Saudi Journal of Kidney Diseases and Transplantation

: 2012  |  Volume : 23  |  Issue : 6  |  Page : 1288--1291

Unusual etiology of recurrent urinary tract infection

Malik Anas Rabbani1, Rabiah Marfani1, Mukesh Kumar1, Najmul Hasan2, Santosh Kumar3, Salman El- Khalid4, Syed Mamun Mahmud4, Aasim Ahmed1,  
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

Correspondence Address:
Malik Anas Rabbani
Department of Nephrology, The Kidney Center Post Graduate Training Institute, Karachi

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;23:1288-1291

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 2023 Feb 6 ];23:1288-1291
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Full Text

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}

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}

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 3}

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.


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