Vol. 115, March
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
URETERAL OBSTRUCTION AND PYELONEPHRITIS CAUSED BY AN INGUINAL HERNIA: REPORT OF A CASE JOHN W. TOMFORD, BARBARA M. ALVING*
AND
DENNIS TORRETTI
From the Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
ABSTRACT
An elderly man had pyelonephritis and sepsis owing to ureteral obstruction. Retrograde pyelography showed of the right ureter in an hernia. This condition, should be considered before •rn•u·~· is performed and which may be cm1g,n-11ta1 as a cause of u.reteral Causes of ureteral obstruction are numerous and may be unsuspected in with severe infections. Herein we describe an man with right lower and ali consequences of ureteral inguinal hernia.
DISCUSSION
Although 53 cases of herniation have been it is an accidental discovery at herniorrhaphy a few authors have described preoperative radiodiagnosis of this condition. 1 • 2 The bladder may be included in 1 to 3 per cent of inguinal or scrotal hernias. 3 When the hernias are large the ureters may be pulled into the sac with the bladder. For this reason, Mallouh and Pellman recommend adequate visualization of the ureter in all cases of bladder herniation. 2 They report that immediate
CASE REPORT
An black man was hospitalized for pain in the lower right side. He had noted nocturia and slight loss of bladder control 3 months ago but no change in size or character of the urinary stream. A week before hospitalization these symptoms became worse and several days later the patient experienced a sudden onset of sharp, constant, severe pain in the right lower quadrant of the abdomen with extension into the right flank. The pain was not relieved by change of ,.,v,Jco,.vu The patient denied nausea and vomiting. He had not had renal stones, hematuria, pyuria or prostatic disease. Physical examination revealed a febrile elderly man in mild distress. Abdominal examination showed guarding and tenderness on palpation of the right side without rebound. No hepatosplenomegaly or abdominal mass was found. Bowel sounds were normal, A massive right hernia was present with visible and audible peristaltic waves in the sac, which was 25 cm. in diameter. Hernatocrit was 41 per cent and white cell count was 11,400 per mm. 3 Electrolytes were normal; the urea nitrogen was 25 mg. and creatinine 2.1 mg. per 100 ml. A plain film of the abdomen was normal. Microscopic examination of the urine showed numerous white cells, gram-negative rods and an occasional white cell cast. The patient was treated for pyelonephritis since blood and urine cultures yielded Escherichia coli. An excretory urogram (IVP) showed delayed visualization of a right hydronephrotic kidney with no visible right ureter or obstructing lesion. The left kidney and ureter, and the bladder were normal. Cystoscopy with right retrograde pyelography demonstrated urethral deviation owing to the hernia, a normal prostate and absent efflux from the right ureter. There was marked calicectasis with ureteral dilatation. The distal portion of the dilated ureter was deviated inferiorly into the hernia sac (see figure). A right ureteronephrectomy was performed. Examination of the kidney confirmed severe acute and chronic pyelonephritis. Postoperatively there was a gradual rise in the urea nitrogen to 100 mg. per 100 mL, returning to normal with conservative measures. The patient is well 4 months after discharge from the Accepted for publication * for reprints: The Baltimm2, Maryland
Hospital, Blalock 1033,
Retrograde pyelograrn shows deviation of right ureter into hernia sac with resulting ureteral obstruction and hydronephrosis,
333
334
TOMFORD, ALVING AND TORRETTI
excision of the herniated loop with reanastomosis may cause fewer complications than replacement of the ureter in the retroperitoneum. Scrotal ureter may be a part of a congenital defect as well as an acquired condition.' Jewett and Harris have reported a young boy with scrotal herniation of the left ureter with resulting hydronephrosis. • The diagnosis was made by retrograde pyelography and the patient underwent satisfactory correction of the obstruction. The patient also had a history of excision of a right hydronephrotic kidney and repair of a right inguinal hernia. It was postulated that he may have had bilateral ureteral obstructions in hernias of congenital origin. Pyelonephritis was the only clue to possible ureteral obstruc-
tion in our case. Bladder herniation was not present but retrograde pyelography clearly showed the course of the obstructed ureter. REFERENCES
1. Dourmashkin, R. L.: Scrotal hernia of ureter, associated with a unilateral fused kidney: case report. J. Ural., 38: 455, 1937. 2. Mallouh, C. and Pellman, C. M.: Scrotal herniation of the ureter. J. Ural., 106: 38, 1971. 3. Emmett, J. L. and Witten, D. M.: Clinical Urography, 3rd ed. Philadelphia: W. B. Saunders Co., vol. 3, p. 1860, 1971. 4. Jewett, H.J. and Harris, A. P.: Scrotal ureter: report of a case. J. Ural., 69: 184, 1953.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
URETERAL OBSTRUCTION AND PYELONEPHRITIS CAUSED BY AN INGUINAL HERNIA: REPORT OF A CASE JOHN W. TOMFORD, BARBARA M. ALVING*
AND
DENNIS TORRETTI
From the Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
ABSTRACT
An elderly man had pyelonephritis and sepsis owing to ureteral obstruction. Retrograde pyelography showed of the right ureter in an hernia. This condition, should be considered before •rn•u·~· is performed and which may be cm1g,n-11ta1 as a cause of u.reteral Causes of ureteral obstruction are numerous and may be unsuspected in with severe infections. Herein we describe an man with right lower and ali consequences of ureteral inguinal hernia.
DISCUSSION
Although 53 cases of herniation have been it is an accidental discovery at herniorrhaphy a few authors have described preoperative radiodiagnosis of this condition. 1 • 2 The bladder may be included in 1 to 3 per cent of inguinal or scrotal hernias. 3 When the hernias are large the ureters may be pulled into the sac with the bladder. For this reason, Mallouh and Pellman recommend adequate visualization of the ureter in all cases of bladder herniation. 2 They report that immediate
CASE REPORT
An black man was hospitalized for pain in the lower right side. He had noted nocturia and slight loss of bladder control 3 months ago but no change in size or character of the urinary stream. A week before hospitalization these symptoms became worse and several days later the patient experienced a sudden onset of sharp, constant, severe pain in the right lower quadrant of the abdomen with extension into the right flank. The pain was not relieved by change of ,.,v,Jco,.vu The patient denied nausea and vomiting. He had not had renal stones, hematuria, pyuria or prostatic disease. Physical examination revealed a febrile elderly man in mild distress. Abdominal examination showed guarding and tenderness on palpation of the right side without rebound. No hepatosplenomegaly or abdominal mass was found. Bowel sounds were normal, A massive right hernia was present with visible and audible peristaltic waves in the sac, which was 25 cm. in diameter. Hernatocrit was 41 per cent and white cell count was 11,400 per mm. 3 Electrolytes were normal; the urea nitrogen was 25 mg. and creatinine 2.1 mg. per 100 ml. A plain film of the abdomen was normal. Microscopic examination of the urine showed numerous white cells, gram-negative rods and an occasional white cell cast. The patient was treated for pyelonephritis since blood and urine cultures yielded Escherichia coli. An excretory urogram (IVP) showed delayed visualization of a right hydronephrotic kidney with no visible right ureter or obstructing lesion. The left kidney and ureter, and the bladder were normal. Cystoscopy with right retrograde pyelography demonstrated urethral deviation owing to the hernia, a normal prostate and absent efflux from the right ureter. There was marked calicectasis with ureteral dilatation. The distal portion of the dilated ureter was deviated inferiorly into the hernia sac (see figure). A right ureteronephrectomy was performed. Examination of the kidney confirmed severe acute and chronic pyelonephritis. Postoperatively there was a gradual rise in the urea nitrogen to 100 mg. per 100 mL, returning to normal with conservative measures. The patient is well 4 months after discharge from the Accepted for publication * for reprints: The Baltimm2, Maryland
Hospital, Blalock 1033,
Retrograde pyelograrn shows deviation of right ureter into hernia sac with resulting ureteral obstruction and hydronephrosis,
333
334
TOMFORD, ALVING AND TORRETTI
excision of the herniated loop with reanastomosis may cause fewer complications than replacement of the ureter in the retroperitoneum. Scrotal ureter may be a part of a congenital defect as well as an acquired condition.' Jewett and Harris have reported a young boy with scrotal herniation of the left ureter with resulting hydronephrosis. • The diagnosis was made by retrograde pyelography and the patient underwent satisfactory correction of the obstruction. The patient also had a history of excision of a right hydronephrotic kidney and repair of a right inguinal hernia. It was postulated that he may have had bilateral ureteral obstructions in hernias of congenital origin. Pyelonephritis was the only clue to possible ureteral obstruc-
tion in our case. Bladder herniation was not present but retrograde pyelography clearly showed the course of the obstructed ureter. REFERENCES
1. Dourmashkin, R. L.: Scrotal hernia of ureter, associated with a unilateral fused kidney: case report. J. Ural., 38: 455, 1937. 2. Mallouh, C. and Pellman, C. M.: Scrotal herniation of the ureter. J. Ural., 106: 38, 1971. 3. Emmett, J. L. and Witten, D. M.: Clinical Urography, 3rd ed. Philadelphia: W. B. Saunders Co., vol. 3, p. 1860, 1971. 4. Jewett, H.J. and Harris, A. P.: Scrotal ureter: report of a case. J. Ural., 69: 184, 1953.
