692
CIANCIO AND BLOCK
DISCUSSION
Obstetric bladder injuries may complicate cesarean section. If there has been a previous pelvic operation bladder injury
may occur during opening of the anterior abdominal wall as a result of adhesions between the bladder and posterior surface of the anterior abdominal muscles. Adherence of the bladder to the lower uterine segment and uterine cervix also can make surgical dissection difficult. Secondary procedures and complications may be avoided if the bladder injury is recognized and repaired during the obstetric procedure. 7 Vaginal birth after cesarean section is relatively safe with an extremely low incidence of complications, especially if the operation was done via a low transverse uterine incision. 3 Approximately 1 to 2% of the low transverse scars separate, an incidenGe that appeal's m>t to be affected by labor. 3 When intrapartum scar separation does occur, it commonly produces alterations in uterine contraction patterns as well as fetal distress, both of which can be detected by appropriate monitoring.3 To our knowledge our case represents the first report from a developed country of spontaneous rupture of the bladder associated with uterine rupture during an attempted vaginal birth after a previous cesarean section. In Libya 3 of 96 patients treated for uterine rupture (cesarean history unknown) had an associated bladder rupture. 5 In Jamaica a bladder rupture associated with a uterine rupture was reported in a patient who delivered vaginally after a previous cesarean section. Unfortunately, the neonate died, either from a cord complication or asphyxia from the uterine rupture. 6 As in the Jamaican patient the presenting sign of a bladder rupture in our patient was gross hematuria when an indwelling urinary catheter was placed. Pain between uterine contractions was absent because of the epidural anesthetic. The operative finding of marked adherence of the bladder to the low uterine segment and cervix is not unusual in patients who have had a previous cesarean section. Similarly, it is not unusual to find a
markedly edematous bladder after an attempted vaginal delivery, since the bladder is repeatedly traumatized during uterine contractions by compression between the fetal head and pubic bone. 8 We suspect that the combination of the trauma of attempted vaginal delivery and the adherence of the bladder to a weakened uterine scar was the mechanism for the spontaneous rupture of the bladder in our patient. Because of the trend toward vaginal birth trials after cesarean section we believe that spontaneous bladder ruptures with uterine ruptures may become a more common finding. It is important to be cognizant of the possibility of spontaneous bladder rupture in these patients, to know its presenting signs and symptoms, and when it occurs to inspect the bladder purposefully and to repair it carefully at the obstetric procedure to avoid secondary procedures and further complications. REFERENCES 1. Halperin, M. E., Moore, D. C. and Hannah, W. J.: Classical versus
2. 3. 4. 5. 6.
7. 8.
low-segment transverse incision for preterm caesarean section: maternal complications and outcome of subsequent pregnancies. Brit. J. Obst. Gynaec., 95: 990, 1988. Nielsen, T. F., Ljungblad, U. and Hagberg, H.: Rupture and dehiscence of cesarean section scar during pregnancy and delivery. Amer. J. Obst. Gynec., 160: 569, 1989. Clark, S. L.: Rupture of the scarred uterus. Obst. Gynec. Clin. N. Amer., 15: 737, 1988. Kirkinen, P.: Multiple caesarean sections: outcomes and complications. Brit. J. Obst. Gynaec., 95: 778, 1988. Rahman, J., Al-Sibai, M. H. and Rahman, M. S.: Rupture of the uterus in labor. A review of 96 cases. Acta Obst. Gynec. Scand., 64: 311, 1985. Mullings, A. M.A. and Hall, J. S. E.: Rupture of uterus and bladder in vaginal delivery following previous caesarean section. W. Indian Med. J., 36: 51, 1987. Tancer, M. L.: Vesicouterine fistula-a review. Obst. Gynec. Surv., 41: 743, 1986. Moir, J.C.: Injuries of the bladder. Amer. J. Obst. Gynec., 82: 124, 1961.
0022-534 7/92/14 73-0692$03.00/0 Vol. 147, 692-695, March 1992
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
SMALL BOWEL PERFORATION ASSOCIATED WITH INTRAPERITONEAL AND EXTRAPERITONEAL BLADDER PERFORATION CAUSED BY STAB WOUND TO THE PENIS GAETANO CIANCIO AND NORMAN L. BLOCK From the Department of Urology, University of Miami School of Medicine and Jackson Memorial Hospital, Miami, Florida
ABSTRACT
We report an unusual case of small bowel and bladder perforation caused by a stab wound to the penis with preservation of intact corporeal penile bodies and urethra. Diagnosis of bladder perforation was made by the urethrogram and diagnosis of small bowel perforation was made by clinical signs even though the initial physical examination suggested neither of these conditions. KEY
WORDS:
wounds and injuries, intestinal perforation, bladder, penis
The male genitalia may be involved in a wide variety of injuries from external causes. Most civilian genital injuries occur in industrial, farm or automobile accidents, athletic contests, or attempts at self-mutilation or malicious assault. 1 Penile injuries are uncommon in civilian practice. Selikowitz in 1977 reported 250 genitourinary injuries sustained in Vietnam. 2 In his series penile injuries accounted for only 5% of the Accepted for publication August 12, 1991.
urological injuries. Waterhouse and Gross in 1969 reported on 251 patients with injuries to the genitourinary tract. 3 Of 74 injuries of the genitalia 32 involved the penis. Abrasions, hematoma and minor lacerations constituted 23 of the penile injuries, and required either no therapy or a conservative operation. Cass et al in 1985 reviewed 70 male genital injuries and found only 7 blade injuries that involved the penis. 4 Of these injuries 4 resulted in superficial lacerations, while there were 3 severe injuries: 1 complete and 2 partial amputations.
693
STAB WOUND TO PENIS
In these series all of the injuries were localized to the penis and
CASE REPORT
no associated injuries were described. 2- 4 The bladder also may be involved in a wide variety of injuries from external causes. In 1943 Bacon reported 14 7 cases of rupture of the bladder. 5 There were 102 cases of external trauma that included only 1 case of a stab wound to the bladder. The other causes of external trauma were traffic accidents (73 patients), fall (11), gunshot wound (9), kick or blow (7), and sitting on an axle (1). Corriere and Sandler reviewe_d a total of 111 patients with bladder ruptures from external v10lence and only 1 stab wound was reported. 6 Cass and Luxenberg in 1987 reported 5 knife wounds among 164 cases of bladder rupture from external trauma. 7 None of these series reported a case of intraperitoneal and extraperitoneal bladder rupture, a~d2 _~mall bowel perforation caused by a stab wound to the pems. We report a case of a single stab wound to the penis with resultant intact penile structures. This innocuous-appearing stab wound was associated with severe bladder damage and urinary extravasation. Associated injuries were suspected after retrograde urethrography and reexamination of the patient were done.
V. a 27-year-old black Haitian man, was assaulted after a soccer game and sustained a single stab wound to the penis approximately 2 hours before admission to the hospital. Examination revealed a 1.5 cm. laceration at the left lateral aspect of the penis close to the base (fig. 1). Blood at the meatus or swelling of the penis or scrotum was not noted during examination. The remainder of the physical examination was unremarkable. The initial urethrogram revealed no urethral injury (fig. 2, A). After more contrast medium was instilled into the bladder there was complete opacification of the urethra, with partial filling of the bladder (fig. 2, B). Extravasation of contrast medium was demonstrated at the right side of the bladder, suggesting an extraperitoneal perforation. Multiple filling defects that were suspicious for blood clots were observed in the bladder base. Gross hematuria was noted on insertion of a Foley catheter. Extravasation of urine then developed from the stab wound site with swelling of the penis and scrotum. Excretory urography (IVP) was within normal limits and a cystogram (fig. 3) revealed significant extravasation of contrast medium from the
FIG. 1. Stab wound to penis
FIG. 3. Cystogram demonstrates significant extravasation of co!ltrast medium from right side of bladder into scrotum and base ofpems.
FIG. 2. A, urethrogram demonstrates no urethral injury. B, more contrast medium instilled into bladder shows extravasation at right side of bladder.
694
CIANCIO AND BLOCK
right side of the bladder, again compatible with an extraperitoneal bladder rupture. Contrast medium extended into the scrotum and the base of the penis. During the radiological evaluation the patient experienced diffuse abdominal tenderness and guarding. Exploratory laparotomy showed 1 to 1.5 1. of blood-stained urine in the peritoneal cavity, explaining the signs of peritonitis. When the bladder was examined 2 defects were noted, 1 on the right side of the dome (which the cystogram failed to reveal) and 1 on the right lateral posterior aspect. Both lacerations were approximately 2 cm. long but the posterolateral laceration appeared to be wider and larger than that on the dome. The ureteral orifices were intact with clear efflux. There was also a small bowel injury at the level of the ileum (approximately 1 cm. long). After the 3 perforations were repaired, the penile wound was explored. The wound extended laterally to the right side of the base of the penis, around Buck's fascia, without damaging the corporeal bodies and urethra, and then through the suprapubic abdominal wall and into the area of the bladder. It seems that the knife entered the right posterolateral aspect of the bladder wall approximately 1 cm. lateral to the right ureteral orifice and exited through the right side of the dome. From the location of the perforations the bladder must have been full at the time of the injury. Upon exiting the bladder the knife perforated the small bowel (fig. 4). The penile wound was irrigated, dartos fascia was approximated and the penile skin was left open. Convalescence was uneventful. A voiding cystourethrogram 9 days postoperatively revealed no evidence of extravasation. DISCUSSION
We report an unusual presentation of penetrating injury apparently isolated to the penis but with associated bladder and bowel injuries. This case illustrates that bladder and bowel injuries should be among the differential diagnoses of penetrating penile injuries when the path of the knife is unknown.
During the initial examination it was believed unlikely that this innocuous-appearing stab wound would be associated with bladder and bowel perforation. Evans and Fowler reported that the bladder could be reached by penetrating instruments in 3 ways: 1) through the suprapubic region, 2) through the obturator foramen and 3) through the perineum. 8 However, they listed several cases in which the entrance wound was not in the aforementioned regions. These other regions included the gluteal area, sacral area, thigh and groin. We add the penis as another such entrance site. After a review of multiple series we found no case of small bowel and intraperitoneal or extraperitoneal bladder perforation in which the penis was the entrance site of the stab wound. 2- 7 In our case associated injuries began to be suspected when the urethrngram instille_d_contrast medium into the blade der. The urethrogram and cystogram established the extraperitoneal bladder perforation but the latter study failed to demonstrate the intraperitoneal injury. In 1940 Weyrauch and Peterfy demonstrated experimentally that ruptures 0.5 to 2 cm. long allowed extravasation from the dog bladder only after the bladder was distended beyond 40 cc. 9 Ruptures larger than 2 cm. gave rise to leakage upon introduction of 20 to 40 cc of fluid. The water escaped as rapidly as it entered the bladder. The cystogram may have failed to reveal the intraperitoneal extravasation due to the fact that the posterolateral defect appeared to be wider and larger compared with the dome defect, and consequently most of the contrast medium escaped through the former injury. Multiple factors are described that account for a negative cystogram in a patient with a penetrating bladder wound. The heat-searing effect (in the case of gunshot wounds), the resultant edema, sharply cut edges, the natural elasticity of the bladder wall and coaptation of the wound produced by the interlacing fibers of the detrusor tend to prevent extravasation. 10 Also, there may be plugging of the bladder defect by clot or surrounding tissue, as for example omentum or small bowel. 11 Oesterling et al reported 2 cases of an intravesical small bowel herniation after an intraperitoneal
FIG. 4. Stab wound path
HYPERSENSITIVITY REACTION AFTER INTRAVESICAL
bladder perforation. 12 Recognition of the bladder rupture was delayed as a result of the tamponade effect from the herniated bowel within the bladder laceration. In our patient, although the diagnosis of extraperitoneal bladder perforation was already made by the urethrogram, additional studies were required to evaluate the extent of the bladder rupture (cystogram) and to rule out any other injuries (IVP). During the radiological evaluation the patient was reexamined and signs of peritonitis were found, establishing unequivocally the presence of injuries in addition to the extraperitoneal bladder laceration. In conclusion, we report a case of a stab wound to the penis associated with small bowel and intraperitoneal and extraperitoneal bladder perforation. Diagnosis of the associated injuries was recognized after urethrocystography and reexamination of the patient. Our case emphasizes the importance of a thorough evaluation and reevaluation of a patient with a penetrating injury.
3. 4. 5. 6. 7. 8. 9. 10. 11.
REFERENCES l. Culp, D. A.: Genital injuries: etiology and initial management.
Urol. Clin. N. Amer., 4: 143, 1977. 2. Selikowitz, S. M.: Penetrating high-velocity genitourinary injuries.
12.
BACILLUS
CALMETTE-GUERIN
695
Part I. Statistics, mechanisms, and renal wounds. Urology, 9: 371, 1977. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. Cass, A. S., Gleich, P. and Smith, C.: Male genital injuries from external trauma. Brit. J. Urol., 57: 467, 1985. Bacon, S. K.: Rupture of the urinary bladder: clinical analysis of 147 cases in the past ten years. J. Urol., 49: 432, 1943. Corriere, J, N., Jr. and Sandler, C. M,: Management of the ruptured bladder: seven years of experience with 111 cases. J. Trauma, 26: 830, 1986. Cass, A. S. and Luxenberg, M.: Features of 164 bladder ruptures. J. Urol., 138: 743, 1987. Evans, E. and Fowler, H. A.: Punctured wounds of the bladder. Ann. Surg., 42: 215, 1905. Weyrauch, H. M., Jr. and Peterfy, R. A.: Tests for leakage in the early diagnosis of the ruptured bladder. J. Urol., 44: 264, 1940. Rieser, C. and Nicholas, E.: Rupture of the bladder: unusual features. J. Urol., 90: 53, 1963. Lieberman, A. L., Walden, T. B., Bogash, M., Pollack, H. M. and Kendall, A. R.: Negative cystography with bladder rupture: pres-_ entation of 2 cases and review of the literature. J. Urol., 123: 428, 1980. Oesterling, J. E., Goldman, S. M. and Lowe, F. C.: Intravesical herniation of small bowel after bladder perforation. J. Urol., 138: 1236, 1987.
0022-534 7/92/1473-0695$03.00/0 Vol. 147, 695-697, March 1992 Printed in U.S,A.
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
HYPERSENSITIVITY SYSTEMIC REACTION FOLLOWING INTRA VESICAL BACILLUS CALMETTE-GUERIN: SUCCESSFUL TREATMENT WITH STEROIDS JEAN-MICHEL MOLINA,* CLAIRE RABIAN, MARIE-FRANCOISE D'AGAY
AND
JACQUES MODAI
From the Departments of Infectious Diseases, Immunology and Pathology, H8pital Saint-Louis, Paris, France
ABSTRACT
Intravesical bacillus Calmette-Guerin (BCG) is an effective treatment for superficial bladder carcinoma, Serious complications, including disseminated BCG infection, are infrequent. We report a case of granulomatous hepatitis with pneumonitis following intravesical administration of BCG. Cultures for mycobacteria were negative in sputum, bronchoalveolar lavage, liver and blood specimens, All symptoms disappeared within days after steroid therapy. Hypersensitivity reaction should be considered in patients with systemic symptoms after imrnunotherapy with BCG. KEY
WORDS: BCG vaccine, bladder neoplasms, hepatitis, pulmonary fibrosis
The efficacy of intravesical bacillus Calmette-Guerin (BCG) in the treatment of superficial bladder carcinoma has been demonstrated in several trials in humans. 1• 2 Side effects of BCG immunotherapy are not rare but usually are self-limited.3-5 However, severe systemic reaction can occur and usually leads to antituberculous therapy. 3-9 We report on a 57-year-old man who had a severe systemic hypersensitivity reaction after intravesical BCG. The patient had a complete remission under steroid therapy alone. CASE
REPORT
A 57-year-old man had a history of pulmonary tuberculosis in 1980 and a 5-year history of superficial carcinoma of the Accepted for publication July 19, 1991. Supported by a grant from the Centre d'Etudes et de Recherche en Infectiologie. *Requests for reprints: Department of Infectious Diseases, Hopital Saint-Louis, 1 Avenue C. Vellefaux, 75010 Paris, France.
bladder. He underwent multiple intravesical resections and a course of intravesical BCG therapy was started in March 1990 with mycobacterium bovis strain (BCG Pasteur) at 75 mg. once a week. No percutaneous BCG was administered. During the initial 2 inoculations a transient fever was noted. There was difficulty in catheterizing the bladder for the third administration and urethral bleeding occurred. Three hours later the patient experienced fever up to 40C with chills and severe dysuria. The next day 300 mg. isoniazid daily were started and the patient was discharged from the hospital. A week later the patient was still febrile and 600 mg. rifampin daily were added to the regimen for suspected disseminated BCG infection. He was transferred to our institution on May 8 because of persistent fever. The patient was acutely ill with a temperature of 39C. Physical examination was remarkable for dyspnea, icteric sclerae, an enlarged liver and bilateral inspiratory crackles in both lungs. Severe hypoxemia (oxygen pressure 59 mm. Hg while
CIANCIO AND BLOCK
DISCUSSION
Obstetric bladder injuries may complicate cesarean section. If there has been a previous pelvic operation bladder injury
may occur during opening of the anterior abdominal wall as a result of adhesions between the bladder and posterior surface of the anterior abdominal muscles. Adherence of the bladder to the lower uterine segment and uterine cervix also can make surgical dissection difficult. Secondary procedures and complications may be avoided if the bladder injury is recognized and repaired during the obstetric procedure. 7 Vaginal birth after cesarean section is relatively safe with an extremely low incidence of complications, especially if the operation was done via a low transverse uterine incision. 3 Approximately 1 to 2% of the low transverse scars separate, an incidenGe that appeal's m>t to be affected by labor. 3 When intrapartum scar separation does occur, it commonly produces alterations in uterine contraction patterns as well as fetal distress, both of which can be detected by appropriate monitoring.3 To our knowledge our case represents the first report from a developed country of spontaneous rupture of the bladder associated with uterine rupture during an attempted vaginal birth after a previous cesarean section. In Libya 3 of 96 patients treated for uterine rupture (cesarean history unknown) had an associated bladder rupture. 5 In Jamaica a bladder rupture associated with a uterine rupture was reported in a patient who delivered vaginally after a previous cesarean section. Unfortunately, the neonate died, either from a cord complication or asphyxia from the uterine rupture. 6 As in the Jamaican patient the presenting sign of a bladder rupture in our patient was gross hematuria when an indwelling urinary catheter was placed. Pain between uterine contractions was absent because of the epidural anesthetic. The operative finding of marked adherence of the bladder to the low uterine segment and cervix is not unusual in patients who have had a previous cesarean section. Similarly, it is not unusual to find a
markedly edematous bladder after an attempted vaginal delivery, since the bladder is repeatedly traumatized during uterine contractions by compression between the fetal head and pubic bone. 8 We suspect that the combination of the trauma of attempted vaginal delivery and the adherence of the bladder to a weakened uterine scar was the mechanism for the spontaneous rupture of the bladder in our patient. Because of the trend toward vaginal birth trials after cesarean section we believe that spontaneous bladder ruptures with uterine ruptures may become a more common finding. It is important to be cognizant of the possibility of spontaneous bladder rupture in these patients, to know its presenting signs and symptoms, and when it occurs to inspect the bladder purposefully and to repair it carefully at the obstetric procedure to avoid secondary procedures and further complications. REFERENCES 1. Halperin, M. E., Moore, D. C. and Hannah, W. J.: Classical versus
2. 3. 4. 5. 6.
7. 8.
low-segment transverse incision for preterm caesarean section: maternal complications and outcome of subsequent pregnancies. Brit. J. Obst. Gynaec., 95: 990, 1988. Nielsen, T. F., Ljungblad, U. and Hagberg, H.: Rupture and dehiscence of cesarean section scar during pregnancy and delivery. Amer. J. Obst. Gynec., 160: 569, 1989. Clark, S. L.: Rupture of the scarred uterus. Obst. Gynec. Clin. N. Amer., 15: 737, 1988. Kirkinen, P.: Multiple caesarean sections: outcomes and complications. Brit. J. Obst. Gynaec., 95: 778, 1988. Rahman, J., Al-Sibai, M. H. and Rahman, M. S.: Rupture of the uterus in labor. A review of 96 cases. Acta Obst. Gynec. Scand., 64: 311, 1985. Mullings, A. M.A. and Hall, J. S. E.: Rupture of uterus and bladder in vaginal delivery following previous caesarean section. W. Indian Med. J., 36: 51, 1987. Tancer, M. L.: Vesicouterine fistula-a review. Obst. Gynec. Surv., 41: 743, 1986. Moir, J.C.: Injuries of the bladder. Amer. J. Obst. Gynec., 82: 124, 1961.
0022-534 7/92/14 73-0692$03.00/0 Vol. 147, 692-695, March 1992
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
SMALL BOWEL PERFORATION ASSOCIATED WITH INTRAPERITONEAL AND EXTRAPERITONEAL BLADDER PERFORATION CAUSED BY STAB WOUND TO THE PENIS GAETANO CIANCIO AND NORMAN L. BLOCK From the Department of Urology, University of Miami School of Medicine and Jackson Memorial Hospital, Miami, Florida
ABSTRACT
We report an unusual case of small bowel and bladder perforation caused by a stab wound to the penis with preservation of intact corporeal penile bodies and urethra. Diagnosis of bladder perforation was made by the urethrogram and diagnosis of small bowel perforation was made by clinical signs even though the initial physical examination suggested neither of these conditions. KEY
WORDS:
wounds and injuries, intestinal perforation, bladder, penis
The male genitalia may be involved in a wide variety of injuries from external causes. Most civilian genital injuries occur in industrial, farm or automobile accidents, athletic contests, or attempts at self-mutilation or malicious assault. 1 Penile injuries are uncommon in civilian practice. Selikowitz in 1977 reported 250 genitourinary injuries sustained in Vietnam. 2 In his series penile injuries accounted for only 5% of the Accepted for publication August 12, 1991.
urological injuries. Waterhouse and Gross in 1969 reported on 251 patients with injuries to the genitourinary tract. 3 Of 74 injuries of the genitalia 32 involved the penis. Abrasions, hematoma and minor lacerations constituted 23 of the penile injuries, and required either no therapy or a conservative operation. Cass et al in 1985 reviewed 70 male genital injuries and found only 7 blade injuries that involved the penis. 4 Of these injuries 4 resulted in superficial lacerations, while there were 3 severe injuries: 1 complete and 2 partial amputations.
693
STAB WOUND TO PENIS
In these series all of the injuries were localized to the penis and
CASE REPORT
no associated injuries were described. 2- 4 The bladder also may be involved in a wide variety of injuries from external causes. In 1943 Bacon reported 14 7 cases of rupture of the bladder. 5 There were 102 cases of external trauma that included only 1 case of a stab wound to the bladder. The other causes of external trauma were traffic accidents (73 patients), fall (11), gunshot wound (9), kick or blow (7), and sitting on an axle (1). Corriere and Sandler reviewe_d a total of 111 patients with bladder ruptures from external v10lence and only 1 stab wound was reported. 6 Cass and Luxenberg in 1987 reported 5 knife wounds among 164 cases of bladder rupture from external trauma. 7 None of these series reported a case of intraperitoneal and extraperitoneal bladder rupture, a~d2 _~mall bowel perforation caused by a stab wound to the pems. We report a case of a single stab wound to the penis with resultant intact penile structures. This innocuous-appearing stab wound was associated with severe bladder damage and urinary extravasation. Associated injuries were suspected after retrograde urethrography and reexamination of the patient were done.
V. a 27-year-old black Haitian man, was assaulted after a soccer game and sustained a single stab wound to the penis approximately 2 hours before admission to the hospital. Examination revealed a 1.5 cm. laceration at the left lateral aspect of the penis close to the base (fig. 1). Blood at the meatus or swelling of the penis or scrotum was not noted during examination. The remainder of the physical examination was unremarkable. The initial urethrogram revealed no urethral injury (fig. 2, A). After more contrast medium was instilled into the bladder there was complete opacification of the urethra, with partial filling of the bladder (fig. 2, B). Extravasation of contrast medium was demonstrated at the right side of the bladder, suggesting an extraperitoneal perforation. Multiple filling defects that were suspicious for blood clots were observed in the bladder base. Gross hematuria was noted on insertion of a Foley catheter. Extravasation of urine then developed from the stab wound site with swelling of the penis and scrotum. Excretory urography (IVP) was within normal limits and a cystogram (fig. 3) revealed significant extravasation of contrast medium from the
FIG. 1. Stab wound to penis
FIG. 3. Cystogram demonstrates significant extravasation of co!ltrast medium from right side of bladder into scrotum and base ofpems.
FIG. 2. A, urethrogram demonstrates no urethral injury. B, more contrast medium instilled into bladder shows extravasation at right side of bladder.
694
CIANCIO AND BLOCK
right side of the bladder, again compatible with an extraperitoneal bladder rupture. Contrast medium extended into the scrotum and the base of the penis. During the radiological evaluation the patient experienced diffuse abdominal tenderness and guarding. Exploratory laparotomy showed 1 to 1.5 1. of blood-stained urine in the peritoneal cavity, explaining the signs of peritonitis. When the bladder was examined 2 defects were noted, 1 on the right side of the dome (which the cystogram failed to reveal) and 1 on the right lateral posterior aspect. Both lacerations were approximately 2 cm. long but the posterolateral laceration appeared to be wider and larger than that on the dome. The ureteral orifices were intact with clear efflux. There was also a small bowel injury at the level of the ileum (approximately 1 cm. long). After the 3 perforations were repaired, the penile wound was explored. The wound extended laterally to the right side of the base of the penis, around Buck's fascia, without damaging the corporeal bodies and urethra, and then through the suprapubic abdominal wall and into the area of the bladder. It seems that the knife entered the right posterolateral aspect of the bladder wall approximately 1 cm. lateral to the right ureteral orifice and exited through the right side of the dome. From the location of the perforations the bladder must have been full at the time of the injury. Upon exiting the bladder the knife perforated the small bowel (fig. 4). The penile wound was irrigated, dartos fascia was approximated and the penile skin was left open. Convalescence was uneventful. A voiding cystourethrogram 9 days postoperatively revealed no evidence of extravasation. DISCUSSION
We report an unusual presentation of penetrating injury apparently isolated to the penis but with associated bladder and bowel injuries. This case illustrates that bladder and bowel injuries should be among the differential diagnoses of penetrating penile injuries when the path of the knife is unknown.
During the initial examination it was believed unlikely that this innocuous-appearing stab wound would be associated with bladder and bowel perforation. Evans and Fowler reported that the bladder could be reached by penetrating instruments in 3 ways: 1) through the suprapubic region, 2) through the obturator foramen and 3) through the perineum. 8 However, they listed several cases in which the entrance wound was not in the aforementioned regions. These other regions included the gluteal area, sacral area, thigh and groin. We add the penis as another such entrance site. After a review of multiple series we found no case of small bowel and intraperitoneal or extraperitoneal bladder perforation in which the penis was the entrance site of the stab wound. 2- 7 In our case associated injuries began to be suspected when the urethrngram instille_d_contrast medium into the blade der. The urethrogram and cystogram established the extraperitoneal bladder perforation but the latter study failed to demonstrate the intraperitoneal injury. In 1940 Weyrauch and Peterfy demonstrated experimentally that ruptures 0.5 to 2 cm. long allowed extravasation from the dog bladder only after the bladder was distended beyond 40 cc. 9 Ruptures larger than 2 cm. gave rise to leakage upon introduction of 20 to 40 cc of fluid. The water escaped as rapidly as it entered the bladder. The cystogram may have failed to reveal the intraperitoneal extravasation due to the fact that the posterolateral defect appeared to be wider and larger compared with the dome defect, and consequently most of the contrast medium escaped through the former injury. Multiple factors are described that account for a negative cystogram in a patient with a penetrating bladder wound. The heat-searing effect (in the case of gunshot wounds), the resultant edema, sharply cut edges, the natural elasticity of the bladder wall and coaptation of the wound produced by the interlacing fibers of the detrusor tend to prevent extravasation. 10 Also, there may be plugging of the bladder defect by clot or surrounding tissue, as for example omentum or small bowel. 11 Oesterling et al reported 2 cases of an intravesical small bowel herniation after an intraperitoneal
FIG. 4. Stab wound path
HYPERSENSITIVITY REACTION AFTER INTRAVESICAL
bladder perforation. 12 Recognition of the bladder rupture was delayed as a result of the tamponade effect from the herniated bowel within the bladder laceration. In our patient, although the diagnosis of extraperitoneal bladder perforation was already made by the urethrogram, additional studies were required to evaluate the extent of the bladder rupture (cystogram) and to rule out any other injuries (IVP). During the radiological evaluation the patient was reexamined and signs of peritonitis were found, establishing unequivocally the presence of injuries in addition to the extraperitoneal bladder laceration. In conclusion, we report a case of a stab wound to the penis associated with small bowel and intraperitoneal and extraperitoneal bladder perforation. Diagnosis of the associated injuries was recognized after urethrocystography and reexamination of the patient. Our case emphasizes the importance of a thorough evaluation and reevaluation of a patient with a penetrating injury.
3. 4. 5. 6. 7. 8. 9. 10. 11.
REFERENCES l. Culp, D. A.: Genital injuries: etiology and initial management.
Urol. Clin. N. Amer., 4: 143, 1977. 2. Selikowitz, S. M.: Penetrating high-velocity genitourinary injuries.
12.
BACILLUS
CALMETTE-GUERIN
695
Part I. Statistics, mechanisms, and renal wounds. Urology, 9: 371, 1977. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. Cass, A. S., Gleich, P. and Smith, C.: Male genital injuries from external trauma. Brit. J. Urol., 57: 467, 1985. Bacon, S. K.: Rupture of the urinary bladder: clinical analysis of 147 cases in the past ten years. J. Urol., 49: 432, 1943. Corriere, J, N., Jr. and Sandler, C. M,: Management of the ruptured bladder: seven years of experience with 111 cases. J. Trauma, 26: 830, 1986. Cass, A. S. and Luxenberg, M.: Features of 164 bladder ruptures. J. Urol., 138: 743, 1987. Evans, E. and Fowler, H. A.: Punctured wounds of the bladder. Ann. Surg., 42: 215, 1905. Weyrauch, H. M., Jr. and Peterfy, R. A.: Tests for leakage in the early diagnosis of the ruptured bladder. J. Urol., 44: 264, 1940. Rieser, C. and Nicholas, E.: Rupture of the bladder: unusual features. J. Urol., 90: 53, 1963. Lieberman, A. L., Walden, T. B., Bogash, M., Pollack, H. M. and Kendall, A. R.: Negative cystography with bladder rupture: pres-_ entation of 2 cases and review of the literature. J. Urol., 123: 428, 1980. Oesterling, J. E., Goldman, S. M. and Lowe, F. C.: Intravesical herniation of small bowel after bladder perforation. J. Urol., 138: 1236, 1987.
0022-534 7/92/1473-0695$03.00/0 Vol. 147, 695-697, March 1992 Printed in U.S,A.
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
HYPERSENSITIVITY SYSTEMIC REACTION FOLLOWING INTRA VESICAL BACILLUS CALMETTE-GUERIN: SUCCESSFUL TREATMENT WITH STEROIDS JEAN-MICHEL MOLINA,* CLAIRE RABIAN, MARIE-FRANCOISE D'AGAY
AND
JACQUES MODAI
From the Departments of Infectious Diseases, Immunology and Pathology, H8pital Saint-Louis, Paris, France
ABSTRACT
Intravesical bacillus Calmette-Guerin (BCG) is an effective treatment for superficial bladder carcinoma, Serious complications, including disseminated BCG infection, are infrequent. We report a case of granulomatous hepatitis with pneumonitis following intravesical administration of BCG. Cultures for mycobacteria were negative in sputum, bronchoalveolar lavage, liver and blood specimens, All symptoms disappeared within days after steroid therapy. Hypersensitivity reaction should be considered in patients with systemic symptoms after imrnunotherapy with BCG. KEY
WORDS: BCG vaccine, bladder neoplasms, hepatitis, pulmonary fibrosis
The efficacy of intravesical bacillus Calmette-Guerin (BCG) in the treatment of superficial bladder carcinoma has been demonstrated in several trials in humans. 1• 2 Side effects of BCG immunotherapy are not rare but usually are self-limited.3-5 However, severe systemic reaction can occur and usually leads to antituberculous therapy. 3-9 We report on a 57-year-old man who had a severe systemic hypersensitivity reaction after intravesical BCG. The patient had a complete remission under steroid therapy alone. CASE
REPORT
A 57-year-old man had a history of pulmonary tuberculosis in 1980 and a 5-year history of superficial carcinoma of the Accepted for publication July 19, 1991. Supported by a grant from the Centre d'Etudes et de Recherche en Infectiologie. *Requests for reprints: Department of Infectious Diseases, Hopital Saint-Louis, 1 Avenue C. Vellefaux, 75010 Paris, France.
bladder. He underwent multiple intravesical resections and a course of intravesical BCG therapy was started in March 1990 with mycobacterium bovis strain (BCG Pasteur) at 75 mg. once a week. No percutaneous BCG was administered. During the initial 2 inoculations a transient fever was noted. There was difficulty in catheterizing the bladder for the third administration and urethral bleeding occurred. Three hours later the patient experienced fever up to 40C with chills and severe dysuria. The next day 300 mg. isoniazid daily were started and the patient was discharged from the hospital. A week later the patient was still febrile and 600 mg. rifampin daily were added to the regimen for suspected disseminated BCG infection. He was transferred to our institution on May 8 because of persistent fever. The patient was acutely ill with a temperature of 39C. Physical examination was remarkable for dyspnea, icteric sclerae, an enlarged liver and bilateral inspiratory crackles in both lungs. Severe hypoxemia (oxygen pressure 59 mm. Hg while
