450
BRITISH JOURNAL OF UROLOGY
result from recurrent infection and/or stone formation (Kuiper, 1976). Approximately 30%of patients have haematuria, occasionally heavy (Kuiper, 1976). Haemorrhage can be severe enough to require surgical control, occasionally by nephrectomy ( R a m and Chisholm, 1976).
References Kuiper, J. J. (1976). Medullary sponge kidney. In Cystic Diseuses ofthe Kidney. Pp. 151-171. New York: Wiley. Ram, M. D. and Chisholm, G . D. (1969). Cystic disease of the renal pyramids (medullary sponge kidney). Br. J . Urol., 41, 280-286.
Requests for reprints to: C. D. Betts, Uro-Neurology Unit, National Hospital for Neurology and Neurosurgery, Queen Square, London WClN 3BG.
Urethro-vaso-cutaneous Fistula: an Unusual Complication following Bladder Neck Incision S.LIU and J. M. O’BRIEN, Department of Urology, East Birmingham Hospital, Birmingham
Case Report A 61-year-old man with a 1-year history of recurrent urinary tract infection underwent elective cystourethroscopy under general anaesthesia. A tight bladder neck was observed and rectal examination revealed a small benignfeeling prostate. A Turner-Warwick type bladder neck incision (Turner-Warwick and Whiteside, 1982) was carried out at 7 o’clock posteriorly and he made an uneventful recovery. Post-operatively, his urinary flow rate was much improved and his MSU was sterile. At routine out-patient follow-up 2 months later, he continued to remain asymptomatic and was discharged from further follow-up. He returned to the urology out-patient clinic 2 years later through referral by his general practitioner with a diagnosis of bilateral epididymo-orchitis which had failed to respond to 2 courses of antibiotics. On further enquiry, he described mild orchitis on and off for 2 years which had been treated by his general practitioner. Examination revealed a markedly enlarged tender right testis and a left testis of normal size. He was treated with parenteral antibiotics and subsequently a right orchiectomy was performed. Histology of the testis confirmed acute epididymo-orchitis. A few weeks after his discharge the patient re-presented with leakage of urine via the right side of the scrotum
Fig. Micturating cystogram showing free bilateral urethrovasal reflux and a right urethro-vaso-cutaneousfistula (with leakage of contrast on to the scrotal skin).
during micturition. Inspection of his genitalia confirmed a demonstrable urine discharge from a small opening at the lateral end of his right scrotal scar. A micturating cystogram (Fig.) showed bilateral urethro-vasal and seminal vesicle reflux with leakage of contrast medium through a right urethro-vaso-cutaneous fistula. The patient was offered either temporary urethral catheterisation or right vasectomy but declined. On review 2 months later the fistula had resolved spontaneously.
Comment
Scrota1 fistulas may arise from surgery for hypospadias (Shapiro, 1984), after implantation of a testicular prosthesis, scrotal injury (Yasumoto et al., 1984), renal transplantation (Noel and Velchik, 1986), complicating paraplegia (Ahn et al., 1989), xanthogranulomatous pyelonephritis (Calvo-Quin-
tero et al., 1989) or hidradenitis suppurativa of the scrotum (Buckley and Sarkeny, 1989). These fistulae seldom involve the vas deferens or urethra except in the case of paraplegic patients. In recurrent epididymo-orchitis, urethro-vasal reflux is sometimes incriminated as the underlying cause and vasectomy has been advocated as t h e appropriate treatment to prevent reflux. Desai and Abrams (1986) reported a single case of vasal urinary fistula after vasectomy. The patient reported here underwent an uneventful bladder neck incision with marked improvement
45 1
CASE REPORTS
of his symptoms. The development of unresolved reaction to the chlorhexidine component of the gel epididymo-orchitis 2 years later was also treated was recognised only after skin tests. Surgeons and promptly by surgical excision and antibiotics. In anaesthesiologists should be aware of this possibilview of the bilateral urethro-vasal reflux as well as ity when an anaphylactic reaction occurs during or free reflux into the seminal vesicles, with a history immediately after operations on the genitourinary of recurrent orchitis since the operation, it seems tract. Although chlorhexidine is widely used as a likely that the reflux resulted from the bladder neck incision. The incision might have damaged the medical disinfectant, reports of adverse reactions “antireflux mechanism” at the ejaculatory duct are rare. Reactions include delayed-type contact level, increasing the susceptibility to recurrent hypersensitivity (type IV allergy) and reactions of bacterial orchitis. Although high pressure bladder the immediate type (type I allergy). Both types of outflow obstruction may cause or contribute to the reaction may occur in the same patient (Bergqvistreflux, the exact aetiology of the formation of the Karlsson, 1988; Okana et al., 1989; Susitaival and fistula subsequent to the orchiectomy remains Hakkinen, 1989). We report a patient who develunknown, since the fistula disappeared sponta- oped anaphylactic reactions on 3 occasions immediately after the use of a catheter gel for cystoscopy. neously and the patient remained unobstructed. References
Case Report
Ahn, J. H., Reiter, R. and Farcon, E. (1989). Scrota1fistula from urethro-vasal reflux in paraplegia. Urology, 34,383-384. Buckley, C . and Sarkeny, I. (1989). Urethral fistula and sinus formation in hidradenitis suppurativa. Clin. Exp. Dermatol., 14,158-160. Calvo-Quintero,J. E., Alcover-Garcia, J. and Gutierrez-del-Pozo, R. (1 989). Fistularisation in xanthogranulomatous pyelonephritis. Presentation of 6 clinical cases and review of the literature. Actas Urol. ESP.,13,363-367. Desai, K. M. and Abrams, P. (1986). Vasal urinary fistula with retrograde reflux of urine after vasectomy. J . Urol., 135,10231024. Noel. A. W. and Velchik, M. G. (1986). Urine extravasation into the scrotum. J . Nucl. Med., 21,807-809. Shapiro, S. R. (1984). Complications of hypospadias repair. J . Urol., 131, 518-522. Turner-Warwick,R. T. and Whiteside, C. G. (1982). Urodynamic studies and their effect upon management. In Scieztifc Foundations of Urology, ed Chisholm, G . D. and InnesWilliams, D. Pp. 442457. London: Heinemann. Yasumoto, R., Nakanishi, J., Kishimoto, T. et al. (1984). Vasocutaneous fistula following scrota1injury. Br. J . Urol., 58, 222.
A 61-year-old man was admitted with obstruction of the prostate and recurrent bladder stone formation, after transurethral resection (TUR) of the prostate 10 years previously. In 1985 he underwent a myocardial revascularisation. He used no medication. The patient was premedicated with morphine-sulphate 10 mg and haloperidol 5 mg intramuscularly. Initial blood pressure was 170/100 mmHg and pulse 70/min. Following pre-oxygenation, anaesthesia was induced with thiopental500 mg, fentanyl200 mg and vecuronium 8 mg to facilitate intubation. After oral tracheal intubation the patient was ventilated with a mixture of 0 2 / N 2 0 (3/6 L/min). Anaesthesia was maintained with isoflurane 0.5%. The duration of anaesthesia was 30 min and the operation was uneventful. Rest curarisation was reversed with atropine 0.5 mg and neostigmine 1.5 mg intravenously. Immediately after this the blood pressure dropped severely, the patient became red and oedematous all over the body, insufflation pressure increased and rales were heard over the chest on auscultation. The surgeon, who had just put a catheter into the bladder, denied giving anything special to the patient, so an allergic reaction to medication, probably atropine, was assumed. Resuscitation was started immediately. Ephedrine 25 mg, calcium gluconate 1 g, hydrocortisone 2 x 200 mg, NaClO.9% 500 ml and Haemaccel500 ml were administered without an adequate increase in blood pressure. Finally, the administration of 0.4 mg epinephrine resulted in an increase in blood pressure to S0/50 mmHg. To clarify the haemodynamic situation a Swan Ganz catheter was inserted. The pulmonary pressure (PP) was 45/10 mmHg and central venous pressure (CVP) 14mmHg. After starting a continuous infusion of dopamine 6 mg/kg/h and nitroglycerine the patient was transferred to the Intensive Care Unit. During the next 12 h further recovery was observed. The arterial blood pressure was 100/40 mmHg, CVP 6 mmHg, PP 24/12 mmHg, cardiac output 8L/min with a total peri-
Requests for reprints to: S. Liu, Department of Urology, St Batholomew’s Hospital, West Smithfield, London EClA 7BE.
~
Severe Allergic Reaction to an Intraurethral Preparation Containing Chlorhexidine C. G. RAMSELAAR, A. CRAENEN and R. Th. BIJLEVELD, Departments of Dermatology,Anaesthesiology and Urology, St Antonius Hospital, Nieuwegein, The Netherlands
A patient developed a severe anaphylactic reaction after the repeated use of a catheter gel. An allergic
BRITISH JOURNAL OF UROLOGY
result from recurrent infection and/or stone formation (Kuiper, 1976). Approximately 30%of patients have haematuria, occasionally heavy (Kuiper, 1976). Haemorrhage can be severe enough to require surgical control, occasionally by nephrectomy ( R a m and Chisholm, 1976).
References Kuiper, J. J. (1976). Medullary sponge kidney. In Cystic Diseuses ofthe Kidney. Pp. 151-171. New York: Wiley. Ram, M. D. and Chisholm, G . D. (1969). Cystic disease of the renal pyramids (medullary sponge kidney). Br. J . Urol., 41, 280-286.
Requests for reprints to: C. D. Betts, Uro-Neurology Unit, National Hospital for Neurology and Neurosurgery, Queen Square, London WClN 3BG.
Urethro-vaso-cutaneous Fistula: an Unusual Complication following Bladder Neck Incision S.LIU and J. M. O’BRIEN, Department of Urology, East Birmingham Hospital, Birmingham
Case Report A 61-year-old man with a 1-year history of recurrent urinary tract infection underwent elective cystourethroscopy under general anaesthesia. A tight bladder neck was observed and rectal examination revealed a small benignfeeling prostate. A Turner-Warwick type bladder neck incision (Turner-Warwick and Whiteside, 1982) was carried out at 7 o’clock posteriorly and he made an uneventful recovery. Post-operatively, his urinary flow rate was much improved and his MSU was sterile. At routine out-patient follow-up 2 months later, he continued to remain asymptomatic and was discharged from further follow-up. He returned to the urology out-patient clinic 2 years later through referral by his general practitioner with a diagnosis of bilateral epididymo-orchitis which had failed to respond to 2 courses of antibiotics. On further enquiry, he described mild orchitis on and off for 2 years which had been treated by his general practitioner. Examination revealed a markedly enlarged tender right testis and a left testis of normal size. He was treated with parenteral antibiotics and subsequently a right orchiectomy was performed. Histology of the testis confirmed acute epididymo-orchitis. A few weeks after his discharge the patient re-presented with leakage of urine via the right side of the scrotum
Fig. Micturating cystogram showing free bilateral urethrovasal reflux and a right urethro-vaso-cutaneousfistula (with leakage of contrast on to the scrotal skin).
during micturition. Inspection of his genitalia confirmed a demonstrable urine discharge from a small opening at the lateral end of his right scrotal scar. A micturating cystogram (Fig.) showed bilateral urethro-vasal and seminal vesicle reflux with leakage of contrast medium through a right urethro-vaso-cutaneous fistula. The patient was offered either temporary urethral catheterisation or right vasectomy but declined. On review 2 months later the fistula had resolved spontaneously.
Comment
Scrota1 fistulas may arise from surgery for hypospadias (Shapiro, 1984), after implantation of a testicular prosthesis, scrotal injury (Yasumoto et al., 1984), renal transplantation (Noel and Velchik, 1986), complicating paraplegia (Ahn et al., 1989), xanthogranulomatous pyelonephritis (Calvo-Quin-
tero et al., 1989) or hidradenitis suppurativa of the scrotum (Buckley and Sarkeny, 1989). These fistulae seldom involve the vas deferens or urethra except in the case of paraplegic patients. In recurrent epididymo-orchitis, urethro-vasal reflux is sometimes incriminated as the underlying cause and vasectomy has been advocated as t h e appropriate treatment to prevent reflux. Desai and Abrams (1986) reported a single case of vasal urinary fistula after vasectomy. The patient reported here underwent an uneventful bladder neck incision with marked improvement
45 1
CASE REPORTS
of his symptoms. The development of unresolved reaction to the chlorhexidine component of the gel epididymo-orchitis 2 years later was also treated was recognised only after skin tests. Surgeons and promptly by surgical excision and antibiotics. In anaesthesiologists should be aware of this possibilview of the bilateral urethro-vasal reflux as well as ity when an anaphylactic reaction occurs during or free reflux into the seminal vesicles, with a history immediately after operations on the genitourinary of recurrent orchitis since the operation, it seems tract. Although chlorhexidine is widely used as a likely that the reflux resulted from the bladder neck incision. The incision might have damaged the medical disinfectant, reports of adverse reactions “antireflux mechanism” at the ejaculatory duct are rare. Reactions include delayed-type contact level, increasing the susceptibility to recurrent hypersensitivity (type IV allergy) and reactions of bacterial orchitis. Although high pressure bladder the immediate type (type I allergy). Both types of outflow obstruction may cause or contribute to the reaction may occur in the same patient (Bergqvistreflux, the exact aetiology of the formation of the Karlsson, 1988; Okana et al., 1989; Susitaival and fistula subsequent to the orchiectomy remains Hakkinen, 1989). We report a patient who develunknown, since the fistula disappeared sponta- oped anaphylactic reactions on 3 occasions immediately after the use of a catheter gel for cystoscopy. neously and the patient remained unobstructed. References
Case Report
Ahn, J. H., Reiter, R. and Farcon, E. (1989). Scrota1fistula from urethro-vasal reflux in paraplegia. Urology, 34,383-384. Buckley, C . and Sarkeny, I. (1989). Urethral fistula and sinus formation in hidradenitis suppurativa. Clin. Exp. Dermatol., 14,158-160. Calvo-Quintero,J. E., Alcover-Garcia, J. and Gutierrez-del-Pozo, R. (1 989). Fistularisation in xanthogranulomatous pyelonephritis. Presentation of 6 clinical cases and review of the literature. Actas Urol. ESP.,13,363-367. Desai, K. M. and Abrams, P. (1986). Vasal urinary fistula with retrograde reflux of urine after vasectomy. J . Urol., 135,10231024. Noel. A. W. and Velchik, M. G. (1986). Urine extravasation into the scrotum. J . Nucl. Med., 21,807-809. Shapiro, S. R. (1984). Complications of hypospadias repair. J . Urol., 131, 518-522. Turner-Warwick,R. T. and Whiteside, C. G. (1982). Urodynamic studies and their effect upon management. In Scieztifc Foundations of Urology, ed Chisholm, G . D. and InnesWilliams, D. Pp. 442457. London: Heinemann. Yasumoto, R., Nakanishi, J., Kishimoto, T. et al. (1984). Vasocutaneous fistula following scrota1injury. Br. J . Urol., 58, 222.
A 61-year-old man was admitted with obstruction of the prostate and recurrent bladder stone formation, after transurethral resection (TUR) of the prostate 10 years previously. In 1985 he underwent a myocardial revascularisation. He used no medication. The patient was premedicated with morphine-sulphate 10 mg and haloperidol 5 mg intramuscularly. Initial blood pressure was 170/100 mmHg and pulse 70/min. Following pre-oxygenation, anaesthesia was induced with thiopental500 mg, fentanyl200 mg and vecuronium 8 mg to facilitate intubation. After oral tracheal intubation the patient was ventilated with a mixture of 0 2 / N 2 0 (3/6 L/min). Anaesthesia was maintained with isoflurane 0.5%. The duration of anaesthesia was 30 min and the operation was uneventful. Rest curarisation was reversed with atropine 0.5 mg and neostigmine 1.5 mg intravenously. Immediately after this the blood pressure dropped severely, the patient became red and oedematous all over the body, insufflation pressure increased and rales were heard over the chest on auscultation. The surgeon, who had just put a catheter into the bladder, denied giving anything special to the patient, so an allergic reaction to medication, probably atropine, was assumed. Resuscitation was started immediately. Ephedrine 25 mg, calcium gluconate 1 g, hydrocortisone 2 x 200 mg, NaClO.9% 500 ml and Haemaccel500 ml were administered without an adequate increase in blood pressure. Finally, the administration of 0.4 mg epinephrine resulted in an increase in blood pressure to S0/50 mmHg. To clarify the haemodynamic situation a Swan Ganz catheter was inserted. The pulmonary pressure (PP) was 45/10 mmHg and central venous pressure (CVP) 14mmHg. After starting a continuous infusion of dopamine 6 mg/kg/h and nitroglycerine the patient was transferred to the Intensive Care Unit. During the next 12 h further recovery was observed. The arterial blood pressure was 100/40 mmHg, CVP 6 mmHg, PP 24/12 mmHg, cardiac output 8L/min with a total peri-
Requests for reprints to: S. Liu, Department of Urology, St Batholomew’s Hospital, West Smithfield, London EClA 7BE.
~
Severe Allergic Reaction to an Intraurethral Preparation Containing Chlorhexidine C. G. RAMSELAAR, A. CRAENEN and R. Th. BIJLEVELD, Departments of Dermatology,Anaesthesiology and Urology, St Antonius Hospital, Nieuwegein, The Netherlands
A patient developed a severe anaphylactic reaction after the repeated use of a catheter gel. An allergic
