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Trop Doct OnlineFirst, published on May 14, 2015 as doi:10.1177/0049475515585640
Short Report
Leach out of reach: presented with haematuria and urinary retention
Tropical Doctor 0(0) 1–3 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475515585640 tdo.sagepub.com
Dilip Kumar Pal1, Sanjay Kumar2, Rajendra Prasad Ray2, Anurag Puri2 and Varun Wats2
Keywords Foreign body, haematuria, leech infestation
Introduction Leech infestation is very common in rural areas of tropical countries. People travelling in marshy areas or through slow-moving brooks or streams are the usual victims. Leeches commonly infest the body surface of the host. They rarely enter through the orifices of the nose, anus, vagina or penis.1–3 Here, we report a case of vesical hirudiniasis, which was confirmed by ultrasonography and cystoscopy The culprit was successfully removed cystoscopically in a living condition.
Case report While playing in a pond in a rural area, a 14-year-old boy sensed a leech entering through his penis. He screamed in fear and tried to extract the leech manually. Owing to its highly slippery nature, however, he failed. The leech entered totally through the urethra, causing severe pain in his penis. After 24 h, the boy presented with haematuria followed by urinary retention. After urinary catherisation, an ultrasonography of the bladder region revealed a tubular 9 cm long nonshadowing structure on the posterior wall of the urinary bladder (Figure 1). Its wall was highly echogenic but the centre was not so. A total of 50 mL normal saline was instilled into the bladder through the catheter, which was kept clamped for 3 h. Then the catheter was removed but the leech did not expel itself spontaneously and, even after 6 fruitless hours, haematuria continued. Consequently, under general anaesthesia, through the cystoscope, after multiple blood clots were evacuated, the large reddish-yellow leech with its usual peristaltic movement was located at the posterior wall of the bladder (Figure 2). It could eventually be removed with tri-pronged forceps (Figure 3). Once outside the bladder, it still retained its usual body
movement (Figure 4). Within 2 h the haematuria stopped and urine became clear.
Discussion Leeches are annelids or segmented sanguinivorous worms. Their body surface is slippery because of a wide distribution of slime glands. The saliva of the leech contains Hirudin which inhibits thrombin in the clotting process.1,2 It also has local anaesthetic properties. Consequently the wound caused by the leech is painless.2–4 Leech bites on exposed skin surface is common. Other rare sites include the nose, mouth, vagina, rectum and urethra. This may cause hoarseness of voice, inspiratory stridor, haemoptysis, dysphagia, vaginal, rectal or urethral bleeding. Very few cases of leech infestation of urinary bladder have been reported so far.1–5 Patients usually present with severe pain in the penis, together with dysuria and frank haematuria.1–5 Diagnosis of such cases are sometimes difficult unless the patient recognises the leech when it enters the urethra.4 Ultrasonography may be diagnostic.3 A tubular structure without any acoustic shadow but with a highly echogenic wall and less echogenic centre indicates a leech in the urinary bladder.3 Cystoscopy confirms the foreign body.2,4 In most reported cases, the 1 Professor & Head, Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India 2 Post Doctoral Trainee, Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India
Corresponding author: Dilip Kumar Pal, Professor & Head, Department of Urology, Postgraduate Institute of Medical Education & Research, 244 AJC Bose Road, Kolkata 700020, West Bengal, India. Email: [email protected]
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Figure 1. Ultrasonography of urinary bladder showing intravesical leech as tubular, non-shadowing structure with highly echogenic wall.
Figure 3. Showing extraction of leech by using tri-pronged forceps.
Figure 4. Intact leech after expulsion.
Figure 2. Cystoscopic view of intravesical leech.
leech was spontaneously expelled within 2–12 h of intravesical instillation of normal saline (0.9%).1–5 In addition, local anaesthetic gel (4%) may be instilled intravesically. Some authors advocate hypertonic saline (3%) instillation by which the leech may be anaesthetised, shrunken and ruptured, and may find easy passage through urethra during micturation.4 Rarely, cases may require suprapubic bladder exploration for removal and control of bleeding. When spontaneous removal fails, cystoscopic removal is usually
the alternative. Local and systemic haemostatic agents may be applied to stop bleeding,4,5 but in most cases bleeding stops spontaneously within a few hours of removal of the leech1 as in our case. To be sure of killing the leach, we strongly recommend hypertonic saline instillation into the bladder. Declaration of conflicting interests All the authors have seen the manuscript and approve it for submission. The authors have no competing interest in the publication of the manuscript to declare.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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References 1. Alam S, Choudhury MKD and Khan I. Leach in urinary bladder causing haematuria. J Pediatr Urol 2008; 4: 70–73. 2. Deka PM and Rajeev TP. Unusual cause of haematuria. Urol Int 2001; 66: 41–42. 3. Paul AK and Islam N. Vesical hirudiniasis: an unusual cause of bleeding from the urethra. J Ultrasound Med 2005; 24: 1731–1733.
4. Ahmmed B, Uddin S and Rumi A. Haematuria due to a leach bite in the urinary bladder: a case report. Bangladesh J Child Health 2013; 37: 183–185. 5. Ghosh D, Saha S, Das S, Samanta N and Konar K. Leach in urinary bladder. J Indian Assoc Pediatr Surg 2002; 7: 46–49.
Downloaded from tdo.sagepub.com by guest on November 17, 2015
(TDO)
[1–3] [PREPRINTER stage]
Trop Doct OnlineFirst, published on May 14, 2015 as doi:10.1177/0049475515585640
Short Report
Leach out of reach: presented with haematuria and urinary retention
Tropical Doctor 0(0) 1–3 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475515585640 tdo.sagepub.com
Dilip Kumar Pal1, Sanjay Kumar2, Rajendra Prasad Ray2, Anurag Puri2 and Varun Wats2
Keywords Foreign body, haematuria, leech infestation
Introduction Leech infestation is very common in rural areas of tropical countries. People travelling in marshy areas or through slow-moving brooks or streams are the usual victims. Leeches commonly infest the body surface of the host. They rarely enter through the orifices of the nose, anus, vagina or penis.1–3 Here, we report a case of vesical hirudiniasis, which was confirmed by ultrasonography and cystoscopy The culprit was successfully removed cystoscopically in a living condition.
Case report While playing in a pond in a rural area, a 14-year-old boy sensed a leech entering through his penis. He screamed in fear and tried to extract the leech manually. Owing to its highly slippery nature, however, he failed. The leech entered totally through the urethra, causing severe pain in his penis. After 24 h, the boy presented with haematuria followed by urinary retention. After urinary catherisation, an ultrasonography of the bladder region revealed a tubular 9 cm long nonshadowing structure on the posterior wall of the urinary bladder (Figure 1). Its wall was highly echogenic but the centre was not so. A total of 50 mL normal saline was instilled into the bladder through the catheter, which was kept clamped for 3 h. Then the catheter was removed but the leech did not expel itself spontaneously and, even after 6 fruitless hours, haematuria continued. Consequently, under general anaesthesia, through the cystoscope, after multiple blood clots were evacuated, the large reddish-yellow leech with its usual peristaltic movement was located at the posterior wall of the bladder (Figure 2). It could eventually be removed with tri-pronged forceps (Figure 3). Once outside the bladder, it still retained its usual body
movement (Figure 4). Within 2 h the haematuria stopped and urine became clear.
Discussion Leeches are annelids or segmented sanguinivorous worms. Their body surface is slippery because of a wide distribution of slime glands. The saliva of the leech contains Hirudin which inhibits thrombin in the clotting process.1,2 It also has local anaesthetic properties. Consequently the wound caused by the leech is painless.2–4 Leech bites on exposed skin surface is common. Other rare sites include the nose, mouth, vagina, rectum and urethra. This may cause hoarseness of voice, inspiratory stridor, haemoptysis, dysphagia, vaginal, rectal or urethral bleeding. Very few cases of leech infestation of urinary bladder have been reported so far.1–5 Patients usually present with severe pain in the penis, together with dysuria and frank haematuria.1–5 Diagnosis of such cases are sometimes difficult unless the patient recognises the leech when it enters the urethra.4 Ultrasonography may be diagnostic.3 A tubular structure without any acoustic shadow but with a highly echogenic wall and less echogenic centre indicates a leech in the urinary bladder.3 Cystoscopy confirms the foreign body.2,4 In most reported cases, the 1 Professor & Head, Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India 2 Post Doctoral Trainee, Department of Urology, Institute of Post Graduate Medical Education & Research, Kolkata, India
Corresponding author: Dilip Kumar Pal, Professor & Head, Department of Urology, Postgraduate Institute of Medical Education & Research, 244 AJC Bose Road, Kolkata 700020, West Bengal, India. Email: [email protected]
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Figure 1. Ultrasonography of urinary bladder showing intravesical leech as tubular, non-shadowing structure with highly echogenic wall.
Figure 3. Showing extraction of leech by using tri-pronged forceps.
Figure 4. Intact leech after expulsion.
Figure 2. Cystoscopic view of intravesical leech.
leech was spontaneously expelled within 2–12 h of intravesical instillation of normal saline (0.9%).1–5 In addition, local anaesthetic gel (4%) may be instilled intravesically. Some authors advocate hypertonic saline (3%) instillation by which the leech may be anaesthetised, shrunken and ruptured, and may find easy passage through urethra during micturation.4 Rarely, cases may require suprapubic bladder exploration for removal and control of bleeding. When spontaneous removal fails, cystoscopic removal is usually
the alternative. Local and systemic haemostatic agents may be applied to stop bleeding,4,5 but in most cases bleeding stops spontaneously within a few hours of removal of the leech1 as in our case. To be sure of killing the leach, we strongly recommend hypertonic saline instillation into the bladder. Declaration of conflicting interests All the authors have seen the manuscript and approve it for submission. The authors have no competing interest in the publication of the manuscript to declare.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from tdo.sagepub.com by guest on November 17, 2015
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References 1. Alam S, Choudhury MKD and Khan I. Leach in urinary bladder causing haematuria. J Pediatr Urol 2008; 4: 70–73. 2. Deka PM and Rajeev TP. Unusual cause of haematuria. Urol Int 2001; 66: 41–42. 3. Paul AK and Islam N. Vesical hirudiniasis: an unusual cause of bleeding from the urethra. J Ultrasound Med 2005; 24: 1731–1733.
4. Ahmmed B, Uddin S and Rumi A. Haematuria due to a leach bite in the urinary bladder: a case report. Bangladesh J Child Health 2013; 37: 183–185. 5. Ghosh D, Saha S, Das S, Samanta N and Konar K. Leach in urinary bladder. J Indian Assoc Pediatr Surg 2002; 7: 46–49.
Downloaded from tdo.sagepub.com by guest on November 17, 2015
