shot in the abdomen. The bullet had partly severed the left renal artery at its take off from the aorta. Reconstruction was attempted but the patient continued to be hypotensive, and it was decided that the safest course would be to remove the kidney and preserve it. This was done, and the kidney was sent to our medical center for perfusion. The donor’s remaining kidney functioned, and there was no indication to reimplant the removed kidney. After obtaining proper consent, we transplanted the kidney into one of our waiting recipients. It is now about two months posttransplant, and the recipient has a creatinine of 1 mg. and blood urea nitrogen of 18 mg. per 100 ml. Close attention must be paid to the perfusion characteristics and that multiple cultures be taken from the donor kidney. S. Boczko, M.D. Montefiore Hospital 111 East 210 Street New York, New York 10467
237
TO
THE
EDITOR
CONSTIPATION: A CAUSE OF URINARY TRACT OBSTRUCTION AND INFECTION I was interested in the “Prostatoanal To the Editor: Syndrome” described by Puigvert, in the October issue (vol. 6, page 530) of UROLOGY. I have believed that there is a close relationship between bowel dysfunction and urinary tract disorders. I believe that constipation is a cause of urinary tract obstruction and, therefore, infection. Degree of constipation will dictate degree of obstruction and subsequent symptomatology. Because of the anatomic relationship of the organs, the pressure of rectal distention may obstruct the urethra, either directly or by angulation at the urethrovesical junction (Figs. 1 and 2). Elevation of the bladder floor by extrinsic bowel pressure can also obstruct one or both intravesical ureters, with resulting hydroureter and/or hydronephrosis. Urologists frequently see, via cystoscopic examination, a raised bladder floor caused by rectal pressure. The bladder in these cases is intrinsically normal. After bowel evacuation its appearance returns to normal. Urethral obstruction can vary with degree of constipation, resulting in residual urine of varying amounts. People with chronic constipation would therefore be most susceptible to recurrent urinary tract infection because of persistent residual urine.
Since patients do not associate these conditions, they do not volunteer the information to urologists. Therefore, physicians should interrogate their patients about their bowel habits as part of the urologic examination. They should treat constipation as a cause of urinary tract obstruction and infection. Experience has shown there is a marked decrease in recurrence of urinary tract infections, as well as urinary complaints, when bowel habits are regular and bowel problems corrected. Although this is most common in females, the male is also affected. It is more common in the young and in the elderly. Marks’ in 1964 coined a phrase “urethrorectal syndrome,” which describes the relationship of rectal pressure and the urge to urinate. Many patients over fifty years of age who complain of frequency and urgency of urination have an associated urge to defecate, which is utilized to relieve pressure. Many men with prostatitis complain of rectal fullness and urethral discharges with the passage of hard, constipated stool. Bowel symptoms are concomitant with prostatitis and benign prostatic hypertrophy. This is similar to Puigvert’s “prostatoanal syndrome.” Ravich, Lerman, and Schell’ previously reported that fecal impaction in a child can cause urinary retention, by causing marked angulation of the urethra
,Uterus
B
Bladder /
9
/ The urethra is shorter than in the mate
FIGURE 1. Sagittal view of female: pressure at (A) can elevate trigone and distort vesicourethral axis at junction, causing either partial or complete obstruction, depending on degree of pressure. Angulation of ureters with obstruction may also occur.
236
FIGURE 2. Sagittal view of male: increased pressures at (A) can cause prostatic symptoms, and at (B) distortion of vesicourethral axis and proportionate obstruction.
UROLOGY
/ FEBRUARY1976
/ VOLUMEVII,
NUMBER2
by extrinsic pressure. Removal of the fecal impaction relieved urinary retention and brought the urinary tract back to normal. Chronic constipation, causing persistent urethral obstruction, may result in an obstructed bladder, with or without trabeculation, with no evidence of intrinsic urethral or bladder neck pathology. Fecal impaction, a relatively common condition in the elderly and in psychiatric patients, was reported by La1 and Brown3 to have caused urinary obstruction in 2 patients. In one they reported bilateral megaloureter, pyonephrosis, and death. There is no question that urologic investigation in elderly patients with bowel problems will reveal mild-to-moderate urinary obstruction despite the lack of urinary complaints. Urinary retention is seen not infrequently in the elderly male with fecal impaction which is relieved by cleansing enemas after catheterization. Constipation should be considered a cause of urinary tract obstruction and of recurrent urinary tract infections. All physicians should include investigation of bowel habits with examinations for urinary tract infections. If there is a bowel disorder, successful correction may prevent further urinary tract infections and relieve urinary obstruction. Lawrence Ravich, M.D. 4277 Hempstead Turnpike Bethpage, New York 11714 References 1. MARKS, M. M.: Urethrorectal syndrome, Dis. Colon Rectum 7: 55 (1964). 2. RAVICH, L., LERMAN, P. H., and SCHELL, N. B.: Urinary retention due to fecal impaction, N.Y. State J. Med. 63: 3289 (1963). 3. LAL, S., and BROWN, G. N.: Unusual complications of fecal impaction in 2 patients, Am. J. Proctol. 18: 226 (1967).
ROLE OF PUBIC HAIR IN URINARY TRACT INFECTIONS As a practicing urologist in both the To the Editor: Middle East and now in the United States, I have noticed there are “occasional” urinary tract infections in the Middle Eastern women compared to “frequent” recurring infections in women in the United States. A striking difference is the customary “shaving” or “epilation” of the pubic genital hair of married women in the Middle East. Many urologists from different countries in the Middle East concur that there is less infection in women in these countries because they shave or epilate the pubic-genital hair. Many pioneer researchers exhausted all possible sources for recurring and relapsing urinary tract infection and found possible introital and rectal
UROLOGY
/
FEBRUARY 1976 /
VOLUME VII, NUMBER 2
contamination. It is surprising that although surgeons order routine shaves in preparing for a surgical procedure because of the high risk of infection carried by hair, to my knowledge no research has been done in this field. I hope someone who has the facilities will do this research. Realizing the possible objection to shaving her pubic hair by the average American woman, I have been instructing my female patients who have resistant and recurrent urinary tract infections to apply antibiotic ointment not only to the introital area but also to the pubic genital hair. These patients have been more comfortable because they had less infections. Han M. Ha&y, M.D. 203 North Vine Street Harrisburg, Illinois 62946
ACUTE RENAL ARTERY THROMBOSIS AND KIDNEY SALVAGE To the Editor: I would like to comment on “Acute Renal Artery Thrombosis Following Blunt Trauma,” by Lt. Col. J. W. McAninch, in the July issue (vol. 6, page 74) of UROLOGY. Although I agree with his management of the case, I do want to suggest that in those cases when nephrectomy is performed and the kidney is thought to be viable, it should be flushed with Collins, Sacks, or modified Ringer’s solution and placed on ice or perfused. Should the patient experience renal shutdown one might consider reimplanting the kidney in the iliac fossa at a later time. Should this not be necessary the kidney could then be used for homotransplantation. We recently received a kidney for perfusion from a hospital. It had been removed from a patient who had been shot in the abdomen. The bullet had partly severed the left renal artery at its take off from the aorta. Reconstruction was attempted but the patient continued to be hypotensive, and it was decided that the safest course would be to remove the kidney and preserve it. This was done, and the kidney was sent to our medical center for perfusion. The donor’s remaining kidney functioned, and there was no indication to reimplant the removed kidney. After obtaining proper consent, we transplanted the kidney into one of our waiting recipients. It is now about two months posttransplant, and the recipient has a creatinine of 1 mg. and blood urea nitrogen of 18 mg. per 100 ml. Close attention must be paid to the perfusion characteristics and that multiple cultures be taken from the donor kidney. S. Boczko, M.D. Montefiore Hospital 111 East 210 Street New York, New York 10467
237
