422
BRITISH JOURNAL OF UROLOGY
Detrusor Failure in Myasthenia Gravis T. J. CHRISTMAS, P. J. DIXON and E. J. G. MILROY, Department of Urology. Middlesex Hospital, London
Myasthenia gravis is an autoimmune disease caused by autoantibodies to acetylcholine (ACh) receptors which leads to neuromuscular blockade and hence weakness in a variety of muscle groups. The muscles of the face and limbs are most often affected. Only nicotinic receptors, and therefore only voluntary muscles, are thought to be involved in the disease process.
be due to weakness of the striated distal urethral sphincter mechanism. The detrusor muscle is predominantly under the control of the parasympathetic nervous system and the cholinergic receptors of the bladder have not been shown to be involved in cases of myasthenia gravis. Detrusor failure is an unusual urodynamic finding which may occur as a result of diabetic neuropathy, chronic urinary retention or lower motor neurone pelvic nerve injury. In this case the disease process of myasthenia gravis appears to affect detrusor function and this could be due to autoantibody attachment to ACh receptors in the detrusor muscle itself or pelvic ganglia. No previous reports have suggested that drug-reversible detrusor weakness is a feature of myasthenia gravis.
Case Report A case of detrusor failure is reported in a female aged 59 years with a 35-year history of idiopathic non-familial myasthenia gravis responsive to pyridostigmine therapy. She complained of difficulty in voiding, a feeling of incomplete bladder emptying and urinary frequency; the symptoms were more pronounced when drug therapy was interrupted and were accompanied by generalised muscular weakness in such circumstances. Urodynamic studies were performed after discontinuation of pyridostigmine for 12 h. The bladder capacity was not reduced (430 ml) and there was normal bladder sensation during filling. However, during attempted voiding the patient was unable to accomplish a detrusor pressure greater than 8 cm of water and she voided by abdominal straining with poor flow rates and an interrupted flow pattern. Free flow rates performed in privacy demonstrated a similar low flow rate and interrupted flow characteristic of detrusor failure with compensatory voiding straining (Fig.).
References Greene, L. F., Ghosh, M. K. and Howard, F. M., Jr. (1974).
Transurethral prostatic resection in patients with myasthenia gravis. J . Urol.. 112, 226227. Wise, G. J., Gerstenfeld, J. N., Brunner, N. e t d . (1982). Urinary incontinence following prostatectorny in patients with rnyasthenia gravis. Br. J . Urol..54, 369-371. Requests for reprints to: T. J . Christmas, Department of Urology, St. Bartholornew’s Hospital, West Srnithfield, London EClA 7BE.
Pilonidal Sinus of the Penis S. M. GRIFFIN, W. McEVlLLY andT. P. COLE, Departments of Surgery and Pathology, CumberlandInfirmary, Carlisle
Comment
The term “pilonidal sinus” was first described by Urinary symptoms have previously been reported Hodges (1880) from the Latin “pilus”-hair and in male patients with myasthenia gravis after “nidus”-nest, and for many years was thought to prostatectomy (Greene et al., 1974; Wise et al., affect only the region of the natal cleft. Neverthe1982). Incontinence in these cases was thought to less, examples of the condition in the hand, axilla, perineum, amputation stump, umbilicus and the suprapubic region have been described. We report a case affecting the penis which, to our knowledge, 50 mlYs has not been described before.
Case Report ..
..
...
....
.
r, L 20 40
0
Fig. Free flow rate showing interrupted voiding pattern.
60
A 29-year-old, uncircumcised married man presented to the dermatologists complaining of an ulcer at the corona adjacent to the glans penis. He had first noticed a problem 7 months previously, when a small abscess appeared. This subsequently burst but failed to heal. A swab was taken by his family doctor and as this grew Candidu
423
CASE REPORTS
Fig. I Sinus tract lined by keratinising squamousepithelium and focally with inflamed granulation tissue. ( x 2.5).
albicans and Staphylococcusaureus, treatment with miconazole and flucloxacillin was instituted. Persistence of a painless bleeding lesion at the base of the glans resulted in a surgical referral. The patient was otherwise fit and well and on no medication. Examination revealeda 2 x 1.5 cmulcerating lesion ventrally at the junction of the glans penis and the prepuce; it bled on contact and was infected. The lesion was indurated and there was a rolled edge to the ulcer. There was no lymphadenopathy. Venereal disease tests, TPHA, G C F T and chest X-ray were all negative and excisional biopsy was arranged under general anaesthesia. The lesion was excised completely and did not infiltrate deeply into the corpora cavernosa. Examination of the resected specimen showed a sinus track containing necrotic debris and hair (Fig. 1). Microscopy confirmed that the track was lined partly by necrotising squamous epithelium and partly by inflamed granulation tissue containing fragments of hair to which there were foci of foreign body giant cell reaction (Fig. 2). The patient had an uneventful post-operative course and there was no recurrence of his symptoms 1 year after surgery.
Fig. 2
Comment
Pilonidal sinus appears to be increasing in frequency (Goligher, 1984); it predominantly affects young dark haired males, is rare in negroes, but nevertheless does occur in blonde hairless types. The aetiology of the condition has remained controversial and a number of theories have been postulated to explain pilonidal sinus in the natal cleft. These are classified into congenital and acquired. Congenital theories implicate persistence of the medullary canal remnant and traction dermoid sinus formation ; suggestions for possible acquired causes include implantation dermoid or simply that the hairs had been introduced into the tissues extrinsically (Goligher, 1984). The support for the theory of extrinsic introduction came from their appearance in separate situations like the finger web (in barbers), the axilla and amputation stumps. Brearley (1955) postulated that the hairs burrowed into the skin by a process of twisting and drilling, finally losing their follicular attachments. Another explanation may simply be that the hair breaks off initially and then directly embeds into the skin. The histological features classically show a sinus track from the skin-lined orifice extending into the subcutaneous tissues. Hairs are nearly always found projecting from the opening and may be attached to the wall of the track. In barbers, the hairs in the sinus are not the patients own hairs, and this may also apply in the case described. The principles of treatment for pilonidal sinus are simple excision with either primary suture or healing by wound Hair and debris present within the sinus cavity. ( x 100). granulation. In this case excisional biopsy and
424 primary suture were performed for diagnostic and iherapeutic reasons. This was the treatment of choice for the underlying condition, the wound healed well and the patient had no resultant disability. We are not aware of any previous report of this condition in this situation and it adds further credence to the acquired theory of aetiology of this old, well recognised but poorly understood condition. References Brearley, R. (1955). Pilonidal sinus; a new theory of origin. Br. .Y.'$rg., 43.62. Goligher-, J. (1984). Surgery of the Anus. Rectum and Colon. Pp. 231 -234. London, Philadelphia, Sydney, Tokyo, Toronto:
Bailliere Tindall. Hodges, R. M. (1880). Pilonidal sinus. Boston M e d . Surg., 103,
BRITISH JOURNAL OF UROLOGY
Comment Rectovesical fistulas account for approximately 20% of all enterovesical fistulas (Couris and Block, 1963; King et af., 1982). Although trauma has been an infrequent cause of enterovesical fistula, traumatic cases have usually involved the rectum. Couris and Block (1963) found that 34 of 46 cases of traumatic rectovesical fistula were due to surgical trauma, usually complicating suprapubic and other forms of prostatectomy. The history and operative findings in this case were most suggestive of the fistula having been due to pressure necrosis by the balloon of the catheter. Although rare cases of rectovesical fistula have been attributed to trauma associated with foreign bodies, we have not found any reports implicating indwelling catheters.
485.
Requests for reprints to: S. M. Griffin, Department of Surgery, Prince of Wales Hospital, Chinese University, Shatin, New
Territories, Hong Kong.
References Couris, G . D. and Block, M. A. (1963). Intestinovesical fistula. Surgery, 54.736-742.
King, R. M., Beart, R. W. and McIlrath, D. C. (1982).Colovesical
and rectovesical fistula. Arch Surg.. 117.680-683.
Rectovesical Fistula due to Indwelling Catheter S. O'GORMAN, A. O'BRIEN, A. LEAHY, M. R. BUTLER and F. B. V. KEANE, Departments of Surgery and Urology, Meath Hospital, Dublin, Ireland
Case Report An 80-year-old man was referred with a 2-week history of passing urine per rectum. He had had a transurethral resection of a benign prostate 4 years previously. Since then he had had an indwelling catheter for incontinence due to Parkinson's disease, senility and immobility. His catheter had been changed every 6 to 8 weeks. On examination he had a moderately enlarged, clinically benign prostate. The anterior rectal wall above the prostate felt indurated and irregular. Sigmoidoscopy and a barium enema were both normal. Cystography confirmed the presence of a rectovesical fistula. At laparotomy a short fistulous track was found to extend from bladder to rectum immediately inferior to the pelvic peritoneal reflection. On opening the bladder, the balloon of the indwelling catheter was found to lie in a trigonal crater, from the centre of which the fistula began. The crater was separated from a normal bladder neck by normal mucosa. Bladder and rectum were otherwise grossly normal. The fistula was resected and both bladder and rectum repaired. Histological examination of resected tissue showed chronic inflammatory change only.
Requests for reprints to: F. B. V. Keane, Department of Surgery. Meath Hospital. HeytesburyStreet, Dublin 8. Ireland.
Spontaneous Thrombosis of the Penis in a 50-year-old Patient Fully Anticoagulated on Warfarin M. S. C. MURISON and B. H. WALMSLEY, Departmentof Urology, St Mary's Hospital, Portsmouth
Case Report A 50-year-old male developed painful engorgement of the penis 2 weeks after commencing oral anticoagulation for a pulmonary embolus. There was no history of trauma. On examination, complete penile thrombosis with a glandular erection was present despite over-anticoagulation (British Prothrombin Ratio 5.0). Warfarin was discontinued and intravenous anticoagulation commenced, requiring 17,000 units of heparin 6-hourly. A single dose of 100,000 units streptokinase was given peripherally and empirical prednisolone commenced. Within 24 h significant improvement had occurred and by the end of 1 week complete resolution had taken place. A venogram was normal and computed tomography revealed no neoplastic cause for his coagulopathy. The clotting cascade was investigated by the haematologists but no diagnostic abnormalities were detected.
BRITISH JOURNAL OF UROLOGY
Detrusor Failure in Myasthenia Gravis T. J. CHRISTMAS, P. J. DIXON and E. J. G. MILROY, Department of Urology. Middlesex Hospital, London
Myasthenia gravis is an autoimmune disease caused by autoantibodies to acetylcholine (ACh) receptors which leads to neuromuscular blockade and hence weakness in a variety of muscle groups. The muscles of the face and limbs are most often affected. Only nicotinic receptors, and therefore only voluntary muscles, are thought to be involved in the disease process.
be due to weakness of the striated distal urethral sphincter mechanism. The detrusor muscle is predominantly under the control of the parasympathetic nervous system and the cholinergic receptors of the bladder have not been shown to be involved in cases of myasthenia gravis. Detrusor failure is an unusual urodynamic finding which may occur as a result of diabetic neuropathy, chronic urinary retention or lower motor neurone pelvic nerve injury. In this case the disease process of myasthenia gravis appears to affect detrusor function and this could be due to autoantibody attachment to ACh receptors in the detrusor muscle itself or pelvic ganglia. No previous reports have suggested that drug-reversible detrusor weakness is a feature of myasthenia gravis.
Case Report A case of detrusor failure is reported in a female aged 59 years with a 35-year history of idiopathic non-familial myasthenia gravis responsive to pyridostigmine therapy. She complained of difficulty in voiding, a feeling of incomplete bladder emptying and urinary frequency; the symptoms were more pronounced when drug therapy was interrupted and were accompanied by generalised muscular weakness in such circumstances. Urodynamic studies were performed after discontinuation of pyridostigmine for 12 h. The bladder capacity was not reduced (430 ml) and there was normal bladder sensation during filling. However, during attempted voiding the patient was unable to accomplish a detrusor pressure greater than 8 cm of water and she voided by abdominal straining with poor flow rates and an interrupted flow pattern. Free flow rates performed in privacy demonstrated a similar low flow rate and interrupted flow characteristic of detrusor failure with compensatory voiding straining (Fig.).
References Greene, L. F., Ghosh, M. K. and Howard, F. M., Jr. (1974).
Transurethral prostatic resection in patients with myasthenia gravis. J . Urol.. 112, 226227. Wise, G. J., Gerstenfeld, J. N., Brunner, N. e t d . (1982). Urinary incontinence following prostatectorny in patients with rnyasthenia gravis. Br. J . Urol..54, 369-371. Requests for reprints to: T. J . Christmas, Department of Urology, St. Bartholornew’s Hospital, West Srnithfield, London EClA 7BE.
Pilonidal Sinus of the Penis S. M. GRIFFIN, W. McEVlLLY andT. P. COLE, Departments of Surgery and Pathology, CumberlandInfirmary, Carlisle
Comment
The term “pilonidal sinus” was first described by Urinary symptoms have previously been reported Hodges (1880) from the Latin “pilus”-hair and in male patients with myasthenia gravis after “nidus”-nest, and for many years was thought to prostatectomy (Greene et al., 1974; Wise et al., affect only the region of the natal cleft. Neverthe1982). Incontinence in these cases was thought to less, examples of the condition in the hand, axilla, perineum, amputation stump, umbilicus and the suprapubic region have been described. We report a case affecting the penis which, to our knowledge, 50 mlYs has not been described before.
Case Report ..
..
...
....
.
r, L 20 40
0
Fig. Free flow rate showing interrupted voiding pattern.
60
A 29-year-old, uncircumcised married man presented to the dermatologists complaining of an ulcer at the corona adjacent to the glans penis. He had first noticed a problem 7 months previously, when a small abscess appeared. This subsequently burst but failed to heal. A swab was taken by his family doctor and as this grew Candidu
423
CASE REPORTS
Fig. I Sinus tract lined by keratinising squamousepithelium and focally with inflamed granulation tissue. ( x 2.5).
albicans and Staphylococcusaureus, treatment with miconazole and flucloxacillin was instituted. Persistence of a painless bleeding lesion at the base of the glans resulted in a surgical referral. The patient was otherwise fit and well and on no medication. Examination revealeda 2 x 1.5 cmulcerating lesion ventrally at the junction of the glans penis and the prepuce; it bled on contact and was infected. The lesion was indurated and there was a rolled edge to the ulcer. There was no lymphadenopathy. Venereal disease tests, TPHA, G C F T and chest X-ray were all negative and excisional biopsy was arranged under general anaesthesia. The lesion was excised completely and did not infiltrate deeply into the corpora cavernosa. Examination of the resected specimen showed a sinus track containing necrotic debris and hair (Fig. 1). Microscopy confirmed that the track was lined partly by necrotising squamous epithelium and partly by inflamed granulation tissue containing fragments of hair to which there were foci of foreign body giant cell reaction (Fig. 2). The patient had an uneventful post-operative course and there was no recurrence of his symptoms 1 year after surgery.
Fig. 2
Comment
Pilonidal sinus appears to be increasing in frequency (Goligher, 1984); it predominantly affects young dark haired males, is rare in negroes, but nevertheless does occur in blonde hairless types. The aetiology of the condition has remained controversial and a number of theories have been postulated to explain pilonidal sinus in the natal cleft. These are classified into congenital and acquired. Congenital theories implicate persistence of the medullary canal remnant and traction dermoid sinus formation ; suggestions for possible acquired causes include implantation dermoid or simply that the hairs had been introduced into the tissues extrinsically (Goligher, 1984). The support for the theory of extrinsic introduction came from their appearance in separate situations like the finger web (in barbers), the axilla and amputation stumps. Brearley (1955) postulated that the hairs burrowed into the skin by a process of twisting and drilling, finally losing their follicular attachments. Another explanation may simply be that the hair breaks off initially and then directly embeds into the skin. The histological features classically show a sinus track from the skin-lined orifice extending into the subcutaneous tissues. Hairs are nearly always found projecting from the opening and may be attached to the wall of the track. In barbers, the hairs in the sinus are not the patients own hairs, and this may also apply in the case described. The principles of treatment for pilonidal sinus are simple excision with either primary suture or healing by wound Hair and debris present within the sinus cavity. ( x 100). granulation. In this case excisional biopsy and
424 primary suture were performed for diagnostic and iherapeutic reasons. This was the treatment of choice for the underlying condition, the wound healed well and the patient had no resultant disability. We are not aware of any previous report of this condition in this situation and it adds further credence to the acquired theory of aetiology of this old, well recognised but poorly understood condition. References Brearley, R. (1955). Pilonidal sinus; a new theory of origin. Br. .Y.'$rg., 43.62. Goligher-, J. (1984). Surgery of the Anus. Rectum and Colon. Pp. 231 -234. London, Philadelphia, Sydney, Tokyo, Toronto:
Bailliere Tindall. Hodges, R. M. (1880). Pilonidal sinus. Boston M e d . Surg., 103,
BRITISH JOURNAL OF UROLOGY
Comment Rectovesical fistulas account for approximately 20% of all enterovesical fistulas (Couris and Block, 1963; King et af., 1982). Although trauma has been an infrequent cause of enterovesical fistula, traumatic cases have usually involved the rectum. Couris and Block (1963) found that 34 of 46 cases of traumatic rectovesical fistula were due to surgical trauma, usually complicating suprapubic and other forms of prostatectomy. The history and operative findings in this case were most suggestive of the fistula having been due to pressure necrosis by the balloon of the catheter. Although rare cases of rectovesical fistula have been attributed to trauma associated with foreign bodies, we have not found any reports implicating indwelling catheters.
485.
Requests for reprints to: S. M. Griffin, Department of Surgery, Prince of Wales Hospital, Chinese University, Shatin, New
Territories, Hong Kong.
References Couris, G . D. and Block, M. A. (1963). Intestinovesical fistula. Surgery, 54.736-742.
King, R. M., Beart, R. W. and McIlrath, D. C. (1982).Colovesical
and rectovesical fistula. Arch Surg.. 117.680-683.
Rectovesical Fistula due to Indwelling Catheter S. O'GORMAN, A. O'BRIEN, A. LEAHY, M. R. BUTLER and F. B. V. KEANE, Departments of Surgery and Urology, Meath Hospital, Dublin, Ireland
Case Report An 80-year-old man was referred with a 2-week history of passing urine per rectum. He had had a transurethral resection of a benign prostate 4 years previously. Since then he had had an indwelling catheter for incontinence due to Parkinson's disease, senility and immobility. His catheter had been changed every 6 to 8 weeks. On examination he had a moderately enlarged, clinically benign prostate. The anterior rectal wall above the prostate felt indurated and irregular. Sigmoidoscopy and a barium enema were both normal. Cystography confirmed the presence of a rectovesical fistula. At laparotomy a short fistulous track was found to extend from bladder to rectum immediately inferior to the pelvic peritoneal reflection. On opening the bladder, the balloon of the indwelling catheter was found to lie in a trigonal crater, from the centre of which the fistula began. The crater was separated from a normal bladder neck by normal mucosa. Bladder and rectum were otherwise grossly normal. The fistula was resected and both bladder and rectum repaired. Histological examination of resected tissue showed chronic inflammatory change only.
Requests for reprints to: F. B. V. Keane, Department of Surgery. Meath Hospital. HeytesburyStreet, Dublin 8. Ireland.
Spontaneous Thrombosis of the Penis in a 50-year-old Patient Fully Anticoagulated on Warfarin M. S. C. MURISON and B. H. WALMSLEY, Departmentof Urology, St Mary's Hospital, Portsmouth
Case Report A 50-year-old male developed painful engorgement of the penis 2 weeks after commencing oral anticoagulation for a pulmonary embolus. There was no history of trauma. On examination, complete penile thrombosis with a glandular erection was present despite over-anticoagulation (British Prothrombin Ratio 5.0). Warfarin was discontinued and intravenous anticoagulation commenced, requiring 17,000 units of heparin 6-hourly. A single dose of 100,000 units streptokinase was given peripherally and empirical prednisolone commenced. Within 24 h significant improvement had occurred and by the end of 1 week complete resolution had taken place. A venogram was normal and computed tomography revealed no neoplastic cause for his coagulopathy. The clotting cascade was investigated by the haematologists but no diagnostic abnormalities were detected.
