Table of Contents2013 Month : August Volume : Vol2 Issue : Issue 32 Page : 5952-5956
UNUSUAL PRESENTATIONS OF FOREIGN BODIES IN UROLOGICAL PRACTICE - A STUDY OF TWO CASES
Vijay K. Singh1, Vikky R. Ajwani2, Jigar Shah3, Akaash Agarwal4, Prarthan Joshi5
1. Professor, Department of Surgery, Rama Medical College, Kanpur.
2. Professor, Department of Surgery, SBKS Medical College, Waghodia, Vadodara.
3. Assistant Professor, Department of Surgery, SBKS Medical College, Waghodia, Vadodara.
4. Resident, Department of Surgery, SBKS Medical College, Waghodia, Vadodara.
5. Assistant Professor, Department of Surgery, SBKS Medical College, Waghodia, Vadodara.
Dr. Vikky Ajwani,
103, Paradise flats,
Opposite Kalyan Hall,
Near Navrachana School,
Sama, Vadodara – 390008.
Email – firstname.lastname@example.org
ABSTRACT: Foreign bodies have always posed a challenge to the surgeons. Foreign bodies seen in urological practice are either self-inserted (1), iatrogenic, traumatic or migrated from other sites. They usually present late with complications and a vague history .It is mostly seen in young adults. Radiological studies aid in the diagnosis. Here we present two such cases .First is a case of a large foreign body, inserted in vagina presented as a large bladder stone, protruding into the vagina with vesico-vaginal fistula. Second is the case of traumatic insertion of a metallic clip on the shaft of the penis, presenting with urethral stricture and persistent local pain. Both were managed successfully.
KEY WORDS: Foreign body, bladder calculi, vesico-vaginal fistula, urethral stricture, urethral fistula.
INTRODUCTION: Foreign bodies in urological practice are frequently met with. Their management poses a challenge and requires surgical experience and expertise along with a thorough knowledge of anatomy to manage the removal of foreign bodies and their complications. Foreign bodies usually present late with the complications and it is typical, that an accurate history of foreign body being the cause is difficult to obtain.
Foreign body inserted in the vagina like a forgotten pessary is a very rare cause of vesico-vaginal fistula, the most common being associated with gynaecological surgery or obstetric cause (obstructed labour) (2) .We present two such cases, managed surgically .First is a case of a foreign body placed in the vagina, presenting as a urinary bladder calculus with vesico-vaginal fistula and second is a case of traumatically inserted metallic clip in the penis shaft.
Case-1: A young female aged 19 yrs with hemiplegia presented with vesico-vaginal fistula. There was no history of any surgery, delivery, or trauma. On examination, a calculus could be seen protruding into the vagina from the bladder (Figure. 1). X- ray abdomen with pelvis showed huge bladder calculi. Thus it was diagnosed as a case of bladder calculus developing in the neurogenic bladder associated with hemiplegia. During the surgery for bladder calculus, it was found that a stone had formed surrounding a plastic container in the bladder which was protruding into the vagina and had embedded in the mucosa of the bladder (Figure. 2). On persistent forced history taking, after finding the foreign body (Figure. 3), the patient revealed insertion of a plastic container by a lady practicing witchcraft. After suprapubic cystolithotomy, the patient was discharged and called after one and half months for vesico-vaginal fistula repair, which was performed by combined extra-vesical and intra –vesical approach .It healed well.
Case -2: Second case was of a 20 year old male patient, who complained of pain and swelling on ventral aspect of penis, accompanied by difficulty in micturition. Patient gave history of trauma in the penile region during a fall with metallic clip at the end of wooden plank. On examination, a 2x2 cm swelling was present in the ventral aspect of the penis (Figure. 4), which was hard in consistency and fixed to the underlying structure. Retrograde urethrogram revealed anterior narrowing with extravasation of dye. On exploration by urethrotomy, an intact cone shaped metallic foreign body embedded in the corpora spongiosum and covered with dense fibrous tissue extending upto the urethra was retrieved (Figure. 5 & 6). Urethral repair was done and Foley’s catheterization was done. Patient developed urethra-cutaneous fistula in the post-operative period, but it healed spontaneously.
DISCUSSION: Urinary bladder is the most susceptible part of the genitourinary tract for the foreign body. (3) Cause of foreign bodies in lower urinary tract includes psychological, iatrogenic, traumatic aspect and migration from other organs. Various materials such as paraffin, metallic cables and plastic tubes have been reported as foreign bodies in lower urinary tract.
The first case was interesting because the foreign body had migrated through the vagina into the bladder and had developed into vesico-vaginal fistula. To determine the exact size and location, radiological evaluation is necessary. (4)
Management is aimed at providing complete removal of the foreign body which should be tailored according to its nature and dimensions, with minimal trauma to the urethra.
In case of associated complications like vesico-vaginal fistula, as in the present case, repair of the fistula should be performed after a period of 6 weeks- 12 weeks, which is required for the severe inflammation to subside.
The second case was unusual too, as the foreign body was in place in the urethra for three years. Here too, radiological investigation like retrograde urethrogram holds the key. Management may be in the form of endoscopic manipulation or open surgical procedure if necessary. (5) In long standing embedded large foreign bodies, open urethrotomy for the removal becomes necessary, thus predisposing to the formation of urethral fistula (6). The fistula may heal spontaneously or may have to be repaired. (7)
The possibility of an intravesical foreign body should be considered in any patient presenting with chronic unexplained lower urinary tract symptoms. (8).
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Figure. 1: Bladder stone protruding from the vagina
Figure. 2: Foreign body within the bladder stone seen from the cystostomy
Figure.3: Foreign body(plastic container) and the broken pieces of calculi.