Aust. Radiol. (1975). 19, 194

htravand Intrauterine Refluxing of Urine in Children Intravaginal Refluxing of Urine in Women: Some postulates a r i s i i from thesefindings G. BEALE, M.B.,CH.B., M.R.A.C.R., D.D.R. Head of the Department of Radiology Rotorua Public Hospital, Rotorua, New Zealand

It is well recognized that in female children, during micturition, urine freely enters the vagina. It has been regarded as a normal variant and Davis and Chumley (1966) give the incidence as 43% in the recumbent position. It may occur regardless of position (Kjellberg, Ericsson and Rudhe 1957). Occasionally it may enter the uterus, 6ll it and flow into the fallopian tubes (Figures 1,2 and 3). Such filling does not relate to posture. Vaginal filling of some degree is also observed in women, regardless of posture. As with the child, the volume may be a variable amount, though it may reach the cervix (Figures 4 and

aetiological factor of vulvo-vaginitis both in the infected and the non-infected form. Strept (1954) feels that vulvovaginitis makes the management of chronic urethritis very difficult. He does not, however, attempt to explain the causes of either. Very tentatively it is suggested that urine emptying out of the vagina may irritate the urethral orifice. In this hospital 39% of 190 micturating cystourethrograms showed some

5).

Although no cases have yet been reported, it is suggested that intrauterine reflux may occur in adult women. Possible Effects of Zntravagiml and Intrauterine Urine In children it seems that intrauterine reflux of urine is not uncommon and occurs regardless of posture. Figure 1 is one example from 56 consecutive micturating cystourethrograms. Figures 2 and 3 are chance findings in paediatric IVPs done for suspected urinary tract infections. Both patients micturated in the sitting position. As urine may enter the fallopian tubes (Figure 3), it is reasonable to assume that some may also reach the peritoneum. It has been suggested (Beale and Hackett 1969) that urine in this manner is the vehicle of transport for pneumococci in idiopathic juvenile pneumococcal peritonitis. It may also explain other unexplained peritoneal problems of children by its abilities to carry organisms and also bv its direct irritative effkts. Intravaginal Urine also Produce ~fEects. Butcher and Donnai (1972) report two examples causing enuresis. The intravaginal urine, by its irritative processes, may well be the

FIGUREl-considerable vaginal and uterine reflux of contrast during micturating cystourethrography in the lateral recumbent position. The child was aged 10. U. Uterus V. Vagina B. Bladder. (from Beale & Hackett (1969) N.Z.Med. 1..69. 158).

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reflux in a post-micturition film in a normal paediatric IVP. Micturition occurred in the sitting position. The child was aged 3. U. Uterus V. Vagina B. Bladder.

FIGURE2-Uteriae

vaginal filling with 10% showing major filling and distention of the vagina. Almost all these emptied, apparently actively, at the end of micturition. There was a suspicion in one case that the expelled vaginal urine refluxed back into the lower urethra. If this is so it may explain some cases of urethritis, acute or chronic. It is postulated that the same sequence of events may occur in adults as in children, modified by the increased volume of the organs involved and the increased distances that are associated. Urine certainly enters the vagina. If it enters the uterus it may either irritate the tubes and the peritoneum or it may carry infection. In the theories of endometriais the opponents of the exfoliative theory of Javert (1949, 1951) headed by Novak and Woodruff (1969)

object to the theory on the ground that there is no suitable vehicle of transport for shed viable endometrial cells back into the peritoneum. Urine may be one vehicle. Once there is transportation the very occasional endometrial metastasis is explainable. Javert and Novak and Woodruff accept the embolic explanation for these cases of distant endometrial spread (as against the metaplastic theory).

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Other agents which may enter the Uterus The iatrogenic agents (air, douche fluid, etc.) are all well-known agents, as are their capacities to embolise through the myometrium. Although such intravasation usually requires pressure, people performing hystero-salpingogram are sometimes surprised at the ease with which the contrast material may intravasate.

G . BEALE

FIGURE3Utcrine and fallopiao tube re5ux in the post micturition film of a normal paediatric IW. Micturition took place in the sitting position. The child was aged 7. FI'.Fallopian Tube.

U. Uterus V. Vagina B. Bladder Ur. Ureter

The physiological agent which enters the uterus and the fallopian tubes is the sperm.

says that the case for semen entering the uterus is quite clear. He considers that in man there is an en masse entry of semen into the uterus The classical theory of sperm migration is and suggeststhat the chief function of the sperm that they leave the wannth and security of the flagella is to enter the ovum. semen in the vagina and travel by their own Whether one accepts one or other theory, motive powers within the female secretions of the uterus and tubes. Their random movements spermatozoa do reach the fallopian tubes. There are marshalled on their journey by the endo- is no reason to assume that they do not also metrial lining and its cellular structure. Without reach the peritoneum. Here the body mechanchemotaxis they still reach the ovum in consid- isms will ultimately put the breakdown products erable numbers. This is not so in some mam- into the vascular system. Similarly, because of mals. Noyes, Adams and Walton (1958) say their propulsive powers, it is reasonable to that in the rat, guinea pig, horse, pig and dog postulate that some live spermatozoa will semen passes rapidly into the uterus at the time occasionally penetrate directly into the vascular of coitus, though not, they say, in the rabbit, system either via the endometrium or via an cow, sheep or man. They conclude that in this abraded cervical area. The effects of this are latter group the semen travels as in the classical not postulated. theory for man. Hartman (1957), however, In the theories of endometriosis semen is 196

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INTRAVAGINAL AND INTRAUTERINE

REFLUXING OF URINE IN CHILDREN AND WOMEN

reflux in the post-micturition film of a normal IVP. Micturition took place in the sitting position. The woman was aged 35. B. Bladder V.V. Vault of Vagina.

FIGURE &Vaginal

It is very tentatively postulated that urine emptying from the vagina may irritate the lower urethra perhaps by partial reflux, causing some cases of acute or chronic urethritis. In women it is postulated that because vaginal reflux occurs, uterine reflux is possible. SUMMARY It is speculated that regardless of the mode of Three examples of intrauterine reflux of urine movement of spermatozoa within the uterus in children and two examples of intravaginal and fallopian tubes, either live spermatozoa reflux in women are shown. or the breakdown products may become intraIt is postulated that urine refluxing back to vascular. If semen enters the uterus en masse the peritoneum explains the mechanism of some it will be the mechanism of transport of gonoidiopathic peritoneal infections and irritations, cocci in gonococcal tubal infections. including idiopathic pneumococcal peritonitis. In the theories of endometrimis the opponIt is postulated that urine in the vagina is the ents to the reimplantation theory of shed viable endometrial cells oppose it mainly on the major aetiological factor in vulvovaginitis.

proposed as a second vehicle for the transport of endometrial cells. Its passage into the uterus and tubes readily explains the carriage of gonococci to the fallopian tubes.

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G . BEALE

FIGURE %Vaginal reflux into a tampon in a post-micturition film of a normal IVP. Micturition took place in the sitting position. The patient was aged 25. B. Bladder T. Tampon.

grounds of a lack of a suitable vehicle of trans- Hartman, C. G.: “How do Sperms get into the Uterus?’ Fertility and Sterility, 8,403, 1957. port from the uterine cavity to the peritoneum. Urine and/or semen are offered as suitable Javert, C. T.: “Observations on the Pathology and Spread of Endometriosis based on the theory of vehicles. Benign Matastasis.” Amer. I. Obst. Gynec., 62, 477,1951. My thanks to Dr. John Stewart, Radiologist of the National Women’s Hospital, Auckland, lavert, C. T.:“Pathogenesis of Endometriosis based on Endometrial Homeoplasia, Direct Extension ExN.Z.,for the example shown in Figure 5.

Butcher, C., and Donnai, D.: “Vaginal Reflux and Enuresis.” Brit. I. Rad., 45,501-502.1972. Davis, L. A., and Chumley, W.F.: “The frequency of Vaginal Reflux during Micturition-its possible importance to the interpretation of urine cultures.” Paediatrics, 38, 293-294, 1966.

foliation and Implantation Lymphatic and Haematogenous Metastasis.” Cancer, 2, 399, 1949. Kjelberg, S. R., Ericsson, N. O., and Rudhe, U.: “The Lower Urinary Tract in Childhood.” 1957 Stockholm Almgvist and Wilsell. Novak, E. R., and Woodruff, J. D.: Gynecologic and Obstefric Pathology,” Ed. 6, 1967. Philadelphia. W.B. Saunders & Co. Noyes, R. W.,Adams, C. E., and Walton, A.: “Transport of Spermatozoa into the Uterus of the Rabbit.” Fertility and Slerility, 9, 288, 1958. Strept, R.: “Importance of Vaginitis in Urinary Infections in Childhood.” I . Urol., 72, 963, 1954.

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REFERENCES Beale, G., and Hackett, A. H.: ”A Case of Uterine Rdlux in a Girl and its suggested role in Primary Pnewococcal Peritonitis.” N.Z. Med. I., 69, 158159,1969.

Intravaginal and intrauterine refluxing of urine in children; intravaginal refluxing of urine in women: some postulates arising from these findings.

Aust. Radiol. (1975). 19, 194 htravand Intrauterine Refluxing of Urine in Children Intravaginal Refluxing of Urine in Women: Some postulates a r i s...
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