British Journalof Urology (1992). 69,541-548 01992 British Journal of Urology
Jordan, G .H. (1987).Segmental haemorrhagic infarct of testicle. Urology, 29,60-65. Tackett, R. E., Ling, D., Catalona, W. J. et d (1986). High resolution sonography in diagnosing testicular neoplasms: clinical significance of false positive scans. J . Urol., 135,494496.
Case Reports Localised Infarction of the Testis
Requests for reprints to: J . D. Nawrocki, Department of Surgery, King’s College Hospital, Denmark Hill, London SE5 9RS.
J. D. NAWROCKI and A. J. COOK, Department of Surgery, Kent and Sussex Hospital, Tunbridge Wells
Case Report A 52-year-old man was admittted with a 24-h history of
left testicular discomfort which had developed while he had been changing for bed. He had no other symptoms and no relevant past medical history. Examination was normal apart from a slightly tender left testis. A full blood count, erythrocyte sedimentation rate, urine microscopy and culture, beta-HCG and alphafetoprotein were normal but a scrota1 ultrasound examination revealed a 16-mm hypoechogenic lesion within the upper pole of the left testis suggestive of a malignant tumour. A radical orchiectomy was performed from which the patient made an uneventful recovery. Histology failed to demonstrate any malignancy but showed a pale area of localised infarction with thrombosis of a small neighbouring vessel.
Perforation of Bladder Carcinoma Presenting as Acute Abdomen M . GOUGH, E. W. M . McDERMOlT, B. LYONS and W. P. H EDE R MAN, Department of Surgery, Mater Misericordiae Hospital, Dublin, Ireland
Case Report A 77-year-old woman presented with a 2-day history of suprapubic pain radiating to the left iliac fossa. Her relatives reported that she had complained of urinary incontinence over the preceding month. On examination she was pyrexial (39.I0C), confused and dehydrated. Examination of the abdomen revealed generalised tenderness and rigidity, most marked in the left iliac fossa. Investigations showed a leucocytosis but plain films of the abdomen were normal. Urethal catheterisation produced a small amount of urine which had a high white cell count on microscopy. The patient was resuscitated with intravenous fluids and antibiotics. At laparotomy, the peritoneal cavity contained approximately 600 ml of cloudy fluid and a marked fibrinous exudate. The dome of the bladder was replaced by a large tumour with a perforation 1.5 cm in diameter on the left side (Fig.). The bowel and uterus were not involved but the bladder tumour was fixed to the side walls of the pelvis. Peritoneal toilet was performed and a suprapubic catheter was placed in the bladder. Biopsies were taken and the perforation was closed and covered with an omental patch. No definitive surgical procedure was possible because of the fixity of the tumour and the patient’s poor clinical condition. The patient made a good post-operative recovery. Histology showed a poorly differentiated squamous cell carcinoma of the bladder. Intravenous urography showed hydronephrosis and hydroureter bilaterally.
Comment Complete infarction of the testis may occur following torsion or trauma. Localised infarction seldom occurs, with only 9 reported cases and in association with a number of conditions, e.g. polycythaemia, sickle cell disease, hypersensitivity angiitis and trauma (Jordan, 1987; Baer et al., 1989). In this case it occurred in the absence of any other detectable pathology but, as with the other cases, led to orchiectomy on the suspicion of malignancy. Scrota1 ultrasound is an accurate investigation for distinguishing testicular from non-testicular swellings, but it is less satisfactory in distinguishing benign from malignant swellings within the testis, and a false positive rate of 50% has been reported (Tackett et al., 1986). With its increasing use it is likely that ultrasound scanning will detect benign conditions such as localised infarction more frequently and unless these can be differentiated from malignant lesions this will lead to a number of unnecessary orchiectomies.
References
Comment
Baer, H. M., Gerber, W. L., Kendall, A. R. et d (1989). Segmental infarct of the testis due to hypersensitivity angiitis. J . Urol., 142, 125-127.
Spontaneous intraperitoneal rupture of the bladder through a carcinoma is a rare event. Only 2 cases
54 1
542
BRITISH JOURNAL OF UROLOGY
Generalised Seizure after Extracorporeal Shock Wave Lithotripsy. A Complication Easy to Prevent? M.T. W.T. LOCK, J. D. MEERWALDT, K. H. KURTH and F. H. SCHRODER, Department of Urology, University of Utrecht; Departments of Urology and Neurology,Erasmus Unversity Hospital Dijkrigt, Rotterdam;Department of Urology, University of Amsterdam, The Netherlands
Urologists are inclined to instruct their patients after stone treatment to drink as much as possible.
Case Report
Fig. Intra-operative view of urinary bladder with arrow at site of perforation.
have previously been described in females (Glashan, 1957; Jenkinson, 1981). The classical history is of a sudden onset of lower abdominal pain, often occurring during micturition, followed by inability to pass urine (Thompson et al., 1961). This may be preceded by dysuria followed by oliguria or anuria. The investigation of choice is cystography, but the symptoms and signs are generally not specific enough for a pre-operative diagnosis to be made. The mortality rate in undiagnosed cases may be as high as 80%. The prognosis of spontaneous rupture of a carcinoma is poor. The treatment of choice is cystectomy, but the clinical condition of the patient may limit operative treatment to excision of the segment of perforated bladder, bladder drainage and closure followed by intensive peritoneal lavage. The diagnosis should be considered in all cases of acute abdomen, especially in patients with pre-existing or recent onset of urinary symptoms. References Glashan, R. W. (1957). Perforation as a complication of carcinoma of the bladder. Er. J . Urol., 39, 178-180. Jenkinson, L. R. ( I 98 I). Spontaneous intraperitoneal rupture of the urinary bladder. Postgrad. Med. J.,57, 269-270. Thompson, I., Johnson, E. L. and Ross, G. (1961). The acute abdomen of unrecognised bladder rupture. Arch. Surg., 90, 371-374. Requests for reprints to: M. Cough, St Vincent’s Hospital, Elm Park, Dublin 4, Ireland.
A 41-year-old woman with normal renal function (creatine 60 pmol/l), suffering from chronic urinary tract infections with Proteus mirabilis, caused by a 14 x 7 mm stone in the lower pole of the renal calix, but otherwise healthy, was treated with the HM-3 Dornier lithotriptor (ESWL). Successful disintegration was achieved with 700 19 kV shocks. Recovery was uneventful until the first day following treatment, when the patient lost consciousness and developed a generalized seizure with urinary incontinence; 10 mg diazepam were given intravenously. Neurological examination revealed no focal abnormalities apart from low serum concentrations of sodium (1 19 mmol/l), chloride (87 mmol/l) and urea (1 .5 mmol/ I). Normal values in this laboratory are sodium 136148 mmol/l, chloride 97-109 mmol/l and urea 2.58.0 mmol/l. She was treated with 1.5 L sodium chloride 0.9% intravenously over 12 h, followed by 2 g NaCl orally 3 times daily for 24 h. Over a period of several hours she regained full consciousness (E4, M5, V5). Follow-up for 6 years has revealed no abnormalities.
Comment As her fellow-patients had noticed, this patient followed too enthusiastically the advice to drink liberally; she drank more than 5 L tap water in 12 h, resulting in hyponatraemia due to dilution. This appears to be the first reported case of hyponatraemia in relation to ESWL treatment. Rapidly developing hyponatraemia is a well known phenomenon in urology (endoresection of the prostate), in internal medicine (rapid rehydration after dehydration due to severe diarrhoea), in psychiatry (compulsive behaviour) and in alcoholism (excessive consumption of water due to gastritis). The severity of neurological disorders is related to the rapidity of the decrease in sodium concentration, but the sodium concentration itself also
Jordan, G .H. (1987).Segmental haemorrhagic infarct of testicle. Urology, 29,60-65. Tackett, R. E., Ling, D., Catalona, W. J. et d (1986). High resolution sonography in diagnosing testicular neoplasms: clinical significance of false positive scans. J . Urol., 135,494496.
Case Reports Localised Infarction of the Testis
Requests for reprints to: J . D. Nawrocki, Department of Surgery, King’s College Hospital, Denmark Hill, London SE5 9RS.
J. D. NAWROCKI and A. J. COOK, Department of Surgery, Kent and Sussex Hospital, Tunbridge Wells
Case Report A 52-year-old man was admittted with a 24-h history of
left testicular discomfort which had developed while he had been changing for bed. He had no other symptoms and no relevant past medical history. Examination was normal apart from a slightly tender left testis. A full blood count, erythrocyte sedimentation rate, urine microscopy and culture, beta-HCG and alphafetoprotein were normal but a scrota1 ultrasound examination revealed a 16-mm hypoechogenic lesion within the upper pole of the left testis suggestive of a malignant tumour. A radical orchiectomy was performed from which the patient made an uneventful recovery. Histology failed to demonstrate any malignancy but showed a pale area of localised infarction with thrombosis of a small neighbouring vessel.
Perforation of Bladder Carcinoma Presenting as Acute Abdomen M . GOUGH, E. W. M . McDERMOlT, B. LYONS and W. P. H EDE R MAN, Department of Surgery, Mater Misericordiae Hospital, Dublin, Ireland
Case Report A 77-year-old woman presented with a 2-day history of suprapubic pain radiating to the left iliac fossa. Her relatives reported that she had complained of urinary incontinence over the preceding month. On examination she was pyrexial (39.I0C), confused and dehydrated. Examination of the abdomen revealed generalised tenderness and rigidity, most marked in the left iliac fossa. Investigations showed a leucocytosis but plain films of the abdomen were normal. Urethal catheterisation produced a small amount of urine which had a high white cell count on microscopy. The patient was resuscitated with intravenous fluids and antibiotics. At laparotomy, the peritoneal cavity contained approximately 600 ml of cloudy fluid and a marked fibrinous exudate. The dome of the bladder was replaced by a large tumour with a perforation 1.5 cm in diameter on the left side (Fig.). The bowel and uterus were not involved but the bladder tumour was fixed to the side walls of the pelvis. Peritoneal toilet was performed and a suprapubic catheter was placed in the bladder. Biopsies were taken and the perforation was closed and covered with an omental patch. No definitive surgical procedure was possible because of the fixity of the tumour and the patient’s poor clinical condition. The patient made a good post-operative recovery. Histology showed a poorly differentiated squamous cell carcinoma of the bladder. Intravenous urography showed hydronephrosis and hydroureter bilaterally.
Comment Complete infarction of the testis may occur following torsion or trauma. Localised infarction seldom occurs, with only 9 reported cases and in association with a number of conditions, e.g. polycythaemia, sickle cell disease, hypersensitivity angiitis and trauma (Jordan, 1987; Baer et al., 1989). In this case it occurred in the absence of any other detectable pathology but, as with the other cases, led to orchiectomy on the suspicion of malignancy. Scrota1 ultrasound is an accurate investigation for distinguishing testicular from non-testicular swellings, but it is less satisfactory in distinguishing benign from malignant swellings within the testis, and a false positive rate of 50% has been reported (Tackett et al., 1986). With its increasing use it is likely that ultrasound scanning will detect benign conditions such as localised infarction more frequently and unless these can be differentiated from malignant lesions this will lead to a number of unnecessary orchiectomies.
References
Comment
Baer, H. M., Gerber, W. L., Kendall, A. R. et d (1989). Segmental infarct of the testis due to hypersensitivity angiitis. J . Urol., 142, 125-127.
Spontaneous intraperitoneal rupture of the bladder through a carcinoma is a rare event. Only 2 cases
54 1
542
BRITISH JOURNAL OF UROLOGY
Generalised Seizure after Extracorporeal Shock Wave Lithotripsy. A Complication Easy to Prevent? M.T. W.T. LOCK, J. D. MEERWALDT, K. H. KURTH and F. H. SCHRODER, Department of Urology, University of Utrecht; Departments of Urology and Neurology,Erasmus Unversity Hospital Dijkrigt, Rotterdam;Department of Urology, University of Amsterdam, The Netherlands
Urologists are inclined to instruct their patients after stone treatment to drink as much as possible.
Case Report
Fig. Intra-operative view of urinary bladder with arrow at site of perforation.
have previously been described in females (Glashan, 1957; Jenkinson, 1981). The classical history is of a sudden onset of lower abdominal pain, often occurring during micturition, followed by inability to pass urine (Thompson et al., 1961). This may be preceded by dysuria followed by oliguria or anuria. The investigation of choice is cystography, but the symptoms and signs are generally not specific enough for a pre-operative diagnosis to be made. The mortality rate in undiagnosed cases may be as high as 80%. The prognosis of spontaneous rupture of a carcinoma is poor. The treatment of choice is cystectomy, but the clinical condition of the patient may limit operative treatment to excision of the segment of perforated bladder, bladder drainage and closure followed by intensive peritoneal lavage. The diagnosis should be considered in all cases of acute abdomen, especially in patients with pre-existing or recent onset of urinary symptoms. References Glashan, R. W. (1957). Perforation as a complication of carcinoma of the bladder. Er. J . Urol., 39, 178-180. Jenkinson, L. R. ( I 98 I). Spontaneous intraperitoneal rupture of the urinary bladder. Postgrad. Med. J.,57, 269-270. Thompson, I., Johnson, E. L. and Ross, G. (1961). The acute abdomen of unrecognised bladder rupture. Arch. Surg., 90, 371-374. Requests for reprints to: M. Cough, St Vincent’s Hospital, Elm Park, Dublin 4, Ireland.
A 41-year-old woman with normal renal function (creatine 60 pmol/l), suffering from chronic urinary tract infections with Proteus mirabilis, caused by a 14 x 7 mm stone in the lower pole of the renal calix, but otherwise healthy, was treated with the HM-3 Dornier lithotriptor (ESWL). Successful disintegration was achieved with 700 19 kV shocks. Recovery was uneventful until the first day following treatment, when the patient lost consciousness and developed a generalized seizure with urinary incontinence; 10 mg diazepam were given intravenously. Neurological examination revealed no focal abnormalities apart from low serum concentrations of sodium (1 19 mmol/l), chloride (87 mmol/l) and urea (1 .5 mmol/ I). Normal values in this laboratory are sodium 136148 mmol/l, chloride 97-109 mmol/l and urea 2.58.0 mmol/l. She was treated with 1.5 L sodium chloride 0.9% intravenously over 12 h, followed by 2 g NaCl orally 3 times daily for 24 h. Over a period of several hours she regained full consciousness (E4, M5, V5). Follow-up for 6 years has revealed no abnormalities.
Comment As her fellow-patients had noticed, this patient followed too enthusiastically the advice to drink liberally; she drank more than 5 L tap water in 12 h, resulting in hyponatraemia due to dilution. This appears to be the first reported case of hyponatraemia in relation to ESWL treatment. Rapidly developing hyponatraemia is a well known phenomenon in urology (endoresection of the prostate), in internal medicine (rapid rehydration after dehydration due to severe diarrhoea), in psychiatry (compulsive behaviour) and in alcoholism (excessive consumption of water due to gastritis). The severity of neurological disorders is related to the rapidity of the decrease in sodium concentration, but the sodium concentration itself also
