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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 1288-1291
Unusual etiology of recurrent urinary tract infection


1 Department of Nephrology, The Kidney Center Post Graduate Training Institute, Karachi, Pakistan
2 Department of Radiology, The Kidney Center Post Graduate Training Institute, Karachi, Pakistan
3 Consultant Psychiatrist, Zia Uddin University Hospital, and Visiting Psychiatrist, The Kidney Center Post Graduate Training Institute, Karachi, Pakistan
4 Department of Urology, The Kidney Center Post Graduate Training Institute, Karachi, Pakistan

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Date of Web Publication17-Nov-2012
 

How to cite this article:
Rabbani MA, Marfani R, Kumar M, Hasan N, Kumar S, El- Khalid S, Mahmud SM, Ahmed A. Unusual etiology of recurrent urinary tract infection. Saudi J Kidney Dis Transpl 2012;23:1288-91

How to cite this URL:
Rabbani MA, Marfani R, Kumar M, Hasan N, Kumar S, El- Khalid S, Mahmud SM, Ahmed A. Unusual etiology of recurrent urinary tract infection. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Jul 28];23:1288-91. Available from: http://www.sjkdt.org/text.asp?2012/23/6/1288/103579
To the Editor,

During the past few decades, reports of intravesical foreign bodies have increased in the literature. A review of the literature on this subject reveals that almost any conceivable object has been introduced into the urinary bladder. Introduction into the bladder may be self-insertion (through the urethra), e.g. during masturbation or in association with psychiatric disorders such as autoerotic stimulation or desire to get relief from urinary symptoms, [1] iatrogenic or accidentally retained (after treatment of voiding disorders such as catheterization and endoscopic treatment of urological diseases), migration from adjacent organs or as a results of penetrating trauma. [2],[3] Patients present with either acute or chronic symptoms due to complications.

The female urinary bladder, because of short urethra with its straight alignment and proximity to genital organs, is relatively easily invaded by foreign bodies, both by ascent from the urethra and by migration. [2],[4] A variety of objects have been reported in the literature as foreign bodies in the female bladder, such as needles, pieces of feeding tube, pieces of latex glove, pen casings, pencils, bamboo sticks, vaginal pessary and intrauterine devices [4],[5] from the uterus via an abnormal fistulous tract, suture materials or bone cement from orthopedic procedures migrating into the bladder by eroding the surrounding tissue, [6] abdominal swabs, gauze and accidental incorporation of pubic hair during self-catheterization.

Another example of iatrogenic foreign body is incompletely removed double J stent. [7] Organisms or parts of animals were also reported, including leeches, snails and squirrels. [8] In underdeveloped communities, some foreign bodies were reported after illegal abortion. Because of poor understanding of the anatomy, foreign bodies used to dilate the cervix or destroy the fetus can accidentally go into the urethra.

An 18-year-old unmarried girl presented to our outpatient clinic with three days' history of dysuria, gross hematuria and fever. Past history was significant for multiple admissions at different hospitals for complaint of recurrent flank pain associated with gross hematuria. Previous laboratory reports revealed left-sided incomplete ureteric duplication on intravenous urography [Figure 1]
Figure 1: Intravenous urography indicating unilateral (left) partial bifid ureter.

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Examination revealed body temperature of 38°C, blood pressure 120/70 mmHg and pulse rate 92/min. Apart from mild tenderness below the umbilical region, her systemic examination was unremarkable. Her laboratory invesigations revealed Hb 13.2 gG/dL, total leukocyte count (WBC) 16,300/mm 3 , platelet count 298,000/mm 3 , prothrombin time (PT) 13.2 s (control 11.5 s), activated partial thrombin time (aPTT) 32.7 s (control 27 s) and SCr 0.6 mg/dL. Urine dipstick analysis revealed large blood and numerous leukocytes. Urine culture revealed E. coli sensitive to all cephalosporins and quinolones. She was treated with ciprofloxacin 500 mg twice a day for ten days. She responded to oral antibiotic and her fever subsided, besides normalization of WBC.

However, the patient continued to have gross hematuria. Ultrasound examination was unremarkable. Her hematuria settled only after she was prescribed capsule tranexamic acid 500 mg thrice a day for three days. Two weeks later, she again presented in our emergency department (E/R) with complains of dysuria, decreased urine output, gross hematuria, sweating, hyperventilation and stiffness of hands. She was admitted through E/R. Routine laboratory investigations revealed Hb 12.9 G%, total leukocyte count 17,300/mm 3 , platelet count 305,000/mm 3 , PT 12.4 s (control 11.5 s), aPTT 30.4 s (control 27 s), serum Cr 0.68 mg/dL and serum Ca 9.05 mg/dL. Arterial blood gases revealed respiratory alkalosis with pH of 7.66. Urine dipstick analysis revealed large blood and numerous leukocytes. Urine culture revealed E. coli sensitive to all cephalosporins and quinolones. A repeat ultrasound examination [Figure 2] revealed thin linear echogenic foreign bodies (needles) shadow in the pelvis.
Figure 2: Thin linear echogenic foreign bodies (needles) shadow seen in pelvis (ultrasound urinary bladder).

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A plain X-ray of the abdomen in the erect posture confirmed linear metal density (needles) shadow in the pelvis [Figure 3]. She was treated with intravenous ceftrioxone in a dose of 1 gm twice a day for ten days. Seventy-two hours after admission, cystoscopic removal of four needles was carried out under general anesthesia. A psychiatrist was involved, but the patient refused psychiatric evaluation. She was finally discharged after successful cystoscopy and removal of needles.
Figure 3a: Linear metal density (needles) shadow seen in the pelvis (X-ray pelvis A/P and lateral views).
Figure 3b: Figure indicating size of needles on a standard scale.


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Review of the literature suggests that such cases mostly presented with recurrent urinary tract infection, hematuria, urolithiasis and pelvic pain. [9] Hematuria, however, was the main presenting symptom, and gross hematuria was found more commonly than microscopic hematuria. [9] Frequency, urgency, urge incontinence and pelvic pain were found in the majority of cases. Moreover, such cases generally present soon after insertion of the foreign body due to the severity of their symptoms. Therefore, minimal stone formation over the foreign body occurs in almost all cases.

Each foreign body poses a challenge to the urologist, and treatment has to be individuallized according to the size and nature of the foreign body and age of the patient. [9] However, because of short size and straight alignment of the female urethra, access into the bladder via the urethra is relatively easy and small foreign bodies in the female bladder are easy to remove endoscopically. [10] Bigger or sharp objects, associated with migration out of the bladder wall, require open surgery for their removal. Risk of complications is minimum, and is found to be only 5%. Urethral stricture is the most common complication reported in the literature. [9]

Finally, although our patient had a history of multiple admissions in different hospitals for recurrent urinary tract infections, the family denied of any history of psychiatric illness or sexual abuse. However, while in the hospital, she exhibited signs and symptoms of hyperventilation, stiffness of hands and unexplained attacks of unresponsiveness, indicating underlying psychiatric illness. Moreover, there were no medical records available except for few antibiotic prescriptions and an initial intravenous urography film that revealed unilateral incomplete ureteric duplication and no evidence of foreign body in the bladder. Incomplete ureteric duplication is generally an incidental finding and is not always associated with any clinical problem.

 
   References Top

1.Pal DK, Bag AK. Intravesical wire as foreign body in urinary bladder. Int Braz J Urol 2005;31:472-4.  Back to cited text no. 1
[PUBMED]    
2.Granados EA, Riley G, Rios GJ, Salvador J, Vicente J. Self introduction of urethrovesical foreign bodies. Eur Urol 1991;19:259-61.  Back to cited text no. 2
    
3.Pal DK. Intravesical foreign body. Indian J Surg 1999;61:381-3.  Back to cited text no. 3
    
4.Eckford SD, Persad RA, Brewster SF, Gingell JC. Intravesical foreign bodies: Five-year review. Br J Urol 1992;69:41-5.  Back to cited text no. 4
[PUBMED]    
5.Robinson D. Foreign body in the bladder. J Emerg Med 2005;29:215.  Back to cited text no. 5
[PUBMED]    
6.De Gier RP, Feitz WF. Surgical instrument migration from the abdominal cavity through the bladder into the vagina; a rare long-term complication. Urology 2002;60:165.  Back to cited text no. 6
[PUBMED]    
7.Cury J, Coelho F, Srougi M. Retroperitoneal migration of self inflated ballpoint pen via the urethra. Int Braz I Urol 2006;32:193-5.  Back to cited text no. 7
    
8.Mukherjee G. Unusual foreign body causing haematuria. J Indian Med Assoc 1974;63:284-5.  Back to cited text no. 8
[PUBMED]    
9.Kochakarn W. Pummanagura W. Foreign Bodies in the Female Urinary Bladder: 20-Year Experience in Ramathibodi Hospital. AsianJ Surg 2008;31:130-3.  Back to cited text no. 9
    
10.Nabi G, Hemal AK, Khaitan A. Endoscopic management of an unusual foreign body in the urinary bladder leading to intractable symptoms. Int Urol Nephrol 2001;33:351-2.  Back to cited text no. 10
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Correspondence Address:
Malik Anas Rabbani
Department of Nephrology, The Kidney Center Post Graduate Training Institute, Karachi
Pakistan
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DOI: 10.4103/1319-2442.103579

PMID: 23168868

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