RECURRENT EOSINOPHILIC CYSTITIS 14. Simon, D. L., Carron, H. and Rowlingson, J. C.: Treatment of bladder pain with transsacral nerve block. Anesth. Analg., 61: 46, 1982.
15. Coombs, D. W. and Fine, N.: Spinal anesthesia via subcutaneously implanted pumps for intrathecal drug infusion. Anesth. Analg., 73: 226, 1991.
0022-534 7/92/14 73-0689$03.00/0 Vol. 147, 689-691, March 1992 Printed in U.S.A.
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
RECURRENT EOSINOPHILIC CYSTITIS: A CASE RESPONSIVE TO STEROIDS H. STEPHEN WATSON, ERROL 0. SINGH, MICHAEL R. HERMANS, K. SCOTT COFFIELD AND GERALD T. KEEGAN From the Division of Urology, Texas A & M University College of Medicine, Scott & White Memorial Hospital, and Scott, Sherwood and Brindley Foundation, Temple, Texas
ABSTRACT
We report a case of eosinophilic cystitis that was responsive to prednisone but that recurred when the drug was withdrawn. The cause of eosinophilic cystitis remains an enigma but it probably represents a form of allergy. Investigation of etiology and therapeutic options are discussed. KEY WORDS: eosinophils, cystitis, allergy and immunology, hypersensitivity, bladder diseases
Eosinophilic infiltration of the bladder wall is a rarely reported finding. It often is associated with food or drug allergies, and it often is recurrent. Therapies range from avoidance of the allergic stimulus to steroids and sometimes urinary diversion. Because of the rarity of the lesion no consensus has been reached as to the suitability of specific treatments and therapy often is empirical.
prompted cessation of the prednisone. Shortly thereafter hematuria recurred, cystoscopy again demonstrated new posterior bladder mucosal lesions and biopsy again showed an eosinophilic infiltrate without evidence of malignancy. The patient has been followed for 2½ years and each attempt to taper or stop prednisone has been met with discouraging results.
CASE REPORT
DISCUSSION
A 46-year-old man was referred to us with a 3-day history of gross painless hematuria. The consulting urologist had visualized a bladder mucosal lesion but biopsy had failed to confirm neoplasia. The patient denied previous hematuria and the physical examination was normal. Urinalysis confirmed the hematuria with greater than 25 red and only 2 white blood cells per high power field. Urine cultures yielded no growth and there was no abnormality on an excretory urogram (IVP). Urine cytology demonstrated no atypia and no eosinophiluria. Cystoscopy and cold-cup biopsy were done (figs. 1 and 2), and fulguration of bleeding points provided hemostasis. Three further episodes of gross hematuria and dysuria occurred, and the cystoscopic findings persisted despite a trial of trimethoprim-sulfamethoxazole and cefadroxil. Repeated biopsies showed eosinophilic infiltration without neoplastic changes. Allergy evaluation revealed no history of asthma, atopic disease or parasitic infestation, and skin sensitivity tests were not helpful. The stool was negative for ova, cysts and parasites. A peripheral blood smear did not reveal eosinophilia. A urine culture for acid-fast bacilli was negative and a purified protein derivative test showed no reaction. Gross hematuria and dysuria recurred until 40 mg. prednisone per day and 60 mg. terfenidine every 8 hours were started. This regimen caused complete resolution of the hematuria and abnormal cystoscopic findings within 2 months. Three months later the prednisone was tapered to 5 mg. per day but hematuria with dysuria and the abnormal cystoscopic findings recurred. The terfenidine was stopped and prednisone was reinstituted at 40 mg. per day. Complete resolution was achieved that lasted for 6 months until cushingoid body features, glucose intolerance, and symptoms of dyspepsia and gastrointestinal upset
Since Brown first observed this condition in 1960,1 at least 43 cases of eosinophilic cystitis have been reported. 2 In adults this rare entity is characterized by recurrent hematuria, dysuria and frequency but in children the course is often self-limited. 3 Symptoms ofpyelonephritis and/or upper tract obstruction are known to occur. 4• 5 The cystoscopic findings are nonspecific but often show an edematous bladder mucosa, submucosal hemorrhage and sometimes ulcers, papillary lesions or velvety erythematous plaques. The cystoscopic findings are commonly confused with bladder neoplasia. In a review by Marshall and Middleton 5 of 15 patients with eosinophilic cystitis were believed to have bladder neoplasia at initial cystoscopic exam ination. 6 Neoplastic transformation has not been recorded but localized eosinophilic infiltrations are known to occur near bladder tumors. 7 An IVP is generally not helpful but it has shown secondary pyeloureterectasis and even extravasation. 5 Bladder biopsy is necessary to confirm the diagnosis, and shows infiltration of the lamina propria and sometimes muscularis with eosinophils and plasma cells, as well as other acute and chronic cells of the granulocytic line. A case of giant macrophage polykaryocyte infiltration has been documented. 8 Localized bladder wall fibrosis is not uncommon, especially with chronic, recurrent disease. Coexistent eosinophilic gastroenteritis, 9 Glanzmann's thrombasthenia, 10 bronchial asthma, parasitic infestations 11 • 12 and atopic disease have been reported. Eosinophilic ureteritis is rare or underreported. 4 • 5 Drug-induced eosinophilic cystitis secondary to methicillin, 13 warfarin, 14 N-( 3' ,4' -dimethoxycinnamoyl) anthranilic acid (an antiallergic compound) 15 and intravesical mitomycin C16 have been reported. Numerous studies acknowledge an allergic etiology of this disease 17 and others recognize urinary tract allergy as a signif-
Accepted for publication August 2, 1991.
690
WATSON AND ASSOCIATES
FIG. 1. Cystourethroscopy shows generalized mucosa! edema with erythema and submucosal hemorrhage in right superolateral aspect of bladder.
FIG. 2. Biopsy specimens reveal chronic cystitis with mixed inflammatory infiltration of lamina propria with plasma cells, lymphocytes and focally numerous eosinophils. A, reduced from XlO. B, reduced from xlOO.
icant cause of refractory lower tract symptomatology.18 Food allergies are often implicated19 but hypersensitivity to inhalant allergens and drugs is also known. Mast cells, which are important in the recruitment of tissue eosinophils, are found lining the bladder and ureteral walls of normal individuals, 20 thus, making the allergic hypothesis reasonable. Still better evidence is found in patients who are symptomatic in the presence of a specific stimulus and become symptom-free in the absence of that stimulus. However, concurrent high serum or urine levels of lgE are considered more specific. 19· 21 · 22 Eosinophiluria is not uncommon with eosinophilic cystitis but it is not found in all cases. The differential diagnosis of urinary eosinophils includes interstitial nephritis, acute tubular necrosis, contrast nephropathy, chronic renal failure and glomerulonephritis.20 However, the most common association in a series by Corwin et al was urinary tract infection. 23 No treatment for esoinophilic cystitis has been universally successful. Steroids have been noted to affect a resolution of symptoms, 15· 17 as in our patient. Other methods include antibiotics, urinary analgesics, desensitization to an allergic stimulus,3 antihistamines, 17 bladder hydrodilation, 4 fulguration of involved areas, partial cystectomy, 11 and even cystectomy and urinary diversion.4· 24 The subject of eosinophilia and eosinophilic-related disorders remains incompletely understood. Eosinophilic infiltration of the bladder wall, however, most likely represents the final pathway by which various endogenous or exogenous aller-
gens stimulate lgE-mediated mast cell degranulation and release of eosinophil chemotactic factors . Whether eosinophils are the primary factor causing the clinical picture of eosiniphilic cystitis is subject to debate. In summary, eosinophilic cystitis is a disease that is uncommonly encountered but often disabling to affected individuals. The diagnosis is made by cystoscopic biopsy, although eosinophiluria may be indicative. Radiographic studies (IVP and ultrasound) are usually normal but they may help rule out upper tract involvement. The disease course may be self-limited but it is often recurrent. A careful search for an allergic etiology is mandatory and all medications should be carefully reviewed. A conservative approach is indicated initially, since this disease may be self-limited. Recurrence warrants a trial of a corticosteroid. However, as with our patient steroid therapy may prove equally disabling. Additionally, detrusor instability or decreased bladder capacity with fibrosis that is resistant to other measures may warrant surgical intervention. REFERENCES 1. Brown, E.W.: Eosinophilic granuloma of the bladder. J. Urol., 83:
665, 1960. 2. Castillo, J ., Jr., Cartagena, R. and Montes, M.: Eosinophilic cystitis: a therapeutic challenge. Urology, 3 2 : 535, 1988. 3. Sutphin, M. and Middleton, A. W., Jr.: Eosinophilic cystitis in
691
BLADDER RUPTURE AFTER CESAREAN SECTION
children: a self-limited process. J. UroL, 132: 117, 1984. 4. Okafo, B. A., Jones, H. W., Dow, D. and Kiruluta, H. G.: Eosinophilic cystitis: pleomorphic manifestations. Canad. J. Surg., 28: 17, 1985. 5. Mitas, J. A., II and Thompson, T.: Ureteral involvement complicating eosinophilic cystitis. Urology, 26: 67, 1985. 6. Marshall, F. F. and Middleton, A. W., Jr.: Eosinophilic cystitis. J. Urol., 112: 335, 1974. 7. Nutman, T. B., Ottesen, E. A. and Cohen, S. G.: Eosinophilia and eosinophil-related disorders. In: Allergy, Principles and Practice. Edited by E. Middleton, Jr., C. E. Reed, E. F. Ellis, N. F. Adkinson, Jr. and J. W. Yunginger. St. Louis: The C.V. Mosby Co., vol. 1, chapt. 38, pp. 861-890, 1988. 8. Antonakopoulos, G. N. and Newman, J.: Eosinophilic cystitis with giant cells. A light microscopic and ultrastructural study. Arch. Path. Lab. Med., 108: 728, 1984. 9. Peterson, N. E., Silverman, A. and Campbell, J. B.: Eosinophilic cystitis and coexistent eosinophilic gastroenteritis in an infant. Ped. Rad., 19: 484, 1989. 10. Botma, J. P., Burger, E. G. and de Kock, M. L. S.: Eosinophilic cystitis associated with Glanzmann's thrombasthenia. A case report. S. Afr. Med. J., 71: 533, 1987. 11. Perlmutter, A. D., Edlow, J.B. and Kevy, S. V.: Toxocara antibodies in eosinophilic cystitis. J. Ped., 73: 340, 1968. 12. Hansman, D. J. and Brown, J. M.: Eosinophilic cystitis: a case associated with possible hydatid infection. Med. J. Aust., 2: 563, 1974. 13. Bracis, R., Sanders, C. V. and Gilbert, D. N.: Methicillin hemorrhagic cystitis. Antimicrob. Agents Chemother., 12: 438, 1977. 14. Littleton, R.H., Farah, R. N. and Cerny, J.C.: Eosinophilic cystitis:
an uncommon form of cystitis. J. Urol., 127: 132, 1982. 15. Nakada, T., Ishikawa, S., Sakamota, M., Katayama, T., Igarashi, T., Mizumura, Y., Koizumi, F., Shigematsu, H. and Fukuda, T.: N-(3' ,4' -dimethoxycinnamoyl) anthranillic acid, an antiallergic compound, induced eosinophilic cystitis. Urol. Int., 41: 457, 1986. 16. Inglis, J. A., Tolley, D. A. and Grigor, KM.: Allergy to mitomycin C complicating topical administration for urothelial cancer. Brit. J. Urol., 59: 547, 1987. 17. Frensilli, F. J., Sacher, E. C. and Keegan, G. T.: Eosinophilic cystitis: observations on etiology. J. Urol., 107: 595, 1972. 18. Powell, N. B., Powell, E. B., Thomas, 0. C., Queng, J. T. and McGovern, J. P.: Allergy of the lower urinary tract. J. Urol., 107: 631, 1972. 19. Palacios, A. S., Quintero de Juana, A., Sagarra, J. M. and Duque, R. A.: Eosinophilic food-induced cystitis. Allergol. Immunopath., 12: 463, 1984. 20. Sutton, J.M.: Urinary eosinophils. Arch. Intern. Med., 146: 2243, 1986. 21. Turner, M. W., Johansson, S. G. 0., Barratt, T. M. and Bennich, H.: Studies on the levels of immunoglobulins in normal human urine with particular reference to IgE. Int. Arch. Allergy Appl. Immunol., 37: 409, 1970. 22. Kessler, W. 0., Clark, P. L. and Kaplan, G. W.: Eosinophilic cystitis. Urology, 6: 499, 1975. 23. Corwin, H. L., Korbet, S. M. and Schwartz, M. M.: Clinical correlates of eosinophiluria. Arch. Intern. Med., 145: 1097, 1985. 24. Sidh, S. M., Smith, S. P., Silber, S. B. and Young, J. D., Jr.: Eosinophilic cystitis: advanced disease requiring surgical intervention. Urology, 15: 23, 1980.
0022-534 7/92/14 73-0691$03.00/0 Vol. 147, 691-692, March 1992
THE JOURNAL OF UROLOGY
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, !NC.
Printed in U.S.A.
SPONTANEOUS BLADDER AND UTERINE RUPTURE WITH ATTEMPTED VAGINAL DELIVERY AFTER CESAREAN SECTION J. Y, LEE
AND
A. S. CASS
From the Department of Urology, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT
We report spontaneous bladder and uterine rupture in a patient undergoing oxytocin augmented labor while under epidural anesthesia after a previous cesarean section. The presenting signs were gross hematuria at placement of an indwelling catheter and fetal distress. Cesarean section produced a healthy newborn, The recovered satisfactorily after subtotal hysterectomy, bladder repair and transfusion. KEY WORDS:
wounds and injuries; bladder; uterus; cesarean section; rupture, spontaneous
A vaginal birth after cesarean section performed via a low transverse incision is considered safe'-'3 and is being permitted more often as knowledge of its safety becomes more widespread. Although uterine scar separations and ruptures after previous cesarean sections are well documented,4 spontaneous rupture of the bladder during labor apparently has been described in only 4 cases, all from underdeveloped countries. 5 • 6 We present a case of spontaneous bladder rupture with associated uterine rupture in a patient who had a previous cesarean section. CASE REPORT
A 34-year-old para III woman with a documented low transverse cesarean scar from the third delivery was hospitalized for induction of labor at 40 weeks because of gestational diabetes Accepted for publication June 28, 1991.
and a history of macrosomatia, During a trial of labor with the patient under epidural anesthesia and with an internal fetal heart rate monitor, the oxytocin infusion rate was advanced to a maximum of 29 mu. per minute. An indwelling urethral catheter after 20 hours of labor yielded grossly bloody urine and fetal distress was detected. Emergency cesarean section produced a 3,750 gm. newborn with Apgar scores of 8 at 1 minute and 9 at 5 minutes. The bladder was edematous and markedly adherent to the low uterine segment. Further inspection showed a uterine rupture in the low anterior segment with extension of the tear from the posterior wall of the bladder through a lacerated cervix and into the proximal third of the vagina. Subtotal hysterectomy was performed and the bladder and vagina were repaired with 3 layers of absorbable suture. The patient received 2 units of packed red blood cells intraoperatively. The hemoglobin remained stable postoperatively. A catheter was left indwelling for 2 weeks. A followup cystogram revealed no extravasation. Convalescence was uneventful.
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.
15. Coombs, D. W. and Fine, N.: Spinal anesthesia via subcutaneously implanted pumps for intrathecal drug infusion. Anesth. Analg., 73: 226, 1991.
0022-534 7/92/14 73-0689$03.00/0 Vol. 147, 689-691, March 1992 Printed in U.S.A.
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
RECURRENT EOSINOPHILIC CYSTITIS: A CASE RESPONSIVE TO STEROIDS H. STEPHEN WATSON, ERROL 0. SINGH, MICHAEL R. HERMANS, K. SCOTT COFFIELD AND GERALD T. KEEGAN From the Division of Urology, Texas A & M University College of Medicine, Scott & White Memorial Hospital, and Scott, Sherwood and Brindley Foundation, Temple, Texas
ABSTRACT
We report a case of eosinophilic cystitis that was responsive to prednisone but that recurred when the drug was withdrawn. The cause of eosinophilic cystitis remains an enigma but it probably represents a form of allergy. Investigation of etiology and therapeutic options are discussed. KEY WORDS: eosinophils, cystitis, allergy and immunology, hypersensitivity, bladder diseases
Eosinophilic infiltration of the bladder wall is a rarely reported finding. It often is associated with food or drug allergies, and it often is recurrent. Therapies range from avoidance of the allergic stimulus to steroids and sometimes urinary diversion. Because of the rarity of the lesion no consensus has been reached as to the suitability of specific treatments and therapy often is empirical.
prompted cessation of the prednisone. Shortly thereafter hematuria recurred, cystoscopy again demonstrated new posterior bladder mucosal lesions and biopsy again showed an eosinophilic infiltrate without evidence of malignancy. The patient has been followed for 2½ years and each attempt to taper or stop prednisone has been met with discouraging results.
CASE REPORT
DISCUSSION
A 46-year-old man was referred to us with a 3-day history of gross painless hematuria. The consulting urologist had visualized a bladder mucosal lesion but biopsy had failed to confirm neoplasia. The patient denied previous hematuria and the physical examination was normal. Urinalysis confirmed the hematuria with greater than 25 red and only 2 white blood cells per high power field. Urine cultures yielded no growth and there was no abnormality on an excretory urogram (IVP). Urine cytology demonstrated no atypia and no eosinophiluria. Cystoscopy and cold-cup biopsy were done (figs. 1 and 2), and fulguration of bleeding points provided hemostasis. Three further episodes of gross hematuria and dysuria occurred, and the cystoscopic findings persisted despite a trial of trimethoprim-sulfamethoxazole and cefadroxil. Repeated biopsies showed eosinophilic infiltration without neoplastic changes. Allergy evaluation revealed no history of asthma, atopic disease or parasitic infestation, and skin sensitivity tests were not helpful. The stool was negative for ova, cysts and parasites. A peripheral blood smear did not reveal eosinophilia. A urine culture for acid-fast bacilli was negative and a purified protein derivative test showed no reaction. Gross hematuria and dysuria recurred until 40 mg. prednisone per day and 60 mg. terfenidine every 8 hours were started. This regimen caused complete resolution of the hematuria and abnormal cystoscopic findings within 2 months. Three months later the prednisone was tapered to 5 mg. per day but hematuria with dysuria and the abnormal cystoscopic findings recurred. The terfenidine was stopped and prednisone was reinstituted at 40 mg. per day. Complete resolution was achieved that lasted for 6 months until cushingoid body features, glucose intolerance, and symptoms of dyspepsia and gastrointestinal upset
Since Brown first observed this condition in 1960,1 at least 43 cases of eosinophilic cystitis have been reported. 2 In adults this rare entity is characterized by recurrent hematuria, dysuria and frequency but in children the course is often self-limited. 3 Symptoms ofpyelonephritis and/or upper tract obstruction are known to occur. 4• 5 The cystoscopic findings are nonspecific but often show an edematous bladder mucosa, submucosal hemorrhage and sometimes ulcers, papillary lesions or velvety erythematous plaques. The cystoscopic findings are commonly confused with bladder neoplasia. In a review by Marshall and Middleton 5 of 15 patients with eosinophilic cystitis were believed to have bladder neoplasia at initial cystoscopic exam ination. 6 Neoplastic transformation has not been recorded but localized eosinophilic infiltrations are known to occur near bladder tumors. 7 An IVP is generally not helpful but it has shown secondary pyeloureterectasis and even extravasation. 5 Bladder biopsy is necessary to confirm the diagnosis, and shows infiltration of the lamina propria and sometimes muscularis with eosinophils and plasma cells, as well as other acute and chronic cells of the granulocytic line. A case of giant macrophage polykaryocyte infiltration has been documented. 8 Localized bladder wall fibrosis is not uncommon, especially with chronic, recurrent disease. Coexistent eosinophilic gastroenteritis, 9 Glanzmann's thrombasthenia, 10 bronchial asthma, parasitic infestations 11 • 12 and atopic disease have been reported. Eosinophilic ureteritis is rare or underreported. 4 • 5 Drug-induced eosinophilic cystitis secondary to methicillin, 13 warfarin, 14 N-( 3' ,4' -dimethoxycinnamoyl) anthranilic acid (an antiallergic compound) 15 and intravesical mitomycin C16 have been reported. Numerous studies acknowledge an allergic etiology of this disease 17 and others recognize urinary tract allergy as a signif-
Accepted for publication August 2, 1991.
690
WATSON AND ASSOCIATES
FIG. 1. Cystourethroscopy shows generalized mucosa! edema with erythema and submucosal hemorrhage in right superolateral aspect of bladder.
FIG. 2. Biopsy specimens reveal chronic cystitis with mixed inflammatory infiltration of lamina propria with plasma cells, lymphocytes and focally numerous eosinophils. A, reduced from XlO. B, reduced from xlOO.
icant cause of refractory lower tract symptomatology.18 Food allergies are often implicated19 but hypersensitivity to inhalant allergens and drugs is also known. Mast cells, which are important in the recruitment of tissue eosinophils, are found lining the bladder and ureteral walls of normal individuals, 20 thus, making the allergic hypothesis reasonable. Still better evidence is found in patients who are symptomatic in the presence of a specific stimulus and become symptom-free in the absence of that stimulus. However, concurrent high serum or urine levels of lgE are considered more specific. 19· 21 · 22 Eosinophiluria is not uncommon with eosinophilic cystitis but it is not found in all cases. The differential diagnosis of urinary eosinophils includes interstitial nephritis, acute tubular necrosis, contrast nephropathy, chronic renal failure and glomerulonephritis.20 However, the most common association in a series by Corwin et al was urinary tract infection. 23 No treatment for esoinophilic cystitis has been universally successful. Steroids have been noted to affect a resolution of symptoms, 15· 17 as in our patient. Other methods include antibiotics, urinary analgesics, desensitization to an allergic stimulus,3 antihistamines, 17 bladder hydrodilation, 4 fulguration of involved areas, partial cystectomy, 11 and even cystectomy and urinary diversion.4· 24 The subject of eosinophilia and eosinophilic-related disorders remains incompletely understood. Eosinophilic infiltration of the bladder wall, however, most likely represents the final pathway by which various endogenous or exogenous aller-
gens stimulate lgE-mediated mast cell degranulation and release of eosinophil chemotactic factors . Whether eosinophils are the primary factor causing the clinical picture of eosiniphilic cystitis is subject to debate. In summary, eosinophilic cystitis is a disease that is uncommonly encountered but often disabling to affected individuals. The diagnosis is made by cystoscopic biopsy, although eosinophiluria may be indicative. Radiographic studies (IVP and ultrasound) are usually normal but they may help rule out upper tract involvement. The disease course may be self-limited but it is often recurrent. A careful search for an allergic etiology is mandatory and all medications should be carefully reviewed. A conservative approach is indicated initially, since this disease may be self-limited. Recurrence warrants a trial of a corticosteroid. However, as with our patient steroid therapy may prove equally disabling. Additionally, detrusor instability or decreased bladder capacity with fibrosis that is resistant to other measures may warrant surgical intervention. REFERENCES 1. Brown, E.W.: Eosinophilic granuloma of the bladder. J. Urol., 83:
665, 1960. 2. Castillo, J ., Jr., Cartagena, R. and Montes, M.: Eosinophilic cystitis: a therapeutic challenge. Urology, 3 2 : 535, 1988. 3. Sutphin, M. and Middleton, A. W., Jr.: Eosinophilic cystitis in
691
BLADDER RUPTURE AFTER CESAREAN SECTION
children: a self-limited process. J. UroL, 132: 117, 1984. 4. Okafo, B. A., Jones, H. W., Dow, D. and Kiruluta, H. G.: Eosinophilic cystitis: pleomorphic manifestations. Canad. J. Surg., 28: 17, 1985. 5. Mitas, J. A., II and Thompson, T.: Ureteral involvement complicating eosinophilic cystitis. Urology, 26: 67, 1985. 6. Marshall, F. F. and Middleton, A. W., Jr.: Eosinophilic cystitis. J. Urol., 112: 335, 1974. 7. Nutman, T. B., Ottesen, E. A. and Cohen, S. G.: Eosinophilia and eosinophil-related disorders. In: Allergy, Principles and Practice. Edited by E. Middleton, Jr., C. E. Reed, E. F. Ellis, N. F. Adkinson, Jr. and J. W. Yunginger. St. Louis: The C.V. Mosby Co., vol. 1, chapt. 38, pp. 861-890, 1988. 8. Antonakopoulos, G. N. and Newman, J.: Eosinophilic cystitis with giant cells. A light microscopic and ultrastructural study. Arch. Path. Lab. Med., 108: 728, 1984. 9. Peterson, N. E., Silverman, A. and Campbell, J. B.: Eosinophilic cystitis and coexistent eosinophilic gastroenteritis in an infant. Ped. Rad., 19: 484, 1989. 10. Botma, J. P., Burger, E. G. and de Kock, M. L. S.: Eosinophilic cystitis associated with Glanzmann's thrombasthenia. A case report. S. Afr. Med. J., 71: 533, 1987. 11. Perlmutter, A. D., Edlow, J.B. and Kevy, S. V.: Toxocara antibodies in eosinophilic cystitis. J. Ped., 73: 340, 1968. 12. Hansman, D. J. and Brown, J. M.: Eosinophilic cystitis: a case associated with possible hydatid infection. Med. J. Aust., 2: 563, 1974. 13. Bracis, R., Sanders, C. V. and Gilbert, D. N.: Methicillin hemorrhagic cystitis. Antimicrob. Agents Chemother., 12: 438, 1977. 14. Littleton, R.H., Farah, R. N. and Cerny, J.C.: Eosinophilic cystitis:
an uncommon form of cystitis. J. Urol., 127: 132, 1982. 15. Nakada, T., Ishikawa, S., Sakamota, M., Katayama, T., Igarashi, T., Mizumura, Y., Koizumi, F., Shigematsu, H. and Fukuda, T.: N-(3' ,4' -dimethoxycinnamoyl) anthranillic acid, an antiallergic compound, induced eosinophilic cystitis. Urol. Int., 41: 457, 1986. 16. Inglis, J. A., Tolley, D. A. and Grigor, KM.: Allergy to mitomycin C complicating topical administration for urothelial cancer. Brit. J. Urol., 59: 547, 1987. 17. Frensilli, F. J., Sacher, E. C. and Keegan, G. T.: Eosinophilic cystitis: observations on etiology. J. Urol., 107: 595, 1972. 18. Powell, N. B., Powell, E. B., Thomas, 0. C., Queng, J. T. and McGovern, J. P.: Allergy of the lower urinary tract. J. Urol., 107: 631, 1972. 19. Palacios, A. S., Quintero de Juana, A., Sagarra, J. M. and Duque, R. A.: Eosinophilic food-induced cystitis. Allergol. Immunopath., 12: 463, 1984. 20. Sutton, J.M.: Urinary eosinophils. Arch. Intern. Med., 146: 2243, 1986. 21. Turner, M. W., Johansson, S. G. 0., Barratt, T. M. and Bennich, H.: Studies on the levels of immunoglobulins in normal human urine with particular reference to IgE. Int. Arch. Allergy Appl. Immunol., 37: 409, 1970. 22. Kessler, W. 0., Clark, P. L. and Kaplan, G. W.: Eosinophilic cystitis. Urology, 6: 499, 1975. 23. Corwin, H. L., Korbet, S. M. and Schwartz, M. M.: Clinical correlates of eosinophiluria. Arch. Intern. Med., 145: 1097, 1985. 24. Sidh, S. M., Smith, S. P., Silber, S. B. and Young, J. D., Jr.: Eosinophilic cystitis: advanced disease requiring surgical intervention. Urology, 15: 23, 1980.
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SPONTANEOUS BLADDER AND UTERINE RUPTURE WITH ATTEMPTED VAGINAL DELIVERY AFTER CESAREAN SECTION J. Y, LEE
AND
A. S. CASS
From the Department of Urology, Hennepin County Medical Center, Minneapolis, Minnesota
ABSTRACT
We report spontaneous bladder and uterine rupture in a patient undergoing oxytocin augmented labor while under epidural anesthesia after a previous cesarean section. The presenting signs were gross hematuria at placement of an indwelling catheter and fetal distress. Cesarean section produced a healthy newborn, The recovered satisfactorily after subtotal hysterectomy, bladder repair and transfusion. KEY WORDS:
wounds and injuries; bladder; uterus; cesarean section; rupture, spontaneous
A vaginal birth after cesarean section performed via a low transverse incision is considered safe'-'3 and is being permitted more often as knowledge of its safety becomes more widespread. Although uterine scar separations and ruptures after previous cesarean sections are well documented,4 spontaneous rupture of the bladder during labor apparently has been described in only 4 cases, all from underdeveloped countries. 5 • 6 We present a case of spontaneous bladder rupture with associated uterine rupture in a patient who had a previous cesarean section. CASE REPORT
A 34-year-old para III woman with a documented low transverse cesarean scar from the third delivery was hospitalized for induction of labor at 40 weeks because of gestational diabetes Accepted for publication June 28, 1991.
and a history of macrosomatia, During a trial of labor with the patient under epidural anesthesia and with an internal fetal heart rate monitor, the oxytocin infusion rate was advanced to a maximum of 29 mu. per minute. An indwelling urethral catheter after 20 hours of labor yielded grossly bloody urine and fetal distress was detected. Emergency cesarean section produced a 3,750 gm. newborn with Apgar scores of 8 at 1 minute and 9 at 5 minutes. The bladder was edematous and markedly adherent to the low uterine segment. Further inspection showed a uterine rupture in the low anterior segment with extension of the tear from the posterior wall of the bladder through a lacerated cervix and into the proximal third of the vagina. Subtotal hysterectomy was performed and the bladder and vagina were repaired with 3 layers of absorbable suture. The patient received 2 units of packed red blood cells intraoperatively. The hemoglobin remained stable postoperatively. A catheter was left indwelling for 2 weeks. A followup cystogram revealed no extravasation. Convalescence was uneventful.
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
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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.
