1992, The British Journal of Radiology, 65, 945-946
Case of the month A curious case of pelvic calcification By D. J. Grier, MRCP, FRCR and *G. N. A. Sibley, DM, MCh, FRCS Departments of Clinical Radiology and *Urology, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK {Received 28 May 1991 and accepted 2 July 1991)
A 48-year-old woman complained of chronic dysuria, urinary frequency and incontinence. 20 years ago invasive carcinoma of the cervix had been treated by Wertheim's hysterectomy and radiotherapy (cobalt 60). Between 5200-6000 rads tumour dose were administered over 36 days with no immediate complication. A colostomy was performed 2 years later for colonic obstruction due to a stricture of the recto-sigmoid. She subsequently developed bilateral ureteric strictures and required an ileal interposition for this, the distal end of the ileal segment being anastomosed to the bladder dome. Both of these episodes were ascribed to fibrosis secondary to radiotherapy. Multiple urine cultures showed persistent growths of proteus and coliform organisms, and urinary pH was frequently raised. During this time there had been several episodes of metabolic acidosis and renal calculi had been treated with lithotripsy. 10 years after this a pneumonectomy was performed for an anaplastic bronchial carcinoma. Her general health was good with no evidence of recurrence of either tumour to date.
Figure 2. Longitudinal ultrasound scan of the pelvis.
Address correspondence to D. J. Grier.
The following investigations were performed in the investigation of her urinary tract (Figs 1-3). What is the most likely cause for these appearances? What is the most appropriate management?
Figure 1. Plain film of the pelvis.
Figure 3. CT scan of the pelvis.
Vol. 65, No. 778
945
Keywords: Vesical calcification
Case of the month
patient had persistent urinary growths of proteus and other organisms. Management of this condition is by acidification and sterilization of the urine. Occasionally cystoscopic removal of adherent calcareous slough is required (Jamieson, 1966). This patient has since undergone an ileal conduit urinary diversion in view of persistent infection and troublesome incontinence. Discussion
Figure 4. Intravenous urogram; delayed film showing bilateral hydronephroses and ileal interposition.
The plain radiograph (Fig. 1) shows extensive calcification within the pelvis. Ultrasound (Fig. 2) demonstrates an echogenic posterior bladder wall with distal acoustic shadowing. Computed tomography (CT) (Fig. 3) confirms extensive calcification, thickening and deformity of the posterior and lateral bladder wall, and also shows para-vesical calcification. Cystoscopy was performed revealing a calcareous slough on the posterior bladder wall, some of which could be scraped away only with difficulty. Intravenous urography (Fig. 4) demonstrates the overall appearance of the urinary tract. The diagnosis is dystrophic calcification of the bladder wall due to alkaline encrusting cystitis. In this condition there is deposition of urinary phosphate on the bladder wall, a process facilitated by chronic inflammation and fibrosis of the bladder wall and alkaline urine in which phosphate is less soluble. Infection with proteus spp. is implicated in the aetiology, as it is a urea splitting organism leading to raised urinary pH. This
946
Radiographically visible calcification of the urinary bladder (other than calculi) is rare. Recognized causes include transitional cell carcinoma, schistosomiasis and tuberculosis, and cyclophosphamide cystitis (Gross, 1979). Visible bladder wall calcification in association with non-granulomatous infection is very rare. There is only one other report of a case 6 years after radiotherapy for carcinoma of the cervix (Harrison et al, 1978). Alkaline encrusting cystitis was a common diagnosis before the widespread use of antibiotics, usually affecting women of childbearing age. Typical symptoms were of dysuria, suprapubic pain and often haematuria. An increased incidence of this condition was noted in patients undergoing radiotherapy for bladder tumours (Jamieson, 1966). Injury to the bladder wall as a result of radiotherapy, leading to inflammation, necrosis and fibrosis, in the presence of alkaline urine was felt to favour deposition of urinary phosphate. That the calcification in this case predominantly affected the posterior bladder wall is probably due to its proximity to the cervix. The region of the interureteric ridge of the bladder wall is considered the most vulnerable site for damage. Further, its vascular supply may have been compromised by the Wertheim's hysterectomy. As this patient has had several complications secondary to pelvic radiotherapy, it is not surprising that the radiological appearances of encrusting cystitis are so florid. Recognition of this condition is helpful because prompt treatment of urinary tract infection, particularly proteus, and acidification of the urine at an early stage may prevent, or even reverse, progression. Acknowledgments We would like to thank Professor E. R. Davies and Dr J. Bullimore for their assistance in the preparation of this manuscript.
References GROSS, B. H., 1979. Bladder and ureteral Seminars in Roentgenology, 14, 261-262. HARRISON, R. B.,
STIER, F. M.
calcifications.
& COCHRANE, J. A.,
1978.
Alkaline encrusting cystitis. American Journal of Roentgenology, 130, 575-577. JAMIESON, R. M., 1966. The treatment of phosphatic encrusted cystitis (alkaline cystitis) with nalidixic acid. British Journal of Urology, 38, 89-92.
The British Journal of Radiology, October 1992
Case of the month A curious case of pelvic calcification By D. J. Grier, MRCP, FRCR and *G. N. A. Sibley, DM, MCh, FRCS Departments of Clinical Radiology and *Urology, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK {Received 28 May 1991 and accepted 2 July 1991)
A 48-year-old woman complained of chronic dysuria, urinary frequency and incontinence. 20 years ago invasive carcinoma of the cervix had been treated by Wertheim's hysterectomy and radiotherapy (cobalt 60). Between 5200-6000 rads tumour dose were administered over 36 days with no immediate complication. A colostomy was performed 2 years later for colonic obstruction due to a stricture of the recto-sigmoid. She subsequently developed bilateral ureteric strictures and required an ileal interposition for this, the distal end of the ileal segment being anastomosed to the bladder dome. Both of these episodes were ascribed to fibrosis secondary to radiotherapy. Multiple urine cultures showed persistent growths of proteus and coliform organisms, and urinary pH was frequently raised. During this time there had been several episodes of metabolic acidosis and renal calculi had been treated with lithotripsy. 10 years after this a pneumonectomy was performed for an anaplastic bronchial carcinoma. Her general health was good with no evidence of recurrence of either tumour to date.
Figure 2. Longitudinal ultrasound scan of the pelvis.
Address correspondence to D. J. Grier.
The following investigations were performed in the investigation of her urinary tract (Figs 1-3). What is the most likely cause for these appearances? What is the most appropriate management?
Figure 1. Plain film of the pelvis.
Figure 3. CT scan of the pelvis.
Vol. 65, No. 778
945
Keywords: Vesical calcification
Case of the month
patient had persistent urinary growths of proteus and other organisms. Management of this condition is by acidification and sterilization of the urine. Occasionally cystoscopic removal of adherent calcareous slough is required (Jamieson, 1966). This patient has since undergone an ileal conduit urinary diversion in view of persistent infection and troublesome incontinence. Discussion
Figure 4. Intravenous urogram; delayed film showing bilateral hydronephroses and ileal interposition.
The plain radiograph (Fig. 1) shows extensive calcification within the pelvis. Ultrasound (Fig. 2) demonstrates an echogenic posterior bladder wall with distal acoustic shadowing. Computed tomography (CT) (Fig. 3) confirms extensive calcification, thickening and deformity of the posterior and lateral bladder wall, and also shows para-vesical calcification. Cystoscopy was performed revealing a calcareous slough on the posterior bladder wall, some of which could be scraped away only with difficulty. Intravenous urography (Fig. 4) demonstrates the overall appearance of the urinary tract. The diagnosis is dystrophic calcification of the bladder wall due to alkaline encrusting cystitis. In this condition there is deposition of urinary phosphate on the bladder wall, a process facilitated by chronic inflammation and fibrosis of the bladder wall and alkaline urine in which phosphate is less soluble. Infection with proteus spp. is implicated in the aetiology, as it is a urea splitting organism leading to raised urinary pH. This
946
Radiographically visible calcification of the urinary bladder (other than calculi) is rare. Recognized causes include transitional cell carcinoma, schistosomiasis and tuberculosis, and cyclophosphamide cystitis (Gross, 1979). Visible bladder wall calcification in association with non-granulomatous infection is very rare. There is only one other report of a case 6 years after radiotherapy for carcinoma of the cervix (Harrison et al, 1978). Alkaline encrusting cystitis was a common diagnosis before the widespread use of antibiotics, usually affecting women of childbearing age. Typical symptoms were of dysuria, suprapubic pain and often haematuria. An increased incidence of this condition was noted in patients undergoing radiotherapy for bladder tumours (Jamieson, 1966). Injury to the bladder wall as a result of radiotherapy, leading to inflammation, necrosis and fibrosis, in the presence of alkaline urine was felt to favour deposition of urinary phosphate. That the calcification in this case predominantly affected the posterior bladder wall is probably due to its proximity to the cervix. The region of the interureteric ridge of the bladder wall is considered the most vulnerable site for damage. Further, its vascular supply may have been compromised by the Wertheim's hysterectomy. As this patient has had several complications secondary to pelvic radiotherapy, it is not surprising that the radiological appearances of encrusting cystitis are so florid. Recognition of this condition is helpful because prompt treatment of urinary tract infection, particularly proteus, and acidification of the urine at an early stage may prevent, or even reverse, progression. Acknowledgments We would like to thank Professor E. R. Davies and Dr J. Bullimore for their assistance in the preparation of this manuscript.
References GROSS, B. H., 1979. Bladder and ureteral Seminars in Roentgenology, 14, 261-262. HARRISON, R. B.,
STIER, F. M.
calcifications.
& COCHRANE, J. A.,
1978.
Alkaline encrusting cystitis. American Journal of Roentgenology, 130, 575-577. JAMIESON, R. M., 1966. The treatment of phosphatic encrusted cystitis (alkaline cystitis) with nalidixic acid. British Journal of Urology, 38, 89-92.
The British Journal of Radiology, October 1992
