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Bowel Evisceration Through the Bladder Neck in a Paraplegic Female Secondary to Urethral Coitus
1226
Bowel Evisceration Through the Bladder Neck in a Paraplegic Female Secondary to Urethral Coitus jsm_2572
1226..1228
Elizabeth T. Brown, MD, MPH, Michelle E. Koski, MD, and Stephen M. LaCour, MD Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA DOI: 10.1111/j.1743-6109.2011.02572.x
ABSTRACT
Introduction. Urethral coitus is rarely reported in the literature. The majority of reported cases have been secondary to vaginal agenesis or hymenal anomalies. Aim. We report a case of urethral coitus in a paraplegic patient with a patulous urethra resulting from chronic indwelling catheter use, with the unfortunate presentation of bladder rupture and evisceration per urethra. To our knowledge, this is the only report of urethral coitus due to sequelae from an indwelling catheter, as well as the only report of the subsequent complication of bowel evisceration per urethra. Results. After initial temporization at an outside facility, we were able to perform primary cystorrhaphy. There was no need for bowel resection. The patient has chosen to defer her decision on permanent reconstruction. Conclusions. Urethral coitus is rare and the subsequent ramifications can be devastating, particularly in neurologically impaired patients. This unusual case speaks to the importance of properly caring for the neurogenic bladder. Brown ET, Koski ME, and LaCour SM. Bowel evisceration through the bladder neck in a paraplegic female secondary to urethral coitus. J Sex Med 2012;9:1226–1228. Key Words. Bladder Injury; Urethral Coitus; Bowel Evisceration; Cystotomy; Paraplegia; Female Urethral Pathology; Coitus
Introduction
U
rethral coitus is rare, with fewer than 20 cases reported in the literature [1,2]. In the majority of these cases, vaginal agenesis or hymenal anomalies are a contributory factor [1–5], although there have been cases reported that resulted from ignorance of the genitourinary anatomy [6], as well as sexual assault [7]. Most of these cases present with urinary incontinence. We present a case of urethral coitus through a patulous urethra secondary to a chronic indwelling catheter, with the unfortunate presentation of bladder rupture and resultant evisceration per urethra.
Case Report
A 27-year-old female with paraplegia secondary to a traumatic C6 burst fracture 7 years prior presented to a rural emergency room with evisceration of her small bowel through her vagina. Her J Sex Med 2012;9:1226–1228
neurogenic bladder had been managed with an indwelling Foley catheter for several years with subsequent erosion, leading to a patulous urethra. The catheter had recently been removed. The patient reported a history of coitus with her longterm male partner that night and later awakened with extrusion of loops of small bowel per vagina. She was insensate in that area and did not report any pain or trauma at the time of intercourse. Her past medical history was significant only for her paraplegia and its sequelae. Her past surgical history included an end colostomy at the time of her accident, a percutaneous endoscopic gastrostomy (PEG) tube placement, a parastomal hernia repair, a Cesarean section 1 year ago, and a tracheostomy, which had subsequently closed. She denied any history of abuse. At the referring hospital, general surgery and urology found that the small bowel had eviscerated through the patient’s urethra (Figure 1) and initially managed this solely by reducing the bowel © 2011 International Society for Sexual Medicine
1227
A Case Report
Figure 1 Bowel evisceration through the bladder neck at presentation to the outside facility.
through the bladder neck. The urologist placed bilateral five-French open-ended ureteral catheters under direct vision and secured them to a leg bag in an attempt to divert the urine until the patient could be definitively managed. Three interrupted sutures were used to roughly approximate the bladder neck to prevent further evisceration of the abdominal contents. At this point, the patient was stable and she was transferred to our facility. On arrival, she was afebrile and mildly tachycardic. Her abdomen was soft but diffusely tender to palpation with rebound tenderness and guarding. Her pelvic exam revealed a normal vagina, as well as the aforementioned bilateral ureteral catheters and sutures closing the bladder neck. The patient decided at this time that she preferred to defer a decision for reconstruction until her current situation was temporized. She was then taken to the operating room for an exploratory laparotomy. Through a low midline incision, we were able to isolate the bladder after a lysis of adhesions. Unexpectedly, her bladder appeared to be of adequate capacity with compliant tissue, which we were able to mobilize. We incised the bladder down the midline. We then removed the stitches closing the bladder neck, revealing a grossly patulous bladder neck and urethra, about 4 cm in diameter, with minimal residual tissue beneath the pubis. Placing a finger through the bladder neck, we were able to isolate the traumatic
cystotomy, which was roughly 5 cm and located in the right posterolateral dome (Figure 2). We placed a 16-French Malencott suprapubic tube through the opposite side of the dome. The mobility of the tissue was excellent, and we were able to close the cystotomy in two layers and place a peritoneal flap over our closure. A Jackson-Pratt drain was placed in proximity to the bladder. From a vaginal approach, we removed the ureteral stents and temporarily closed the bladder neck with three widely spaced interrupted sutures to be kept in place until definitive reconstruction. Subsequently, general surgery systematically inspected the integrity of the bowel, and the terminal ileum was abraded but viable. Her inpatient postoperative course was uneventful. The patient has recovered well from the initial surgical management of her injury and is currently considering options of either a complete bladder neck reconstruction or a diverting urostomy with or without cystectomy for definitive management. Informed consent for publication was obtained from the patient. Discussion
Urethral coitus, itself, may result in a large and dilated urethra. Our patient’s original urethral erosion stemmed from a chronic indwelling urethral catheter. It is unclear if other factors
Figure 2 Surgeon’s finger placed through the bladder neck demonstrating the traumatic cystotomy to the posterolateral dome.
J Sex Med 2012;9:1226–1228
1228 advanced the dilation of her urethra. Nonetheless, this complication illustrates potential detrimental consequences of chronic indwelling urethral catheters in female patients causing urethral destruction. Additionally, her case should be kept in mind when counseling patients with urethral dilation who are sexually active. Cases of bladder perforation with resultant intra-abdominal trauma due to foreign bodies inserted per urethra or vagina are not uncommon [8,9]. To our knowledge, this is the first case reported of consensual urethral coitus resulting in bladder perforation with resultant intestinal sequelae. It speaks to the importance of properly caring for the neurogenic bladder. Additionally, although the practice was consensual in our patient, this population should be screened for abuse. Corresponding Author: Elizabeth Brown, MD, MPH, Department of Urology, Louisiana State University Health Sciences Center, School of Medicine, 1542 Tulane Ave, New Orleans, LA 70112, USA. Tel: 504568-2207; Fax: 504-568-2307; E-mail: elizbrown@ ochsner.org Conflict of Interest: None.
Statement of Authorship
Category 1 (a) Conception and Design Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour (b) Acquisition of Data Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour
J Sex Med 2012;9:1226–1228
Brown et al. (c) Analysis and Interpretation of Data Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour
Category 2 (a) Drafting the Article Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour (b) Revising It for Intellectual Content Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour
Category 3 (a) Final Approval of the Completed Article Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour References 1 Shukla VK, Tripathy VN. Urethral coitus. Urology 1982;19: 542–3. 2 Deniz N, Perk H, Serel T, Kos¸ar A, Ozsoy MH, Arslan M. Urethral coitus and urinary incontinence in a case of MayerRokitansky syndrome: An alternative surgical procedure. Eur J Obstet Gynecol Reprod Biol 2002;103:95–6. 3 Zeigerman JH, Gillenwater JY. Coitus per urethrum and the rigid hymen. JAMA 1965;194:909–10. 4 Borski AA, Mittemeyer BT. Urethral coitus—Maximum urethral dilatation. J Urol 1971;105:400–2. 5 Taneja PP, Heera D, Gulati SM, Grover NK. Urethral coitus in a case of vaginal agenesis. Br J Urol 1973;54:451. 6 Ayan S, Gökçe G, Kiliçarslan H, Kaya K, Gültekin EY. An unusual cause of incontinence: Urethral coitus. Scand J Urol Nephrol 2001;35:254. 7 Okeke L, Aisuodionoe-Shadrach O, Ogbimi A. Female urethral and bladder neck injury after rape: An appraisal of the surgical management. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:683–5. 8 Donagay M, Metin E, Donagay M. Acute abdomen due to a foreign body in the urinary bladder in an adolescent. J Emerg Med 2011;40:391–2. 9 Piercy SL, Gregory JG, Freel JH. Bladder perforation caused by cucumis sativus repaired per vagina. Urology 1987;30:265–6.
Bowel Evisceration Through the Bladder Neck in a Paraplegic Female Secondary to Urethral Coitus jsm_2572
1226..1228
Elizabeth T. Brown, MD, MPH, Michelle E. Koski, MD, and Stephen M. LaCour, MD Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA DOI: 10.1111/j.1743-6109.2011.02572.x
ABSTRACT
Introduction. Urethral coitus is rarely reported in the literature. The majority of reported cases have been secondary to vaginal agenesis or hymenal anomalies. Aim. We report a case of urethral coitus in a paraplegic patient with a patulous urethra resulting from chronic indwelling catheter use, with the unfortunate presentation of bladder rupture and evisceration per urethra. To our knowledge, this is the only report of urethral coitus due to sequelae from an indwelling catheter, as well as the only report of the subsequent complication of bowel evisceration per urethra. Results. After initial temporization at an outside facility, we were able to perform primary cystorrhaphy. There was no need for bowel resection. The patient has chosen to defer her decision on permanent reconstruction. Conclusions. Urethral coitus is rare and the subsequent ramifications can be devastating, particularly in neurologically impaired patients. This unusual case speaks to the importance of properly caring for the neurogenic bladder. Brown ET, Koski ME, and LaCour SM. Bowel evisceration through the bladder neck in a paraplegic female secondary to urethral coitus. J Sex Med 2012;9:1226–1228. Key Words. Bladder Injury; Urethral Coitus; Bowel Evisceration; Cystotomy; Paraplegia; Female Urethral Pathology; Coitus
Introduction
U
rethral coitus is rare, with fewer than 20 cases reported in the literature [1,2]. In the majority of these cases, vaginal agenesis or hymenal anomalies are a contributory factor [1–5], although there have been cases reported that resulted from ignorance of the genitourinary anatomy [6], as well as sexual assault [7]. Most of these cases present with urinary incontinence. We present a case of urethral coitus through a patulous urethra secondary to a chronic indwelling catheter, with the unfortunate presentation of bladder rupture and resultant evisceration per urethra.
Case Report
A 27-year-old female with paraplegia secondary to a traumatic C6 burst fracture 7 years prior presented to a rural emergency room with evisceration of her small bowel through her vagina. Her J Sex Med 2012;9:1226–1228
neurogenic bladder had been managed with an indwelling Foley catheter for several years with subsequent erosion, leading to a patulous urethra. The catheter had recently been removed. The patient reported a history of coitus with her longterm male partner that night and later awakened with extrusion of loops of small bowel per vagina. She was insensate in that area and did not report any pain or trauma at the time of intercourse. Her past medical history was significant only for her paraplegia and its sequelae. Her past surgical history included an end colostomy at the time of her accident, a percutaneous endoscopic gastrostomy (PEG) tube placement, a parastomal hernia repair, a Cesarean section 1 year ago, and a tracheostomy, which had subsequently closed. She denied any history of abuse. At the referring hospital, general surgery and urology found that the small bowel had eviscerated through the patient’s urethra (Figure 1) and initially managed this solely by reducing the bowel © 2011 International Society for Sexual Medicine
1227
A Case Report
Figure 1 Bowel evisceration through the bladder neck at presentation to the outside facility.
through the bladder neck. The urologist placed bilateral five-French open-ended ureteral catheters under direct vision and secured them to a leg bag in an attempt to divert the urine until the patient could be definitively managed. Three interrupted sutures were used to roughly approximate the bladder neck to prevent further evisceration of the abdominal contents. At this point, the patient was stable and she was transferred to our facility. On arrival, she was afebrile and mildly tachycardic. Her abdomen was soft but diffusely tender to palpation with rebound tenderness and guarding. Her pelvic exam revealed a normal vagina, as well as the aforementioned bilateral ureteral catheters and sutures closing the bladder neck. The patient decided at this time that she preferred to defer a decision for reconstruction until her current situation was temporized. She was then taken to the operating room for an exploratory laparotomy. Through a low midline incision, we were able to isolate the bladder after a lysis of adhesions. Unexpectedly, her bladder appeared to be of adequate capacity with compliant tissue, which we were able to mobilize. We incised the bladder down the midline. We then removed the stitches closing the bladder neck, revealing a grossly patulous bladder neck and urethra, about 4 cm in diameter, with minimal residual tissue beneath the pubis. Placing a finger through the bladder neck, we were able to isolate the traumatic
cystotomy, which was roughly 5 cm and located in the right posterolateral dome (Figure 2). We placed a 16-French Malencott suprapubic tube through the opposite side of the dome. The mobility of the tissue was excellent, and we were able to close the cystotomy in two layers and place a peritoneal flap over our closure. A Jackson-Pratt drain was placed in proximity to the bladder. From a vaginal approach, we removed the ureteral stents and temporarily closed the bladder neck with three widely spaced interrupted sutures to be kept in place until definitive reconstruction. Subsequently, general surgery systematically inspected the integrity of the bowel, and the terminal ileum was abraded but viable. Her inpatient postoperative course was uneventful. The patient has recovered well from the initial surgical management of her injury and is currently considering options of either a complete bladder neck reconstruction or a diverting urostomy with or without cystectomy for definitive management. Informed consent for publication was obtained from the patient. Discussion
Urethral coitus, itself, may result in a large and dilated urethra. Our patient’s original urethral erosion stemmed from a chronic indwelling urethral catheter. It is unclear if other factors
Figure 2 Surgeon’s finger placed through the bladder neck demonstrating the traumatic cystotomy to the posterolateral dome.
J Sex Med 2012;9:1226–1228
1228 advanced the dilation of her urethra. Nonetheless, this complication illustrates potential detrimental consequences of chronic indwelling urethral catheters in female patients causing urethral destruction. Additionally, her case should be kept in mind when counseling patients with urethral dilation who are sexually active. Cases of bladder perforation with resultant intra-abdominal trauma due to foreign bodies inserted per urethra or vagina are not uncommon [8,9]. To our knowledge, this is the first case reported of consensual urethral coitus resulting in bladder perforation with resultant intestinal sequelae. It speaks to the importance of properly caring for the neurogenic bladder. Additionally, although the practice was consensual in our patient, this population should be screened for abuse. Corresponding Author: Elizabeth Brown, MD, MPH, Department of Urology, Louisiana State University Health Sciences Center, School of Medicine, 1542 Tulane Ave, New Orleans, LA 70112, USA. Tel: 504568-2207; Fax: 504-568-2307; E-mail: elizbrown@ ochsner.org Conflict of Interest: None.
Statement of Authorship
Category 1 (a) Conception and Design Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour (b) Acquisition of Data Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour
J Sex Med 2012;9:1226–1228
Brown et al. (c) Analysis and Interpretation of Data Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour
Category 2 (a) Drafting the Article Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour (b) Revising It for Intellectual Content Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour
Category 3 (a) Final Approval of the Completed Article Elizabeth T. Brown; Michelle E. Koski; Stephen M. LaCour References 1 Shukla VK, Tripathy VN. Urethral coitus. Urology 1982;19: 542–3. 2 Deniz N, Perk H, Serel T, Kos¸ar A, Ozsoy MH, Arslan M. Urethral coitus and urinary incontinence in a case of MayerRokitansky syndrome: An alternative surgical procedure. Eur J Obstet Gynecol Reprod Biol 2002;103:95–6. 3 Zeigerman JH, Gillenwater JY. Coitus per urethrum and the rigid hymen. JAMA 1965;194:909–10. 4 Borski AA, Mittemeyer BT. Urethral coitus—Maximum urethral dilatation. J Urol 1971;105:400–2. 5 Taneja PP, Heera D, Gulati SM, Grover NK. Urethral coitus in a case of vaginal agenesis. Br J Urol 1973;54:451. 6 Ayan S, Gökçe G, Kiliçarslan H, Kaya K, Gültekin EY. An unusual cause of incontinence: Urethral coitus. Scand J Urol Nephrol 2001;35:254. 7 Okeke L, Aisuodionoe-Shadrach O, Ogbimi A. Female urethral and bladder neck injury after rape: An appraisal of the surgical management. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:683–5. 8 Donagay M, Metin E, Donagay M. Acute abdomen due to a foreign body in the urinary bladder in an adolescent. J Emerg Med 2011;40:391–2. 9 Piercy SL, Gregory JG, Freel JH. Bladder perforation caused by cucumis sativus repaired per vagina. Urology 1987;30:265–6.