- Email: [email protected]
Case profile: Gonorrheal pelvic inflammatory disease presenting as bullous cystitis
URORADIOLOGY
CASE PROFILE:
GONORRHEAL PRESENTING
PELVIC INFLAMMATORY AS BULLOUS
Classically, acute gonorrhea1 pelvic inflammatory disease produces lower abdominal and pelvie pain, vaginal discharge, fever, and adnexal tenderness. Irritative urinary tract symptoms occur not uncommonly but rarely comprise the only complaints of pelvic inflammatory disease.
Cystogram portion of excretory urograms: (A) demonstrates with bullous cystitis, and (B) normal findings on follow-up.
A twenty-three-year-old nulligravida black female presented with a one-month history of suprapubic pain and dysuria without fever. Pertinent physical findings included an edematous urethral meatus, a scant blood-stained vaginal discharge, peri-anal edema, and severe tenderness over the urethra and bladder with less tenderness of the uterus and adnexa. Urinalysis 15 to 20 red blood cells per highdisclosed power field, and a routine urine culture showed no growth. A vaginal culture grew Neisseria gonorrhea. An excretory urogram demonstrated normal upper tracts but a bladder that was elevated from its normal position and which demonstrated scalloping of the inferior border (Fig. 1A). Cystoscopy confirmed bullous inflammation of the bladder floor. She showed only partial symptomatic improvement with intramuscular
196
CYSTITIS
penicillin and was therefore treated with five days of intravenous aqueous penicillin (5 million (60 mg. units every six hours) and gentamicin every eight hours). This therapy effected complete resolution of her symptoms, urethral and bladder tenderness, and vaginal discharge. Two
FIGURE 1.
consistent
DISEASE
marked irregularity
of bladder joor
weeks later the bladder had returned to normal radiographically (Fig. lB), and cystoscopic examination was normal. Comment We are unable to find reported such striking bladder distortion by gonorrhea, however it would appear clear from the clinical presentation that the bullous appearance of the bladder was due to juxtaposed pelvic inflammatory disease. We therefore suggest that this disease be considered in cases of bullous cystitis, particularly when urine cultures are negative and the patient is unresponsive to appropriate antibacterial therapy. Edward M. Blight, Jr., M.D. Tripler
UROLOGY
/ FEBRUARY1978
Army Medical Center Honolulu, Hawaii
/ VOLUMEXI,
NUMBER2
CASE PROFILE:
GONORRHEAL PRESENTING
PELVIC INFLAMMATORY AS BULLOUS
Classically, acute gonorrhea1 pelvic inflammatory disease produces lower abdominal and pelvie pain, vaginal discharge, fever, and adnexal tenderness. Irritative urinary tract symptoms occur not uncommonly but rarely comprise the only complaints of pelvic inflammatory disease.
Cystogram portion of excretory urograms: (A) demonstrates with bullous cystitis, and (B) normal findings on follow-up.
A twenty-three-year-old nulligravida black female presented with a one-month history of suprapubic pain and dysuria without fever. Pertinent physical findings included an edematous urethral meatus, a scant blood-stained vaginal discharge, peri-anal edema, and severe tenderness over the urethra and bladder with less tenderness of the uterus and adnexa. Urinalysis 15 to 20 red blood cells per highdisclosed power field, and a routine urine culture showed no growth. A vaginal culture grew Neisseria gonorrhea. An excretory urogram demonstrated normal upper tracts but a bladder that was elevated from its normal position and which demonstrated scalloping of the inferior border (Fig. 1A). Cystoscopy confirmed bullous inflammation of the bladder floor. She showed only partial symptomatic improvement with intramuscular
196
CYSTITIS
penicillin and was therefore treated with five days of intravenous aqueous penicillin (5 million (60 mg. units every six hours) and gentamicin every eight hours). This therapy effected complete resolution of her symptoms, urethral and bladder tenderness, and vaginal discharge. Two
FIGURE 1.
consistent
DISEASE
marked irregularity
of bladder joor
weeks later the bladder had returned to normal radiographically (Fig. lB), and cystoscopic examination was normal. Comment We are unable to find reported such striking bladder distortion by gonorrhea, however it would appear clear from the clinical presentation that the bullous appearance of the bladder was due to juxtaposed pelvic inflammatory disease. We therefore suggest that this disease be considered in cases of bullous cystitis, particularly when urine cultures are negative and the patient is unresponsive to appropriate antibacterial therapy. Edward M. Blight, Jr., M.D. Tripler
UROLOGY
/ FEBRUARY1978
Army Medical Center Honolulu, Hawaii
/ VOLUMEXI,
NUMBER2