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Rifle Bullet Impacted in the Anterior Urethra
THE JOURNAL OF UROLOGY
Vol. 61, No. 4, April 1949 Printed in U.S.A.
RIFLE BULLET IMPACTED IN THE ANTERIOR URETHRA SAJVIUEL SIMON
Foreign bodies of the most varied types have been frequently reported in the urethra. For the most part, those foreign bodies placed on record by various authors have been introduced from without into the urethra. Catheters, bougies, glass tubes, pieces of silver nitrate, cannulas of syringes, thermometers etc., have been found in the urethra. Poulet mentioned endless lists of household articles, including every type of household appliance capable of being pushed into the meatus. The following case report is of interest since it represents an unusual foreign body that migrated into the urethra from the bladder more than 3 years after the original entry of the bullet into the body. CASE REPORT
J. W., a 35 year old Polish soldier, was admitted to the 189th U.S. General Hospital, Mourmelon, France on November 13, 1945 ·with the chief complaints of inability to void for the past 6 hours, pain in the perineum, and pain over the underside of the shaft of the penis in front of the scrotum. He also gave a history of marked frequency, dysuria, and hematuria for 3 days prior to admiss10n. He had also noted for 3 days prior to admission that he had pain in the perineum when he sat dmvn or when twisting and turning in bed. The patient had first appeared in the out-patient clinic of our hospital one day prior to admission. At this time, the history of frequency, dysuria, and hematuria of 2 days' duration was elicited. The history was also obtained that he had sustained a gunshot wound of the lower back on September 4, 1942, on the Russian front, at which time he was a soldier in the German army. He stated that within 5 hours of injury he was operated upon in a front line German hospital. He recalled that subsequent to the injury, he had had inability to void and was catheterized preoperatively, and bloody urine was obtained. He recalled further that the catheter was left in place for 3 days following the operation. He stated that he was informed at the time of operation that 6 perforations of the bowel were closed. He did not know of any injury to the bladder that necessitated surgical repair. He stated there was never any x-ray taken of the abdomen pre- or postoperatively. He had no urinary difficulties subsequent to the operation and presented no urinary complaints until 3 days prior to admission. When patient was seen in the out-patient clinic 1 day prior to present admission, an intravenous urogram ·was ordered because of the history of hematuria. The urine was noted to be grossly bloody at this time. The following morning this intravenous urogram was done. That same afternoon, he noted inability to void, lower abdominal pain, and pain in the perineum. He was then returned to the out-patient clinic and ,vas seen by Captain Eschelbacher who upon examination felt a hard, metallic foreign body in the penile urethra about 7 cm. from the meatus. He attempted to catheterize the patient and the catheter was felt to 785
786
SAMUEL SIMON
impinge directly upon the foreign body. At this time, he also noted that the bladder was distended almost to the umbilicus. The patient was then admitted to the urological service and the author was called. The temperature was 100.6, pulse 76, respirations 20, blood pressure 110/70. The patient complained of severe low abdominal pain and inability to void. The head, eyes, ears, nose, mouth and throat, neck, heart and lungs were normal. The bladder was markedly distended and palpable just above the umbilicus. There was a low midline operative scar 4 inches in length. An old, nonadherent burn scar involved the entire epigastrium. A foreign body was felt in the penile urethra 7 cm. from the meatus. It was approximately 2.5 cm. in length and had the contour and consistency of a bullet. The foreign body could be displaced proximally and distally along the urethra for a distance of 1 cm. in each direction without any marked difficulty. The point of the missile was identified as being directed towards the meatus. The meatus showed moderate narrowing. The testes and epididymes were normal. On rectal examination no abnormality was noted; the prostate was not enlarged. A small oval scar 1.5 cm. in diameter was noted to the left of the first segment of the sacrum, 5 cm. from midline. This scar marked the site of entry of the missile. The clinical impression with the above history and physical findings was that he had a bullet impacted in the anterior urethra with subsequent acute urinary retention. X-ray films confirmed the clinical impression. The bullet was distinctly visualized in the penile urethra. The intravenous urogram that had been done on the morning of admission was also reviewed and the upper portion of the bullet could be visualized in these films to be situated in the prostatic urethra (fig. 1, A). During the course of the day the bullet had migrated from the prostatic urethra to the anterior urethra and then had become impacted with subsequent acute urinary retention (fig. 1, B.) The patient was then brought to surgery the same evening of admission. A meatotomy was done about ½inch in length on the underside of the penis under local anesthesia. Then with no further anesthesia, it was possible to milk the foreign body distally out of the urethra and remove it through the meatus. An assistant steadied the bullet from moving posteriorly by exerting pressure behind it, then by external pressure along the urethra the foreign body was milked out without much difficulty through the meatus. Despite the meatotomy, after the tip of the bullet presented at the meatus, the rear portion of the bullet could not be delivered. The meatotomy was then enlarged another ¾inch and then the bullet was grasped with a Kocher clamp and delivered. The bullet itself was irregularly coated with a blackish urate deposit and was approximately 30 caliber in size (fig. 2). The entire procedure including the meatotomy required just a few minutes. The patient was unable to void after the removal of the foreign body. A 14 F catheter was then introduced into the bladder with ease and taped into place. Four ounces of urine were drawn off and then the
RIFLE BULLET IMPACTED IN ANTERIOR URETHRA
787
patient was placed on slow bladder decompression. He experienced immediate relief of abdominal and perineal pain following completion of the above procedure. On the second postoperative day, the catheter was removed and the patient was able to void without difficulty following removal. Microscopic examina-
Fm. 1. A, arrow points to rear portion of bullet which is situated in prostatic urethra. This is a 5 minute film taken after intravenous injection of diodrast. Presence of bullet was not suspected at time of film. B, bullet is clearly visible in anterior urethra. K ote distended bladder which contains diodrast given 12 hours previously.
Fm. 2. Photograph of bullet recovered. Note large amount of dark urate deposit on surface of bullet. Bullet measured approximately 3 cm. in length and was estimated to be 30 caliber in size.
tion of urine 1 ·week postoperatively showed a rare red blood cell and white blood cell in contrast to the preoperative specimen which was found to be loaded with both red blood cells and white blood cells. Cystoscopy on the tenth postoperative day showed that the bladder was essentially normal except for a small, slightly raised hemorrhagic area, 2 cm. in diameter in the retrotrigonal area just posterior to the left half of the interureteric ridge. It was believed that this area might have been the site of the original penetration of the bullet into the
788
SAMUEL SIMON
bladder. The bladder neck and urethra were normal. Kidney function on both sides was normal, as demonstrated by the excretion of indigo carmine. Retrograde pyelo-uretrograms were normal. The patient was discharged to duty, cured, on the twelfth postoperative day. In attempting to retrace the sequence of events in this case, it was believed that at the time of the original gunshot wound on September 1942, three years prior to present admission, the bullet had penetrated the back to the left of the first segment of the sacrum and had then entered the peritoneal cavity injuring the bowel and urinary bladder and probably remaining in the urinary bladder at the time of the original injury. The fact that the patient had an indweUing catheter for 3 days subsequent to the original injury may have constituted sufficient time for the rent in the bladder to close. For the subsequent 3 years, the bullet resided in the bladder without any apparent symptomatology. After this time the bullet, by being able to present at the bladder neck with the tapering point forward, was able to migrate into the posterior urethra and produce symptoms of frequency, dysuria, and hematuria, and actual pain upon sitting. The bullet then proceeded to migrate into the anterior urethra, became impacted and produced urinary retention. At this stage, removal was performed, DISCUSSION
Diagnosis of a foreign body in the urethra as a rule is not difficult. Since every part of the urethra, with the exception of the prostatic urethra, is available for palpation if one includes rectal examination, it ·would usually be possible to detect the object unless it were very small. X-ray and endoscopy serve further to confirm diagnosis. Treatment as recommended by Young is 1) by means taken to favor spontaneous expulsion; 2) by pushing the object into the bladder, with subsequent removal by lithotrite, rongeur forceps, or cystotomy; 3) by endo-urethral removal by forceps, with or ·without the aid of the endoscope, and 4) by urethrotomy. Gutierrez in his discussion of the treatment of the urethral foreign body states that first a meatotomy should be performed and an attempt made to induce the foreign body to return by the natural route; when this fails and the foreign body continues to maintain its blockade of the urethra, exploratory urethral catheters, bougies, filiforms and urethroscopic instruments should be used in effort to remove the foreign body or at least to push it into the bladder so that it can be removed by cystoscopic manipulation or cystotomy. Finally an external urethrotomy may be necessary. Gutierrez further points out that if the foreign body is fixed in the anterior portion of the penile urethra, an external urethrotomy must be carried out on the glans penis, or anterior portion of the urethra. Plastic operations on the penile portion of the urethra have notoriously resulted in fistulas; hence, before this performance, he recommends that one institute a diversion of the urine by a preliminary cystotomy in order to forstall infection and secure a perfect healing.
RIFLE BULLET IMPACTED IN ANTERIOR URETHRA
789
SUMMARY
An unusual case of foreign body in the urethra is presented with x-rays which show the migration of a 30 caliber bullet from the prostatic urethra into the anterior urethra with subsequent impaction and urinary retention. Migration of the bullet from the bladder into the urethra occurred more than three years after the original entry of the bullet. The diagnosis and treatment of a foreign body in the urethra is discussed. 94 Jl![ arket St., Poughkeepsie, N. Y. REFERENCES BAILEY, H.: Surgery of Modern Warfare. Edinburgh: E. and S. Livingston, 1942. BoND, S. P.: Foreign bodies in bladder. J. A. M.A., 83: 1163, 1924. BoRs, E.: Removal of a broken glass catheter from female bladder. J. Urol., 49: 658, 1943. BoRs, E. AND Bowrn, C. S.: Migration of foreign bodies, with report of a case of migration of a shell fragment into bladder. J. Urol., 55: 358, 1946. CAMPBELL, M. F.: Needles in deep urethra. Arn. J. Surg., 21: 452, 1933. GORDON, L. Z.: Safety pins in male urethra. Urol. & Cutan. Rev., 45: 500, 1941. GROSSMAN, S. L. AND HoFFENSTEIN, H. F.: Foreign bodies in bladder, report of 3 cases. · Urol. & Cutan. Rev., 41: 788, 1937. GUTIERREZ, R.: Foreign body in urethra. J. Urol., 49: 865, 1943. JECK, H. S.: Removal of foreign bodies from urethra and bladder. Arn. J. Surg., 36: 197, 1937. LuYs, G.: Extraction of a rifle bullet from bladder by natural route. New York Med. J., 111: 181, 1930. POULET, A.: A Treatise on Foreign Bodies in Surgical Practice. Chapter on Male Urethra. New York: Wm. Wood & Co., 1880, vol. 2, pp. 113-144. RILEY, A.: Foreign bodies in male urethra. Report of an unusual case. New Eng. J. Med., 218: 884, 1938. SHELLEY, J. H.: Gunshot wounds of urinary bladder. Am. J. Surg., 16: 301, 1932. S1°AHLER, A. A.: Foreign bodies in urethra. No. 16-penny nails present for 12 years. J. Urol., 55: 397, 1946. TURNER, J. H.: Two unusual foreign bodies in male urinary bladder. J. Urol., 11: 581, 1924, WALKER, A. S. AND KAUFMAN, D.R.: Spontaneous migration of bullet into urinary bladder after a 5 year interval. Urol. & Cutan. Rev., 46: 217, 1942. YouNo, H. H. AND DAVIS, D. M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926, vol. 2, pp. 178-181.
Vol. 61, No. 4, April 1949 Printed in U.S.A.
RIFLE BULLET IMPACTED IN THE ANTERIOR URETHRA SAJVIUEL SIMON
Foreign bodies of the most varied types have been frequently reported in the urethra. For the most part, those foreign bodies placed on record by various authors have been introduced from without into the urethra. Catheters, bougies, glass tubes, pieces of silver nitrate, cannulas of syringes, thermometers etc., have been found in the urethra. Poulet mentioned endless lists of household articles, including every type of household appliance capable of being pushed into the meatus. The following case report is of interest since it represents an unusual foreign body that migrated into the urethra from the bladder more than 3 years after the original entry of the bullet into the body. CASE REPORT
J. W., a 35 year old Polish soldier, was admitted to the 189th U.S. General Hospital, Mourmelon, France on November 13, 1945 ·with the chief complaints of inability to void for the past 6 hours, pain in the perineum, and pain over the underside of the shaft of the penis in front of the scrotum. He also gave a history of marked frequency, dysuria, and hematuria for 3 days prior to admiss10n. He had also noted for 3 days prior to admission that he had pain in the perineum when he sat dmvn or when twisting and turning in bed. The patient had first appeared in the out-patient clinic of our hospital one day prior to admission. At this time, the history of frequency, dysuria, and hematuria of 2 days' duration was elicited. The history was also obtained that he had sustained a gunshot wound of the lower back on September 4, 1942, on the Russian front, at which time he was a soldier in the German army. He stated that within 5 hours of injury he was operated upon in a front line German hospital. He recalled that subsequent to the injury, he had had inability to void and was catheterized preoperatively, and bloody urine was obtained. He recalled further that the catheter was left in place for 3 days following the operation. He stated that he was informed at the time of operation that 6 perforations of the bowel were closed. He did not know of any injury to the bladder that necessitated surgical repair. He stated there was never any x-ray taken of the abdomen pre- or postoperatively. He had no urinary difficulties subsequent to the operation and presented no urinary complaints until 3 days prior to admission. When patient was seen in the out-patient clinic 1 day prior to present admission, an intravenous urogram ·was ordered because of the history of hematuria. The urine was noted to be grossly bloody at this time. The following morning this intravenous urogram was done. That same afternoon, he noted inability to void, lower abdominal pain, and pain in the perineum. He was then returned to the out-patient clinic and ,vas seen by Captain Eschelbacher who upon examination felt a hard, metallic foreign body in the penile urethra about 7 cm. from the meatus. He attempted to catheterize the patient and the catheter was felt to 785
786
SAMUEL SIMON
impinge directly upon the foreign body. At this time, he also noted that the bladder was distended almost to the umbilicus. The patient was then admitted to the urological service and the author was called. The temperature was 100.6, pulse 76, respirations 20, blood pressure 110/70. The patient complained of severe low abdominal pain and inability to void. The head, eyes, ears, nose, mouth and throat, neck, heart and lungs were normal. The bladder was markedly distended and palpable just above the umbilicus. There was a low midline operative scar 4 inches in length. An old, nonadherent burn scar involved the entire epigastrium. A foreign body was felt in the penile urethra 7 cm. from the meatus. It was approximately 2.5 cm. in length and had the contour and consistency of a bullet. The foreign body could be displaced proximally and distally along the urethra for a distance of 1 cm. in each direction without any marked difficulty. The point of the missile was identified as being directed towards the meatus. The meatus showed moderate narrowing. The testes and epididymes were normal. On rectal examination no abnormality was noted; the prostate was not enlarged. A small oval scar 1.5 cm. in diameter was noted to the left of the first segment of the sacrum, 5 cm. from midline. This scar marked the site of entry of the missile. The clinical impression with the above history and physical findings was that he had a bullet impacted in the anterior urethra with subsequent acute urinary retention. X-ray films confirmed the clinical impression. The bullet was distinctly visualized in the penile urethra. The intravenous urogram that had been done on the morning of admission was also reviewed and the upper portion of the bullet could be visualized in these films to be situated in the prostatic urethra (fig. 1, A). During the course of the day the bullet had migrated from the prostatic urethra to the anterior urethra and then had become impacted with subsequent acute urinary retention (fig. 1, B.) The patient was then brought to surgery the same evening of admission. A meatotomy was done about ½inch in length on the underside of the penis under local anesthesia. Then with no further anesthesia, it was possible to milk the foreign body distally out of the urethra and remove it through the meatus. An assistant steadied the bullet from moving posteriorly by exerting pressure behind it, then by external pressure along the urethra the foreign body was milked out without much difficulty through the meatus. Despite the meatotomy, after the tip of the bullet presented at the meatus, the rear portion of the bullet could not be delivered. The meatotomy was then enlarged another ¾inch and then the bullet was grasped with a Kocher clamp and delivered. The bullet itself was irregularly coated with a blackish urate deposit and was approximately 30 caliber in size (fig. 2). The entire procedure including the meatotomy required just a few minutes. The patient was unable to void after the removal of the foreign body. A 14 F catheter was then introduced into the bladder with ease and taped into place. Four ounces of urine were drawn off and then the
RIFLE BULLET IMPACTED IN ANTERIOR URETHRA
787
patient was placed on slow bladder decompression. He experienced immediate relief of abdominal and perineal pain following completion of the above procedure. On the second postoperative day, the catheter was removed and the patient was able to void without difficulty following removal. Microscopic examina-
Fm. 1. A, arrow points to rear portion of bullet which is situated in prostatic urethra. This is a 5 minute film taken after intravenous injection of diodrast. Presence of bullet was not suspected at time of film. B, bullet is clearly visible in anterior urethra. K ote distended bladder which contains diodrast given 12 hours previously.
Fm. 2. Photograph of bullet recovered. Note large amount of dark urate deposit on surface of bullet. Bullet measured approximately 3 cm. in length and was estimated to be 30 caliber in size.
tion of urine 1 ·week postoperatively showed a rare red blood cell and white blood cell in contrast to the preoperative specimen which was found to be loaded with both red blood cells and white blood cells. Cystoscopy on the tenth postoperative day showed that the bladder was essentially normal except for a small, slightly raised hemorrhagic area, 2 cm. in diameter in the retrotrigonal area just posterior to the left half of the interureteric ridge. It was believed that this area might have been the site of the original penetration of the bullet into the
788
SAMUEL SIMON
bladder. The bladder neck and urethra were normal. Kidney function on both sides was normal, as demonstrated by the excretion of indigo carmine. Retrograde pyelo-uretrograms were normal. The patient was discharged to duty, cured, on the twelfth postoperative day. In attempting to retrace the sequence of events in this case, it was believed that at the time of the original gunshot wound on September 1942, three years prior to present admission, the bullet had penetrated the back to the left of the first segment of the sacrum and had then entered the peritoneal cavity injuring the bowel and urinary bladder and probably remaining in the urinary bladder at the time of the original injury. The fact that the patient had an indweUing catheter for 3 days subsequent to the original injury may have constituted sufficient time for the rent in the bladder to close. For the subsequent 3 years, the bullet resided in the bladder without any apparent symptomatology. After this time the bullet, by being able to present at the bladder neck with the tapering point forward, was able to migrate into the posterior urethra and produce symptoms of frequency, dysuria, and hematuria, and actual pain upon sitting. The bullet then proceeded to migrate into the anterior urethra, became impacted and produced urinary retention. At this stage, removal was performed, DISCUSSION
Diagnosis of a foreign body in the urethra as a rule is not difficult. Since every part of the urethra, with the exception of the prostatic urethra, is available for palpation if one includes rectal examination, it ·would usually be possible to detect the object unless it were very small. X-ray and endoscopy serve further to confirm diagnosis. Treatment as recommended by Young is 1) by means taken to favor spontaneous expulsion; 2) by pushing the object into the bladder, with subsequent removal by lithotrite, rongeur forceps, or cystotomy; 3) by endo-urethral removal by forceps, with or ·without the aid of the endoscope, and 4) by urethrotomy. Gutierrez in his discussion of the treatment of the urethral foreign body states that first a meatotomy should be performed and an attempt made to induce the foreign body to return by the natural route; when this fails and the foreign body continues to maintain its blockade of the urethra, exploratory urethral catheters, bougies, filiforms and urethroscopic instruments should be used in effort to remove the foreign body or at least to push it into the bladder so that it can be removed by cystoscopic manipulation or cystotomy. Finally an external urethrotomy may be necessary. Gutierrez further points out that if the foreign body is fixed in the anterior portion of the penile urethra, an external urethrotomy must be carried out on the glans penis, or anterior portion of the urethra. Plastic operations on the penile portion of the urethra have notoriously resulted in fistulas; hence, before this performance, he recommends that one institute a diversion of the urine by a preliminary cystotomy in order to forstall infection and secure a perfect healing.
RIFLE BULLET IMPACTED IN ANTERIOR URETHRA
789
SUMMARY
An unusual case of foreign body in the urethra is presented with x-rays which show the migration of a 30 caliber bullet from the prostatic urethra into the anterior urethra with subsequent impaction and urinary retention. Migration of the bullet from the bladder into the urethra occurred more than three years after the original entry of the bullet. The diagnosis and treatment of a foreign body in the urethra is discussed. 94 Jl![ arket St., Poughkeepsie, N. Y. REFERENCES BAILEY, H.: Surgery of Modern Warfare. Edinburgh: E. and S. Livingston, 1942. BoND, S. P.: Foreign bodies in bladder. J. A. M.A., 83: 1163, 1924. BoRs, E.: Removal of a broken glass catheter from female bladder. J. Urol., 49: 658, 1943. BoRs, E. AND Bowrn, C. S.: Migration of foreign bodies, with report of a case of migration of a shell fragment into bladder. J. Urol., 55: 358, 1946. CAMPBELL, M. F.: Needles in deep urethra. Arn. J. Surg., 21: 452, 1933. GORDON, L. Z.: Safety pins in male urethra. Urol. & Cutan. Rev., 45: 500, 1941. GROSSMAN, S. L. AND HoFFENSTEIN, H. F.: Foreign bodies in bladder, report of 3 cases. · Urol. & Cutan. Rev., 41: 788, 1937. GUTIERREZ, R.: Foreign body in urethra. J. Urol., 49: 865, 1943. JECK, H. S.: Removal of foreign bodies from urethra and bladder. Arn. J. Surg., 36: 197, 1937. LuYs, G.: Extraction of a rifle bullet from bladder by natural route. New York Med. J., 111: 181, 1930. POULET, A.: A Treatise on Foreign Bodies in Surgical Practice. Chapter on Male Urethra. New York: Wm. Wood & Co., 1880, vol. 2, pp. 113-144. RILEY, A.: Foreign bodies in male urethra. Report of an unusual case. New Eng. J. Med., 218: 884, 1938. SHELLEY, J. H.: Gunshot wounds of urinary bladder. Am. J. Surg., 16: 301, 1932. S1°AHLER, A. A.: Foreign bodies in urethra. No. 16-penny nails present for 12 years. J. Urol., 55: 397, 1946. TURNER, J. H.: Two unusual foreign bodies in male urinary bladder. J. Urol., 11: 581, 1924, WALKER, A. S. AND KAUFMAN, D.R.: Spontaneous migration of bullet into urinary bladder after a 5 year interval. Urol. & Cutan. Rev., 46: 217, 1942. YouNo, H. H. AND DAVIS, D. M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926, vol. 2, pp. 178-181.