- Email: [email protected]
Foreign Body in Bladder with Unusual Aspects
THE JOURNAL OF UROLOGY
Vol. 86, No. 4 October 1961 Copyright@ 1961 by Th_e Williams & W1lkms Co. Pnnted in U.S.A.
FOREIGN BODY IN BLADDER WITH UNUSUAL ASPECTS JOSEPH T. MARCONIS From the Department of Urology, Good Samaritan Hospital, Pottsville, Pa.
A mystifying feature of this case was that a surgical sponge was discovered in the patient's bladder without any antecedent history of urological surgery. There were several other pertinent aspects to this case which compelled the author to consider that it was worth reporting. The presence of foreign bodies in the bladder is not unusual. In most instances, foreign bodies are self-introduced as a means of sexual gratification, accidentally during self-treatment for some genitourinary complaint, or by a second party as a sadistic type of humor. Then too, unfortunately, both for the patie~t and operator, foreio·n bodies have been left m bladders madve;tently by well-intentioned, highly skilled and respected surgeons. Foreign bodies, such as packs, drains and surgical instruments, have been known to migrate to the bladder after they have be~n left in adjacent structures, such as the vagma or lower abdomen. This type of situation is usually attended by a fistula communicating with the bladder from the neighboring viscus or structure and it is ordinarily associated with much bladder infection and symptoms. The case described in this report does not appear to fall in this category. . . The literature abounds with the vanety of foreign objects found in the bladder and the devious and ingenious ways in which they have been introduced. This is well described and summarized in Campbell's Urology in a chapter on the subject by Dr. D. K. Rose. Virtually every urological surgeon has removed some form of foreign body from a bladder and the objects removed are as different as each surgeon's personality. Everything, from. human hair _as described by Zeitlin and associates to a Stemmann pin as described by Fitzpatrick, has been found in bladders. For obvious reasons, the literature is rather reticent concerning the discovery of a surgical sponge as a foreign body in the bladder, but the author felt that this case possessed so many unique aspects that it should be presented to the medical profession. Accepted for publication March 1, 1961.
400
CASE REPORT
M. M. (No. 106,80.5), a 70-year-old white man, was first seen by me at my office on September 11, 19.58. He complained of frequency of urination with urgency and burning on urination. These dysuric symptoms had been present only the past 24 hours. Interestingly enough, prior to that time the patient had had no subjective urinary complaints. The past medical history was n~gative for any relevant illnesses but the patient had had three major operative procedures performed in the same hospital in a large medical center and in each instance by the same general surgeon. The first operation was for a bowel obstruction in 19.52. In 19.53 a cholecysteetomy was done, and in 19.54 a right herniorrhaphy. Convalescence from each of these operations was uneventful. Phvsical evaluation disclosed a tall, wellprese~ved, elderly white man, whose chief complaint centered around his distress on urination. Examination of the abdomen disclosed scars from previous surgery as mentioned above, but there were no palpable masses or areas of tenderness. The genitalia were negative to inspection and palpation. Evaluation of the prostate, per rectum, revealed a gland which was symmetrical in outline, of a benign consistency and enlarged to about a grade 1 degree. A freshly voided urine specimen on analysis had a hazy appearance, the specific gravity was 1.01.5; albumin, 2 plus; sugar, negative; on microscopic examination many pus cells per high power field were observed. My initial impression was that the patient had prostatocystitis, and cystoscopy was deferred because of the marked pyuria and bladder tenesmus. He was placed on gantrisin and told to return in one week. I did not hear from him again until 3 weeks later when a member of the family called stating that his bladder was distended and that he was unable to urinate. Immediate entrance to the Good Samaritan Hospital was obtained. Catherization recovered 600 cc residual urine, and catheter drainage was maintained. Further laboratory studies in the hospital showed urine which gave a 3 plus reaction for
FOREIGN BODY IN BLADDER
albumin, and many pus cells per high power fiPld ..A complete blood eount and differential studies were within normal limits. The blood urea on admission was 31 mg. per cent but by mean.~ of catheter drainage and copious intake of oral fiuids, the blood urea receded to 21 mg. per cent. An x-rn.y of the abdomen disclosed advanced degenerative arthritic changes of the lumbosacral spine, sacroiliac and hip joints bilaterally Since the sponge was of a non-x-ray type, no evidence of its existence was noted on this film. 1Vith the use of ga.ntrisin tablets 2 q.i.d. the urine became grosdy clear, the albumin rraction showed only a tn1r:e and the pus cell count was reduced to 6-8 per high power field. A eystol'Xamination was pnformed under pentotha.1 a.nesthrsia on October :30, 1958. Visualization of tbe interior of the bladder immediately clisclosecl a dirty grayish-white object lying on tlw posterior bladder wall U1()asuring about 7 by 4 by :3 cm. It had a ball-like appearance and a fine thread-like mesh. Using a Lowsley grasping a portion of this matrrial was remov<·d a.nd it had all of the charnderistics of a of surgical sponge. The bladder wall showed a mild degree of tmbeculation and a very subsiding inflammatory change . >i'owhere, either on the foreign body described or within the bladder, was there any e,·idenc:c of any stones or alkaline incrustations. Obscrn,tion of the urethra showed a slight posterior commissnral hypertrophy with about 1 intrnurethral hypertrophy of the
FIG. 1. Ball-like surgical sponge removed from bl,l.(lder :1fter there about J vears. Note ah .. ,cmce of and the \vell-visualizecl threads.
lateral lobes but the obstruction to the of the posterior urethra was minim.al. Three later, a done and the foreign sponge (fig. The closed, drainage bf)ing obtained urethral ea.theter. The catheter was removed, the ma]ly. He has been without DISCUSSION
and a right herniorrhaphy ability the sponge was bladder during the herniorrlmphy. Yet communication with tbc surgeon who this proc:eclure indicated that the hernial was a routine one with 110 c,videncc of bbddct the hernial sac. The surgeon was a compet: nt. 011c with many yearn nf A most interesting feature that this patient Imel 110 ,-;ymptnm,; unh1 which was morl' than J yearn after surgical procedure, , a bcrniorrhaphy. He was quite active aU this time in a dry cleaning t,stablishnwnt. ..\nothrr finding 1vas thr, complde absern·c of any material either on the sponge or witbi.ii t.he bladder itself. As ,1 matter of the muc;osa showed very little eYidcucc of chrcmic irritation or infiarrn1rntio11 at the time totorny. One can conjecture that the ~pong,: an in11oeuo11s substance until n. bladdf:r developed and with tbc a,;.sociated tern'SElUS sponge changed position to tause obstruc:twn the vesical outlet, To be asymptomatic for at, least four with a surgical sponge in the bladder no evidencr of c:alcifica.tion or chronic augurs wdl for the cnJlvtion nf n, :-lie, nocuous described study of onr patient's urine on the pH value~ and have been interesting but he IYiLS very tive when his health was
LlJJCOOJWt':.<.
402
JOSEPH T, MARCONIS
One cannot be overly repetitious in cautioning anyone doing surgery to be fussy about the sponge count and to always use x-ray opaque surgical sponges.
the bladder itself. This case lends some supporting clinical weight to the tolerance of the bladder for innocuous artificial replacement devices as, for example, plastic ureteral valves.
413 W. Market St., Pottsville, Pa. SUMMARY
A case study of a surgical sponge being in the bladder as a foreign body for at least four years was presented. The unusual feature of this case was that the patient was without urinary symptoms over this period of time although actively employed. In addition, when the sponge was removed by cystotomy, the bladder showed very slight irritative changes and there was absolutely no calcification present on the sponge or within
REFERENCES CAMPBELL, M. F.: Urology. Philadelphia: W. B. Saunders Co., 1954. FITZPATRICK, R. J.: Unusual foreign body (Steinmann pin) in bladder. J.A.M.A., 170: 127-128, 1959. KOHLER, F. P. AND MURPHY, J. J.: Experimental evaluation of a plastic mechanical ureteral valve. J. Urol., 84: 293-296, 1960. ZEITLIN, A. B., COTTRELL, T. L. AND LLOYD, F. A.: Hair as a lower urinary tract foreign body. J. Urol., 77: 840-842, 1957.
Vol. 86, No. 4 October 1961 Copyright@ 1961 by Th_e Williams & W1lkms Co. Pnnted in U.S.A.
FOREIGN BODY IN BLADDER WITH UNUSUAL ASPECTS JOSEPH T. MARCONIS From the Department of Urology, Good Samaritan Hospital, Pottsville, Pa.
A mystifying feature of this case was that a surgical sponge was discovered in the patient's bladder without any antecedent history of urological surgery. There were several other pertinent aspects to this case which compelled the author to consider that it was worth reporting. The presence of foreign bodies in the bladder is not unusual. In most instances, foreign bodies are self-introduced as a means of sexual gratification, accidentally during self-treatment for some genitourinary complaint, or by a second party as a sadistic type of humor. Then too, unfortunately, both for the patie~t and operator, foreio·n bodies have been left m bladders madve;tently by well-intentioned, highly skilled and respected surgeons. Foreign bodies, such as packs, drains and surgical instruments, have been known to migrate to the bladder after they have be~n left in adjacent structures, such as the vagma or lower abdomen. This type of situation is usually attended by a fistula communicating with the bladder from the neighboring viscus or structure and it is ordinarily associated with much bladder infection and symptoms. The case described in this report does not appear to fall in this category. . . The literature abounds with the vanety of foreign objects found in the bladder and the devious and ingenious ways in which they have been introduced. This is well described and summarized in Campbell's Urology in a chapter on the subject by Dr. D. K. Rose. Virtually every urological surgeon has removed some form of foreign body from a bladder and the objects removed are as different as each surgeon's personality. Everything, from. human hair _as described by Zeitlin and associates to a Stemmann pin as described by Fitzpatrick, has been found in bladders. For obvious reasons, the literature is rather reticent concerning the discovery of a surgical sponge as a foreign body in the bladder, but the author felt that this case possessed so many unique aspects that it should be presented to the medical profession. Accepted for publication March 1, 1961.
400
CASE REPORT
M. M. (No. 106,80.5), a 70-year-old white man, was first seen by me at my office on September 11, 19.58. He complained of frequency of urination with urgency and burning on urination. These dysuric symptoms had been present only the past 24 hours. Interestingly enough, prior to that time the patient had had no subjective urinary complaints. The past medical history was n~gative for any relevant illnesses but the patient had had three major operative procedures performed in the same hospital in a large medical center and in each instance by the same general surgeon. The first operation was for a bowel obstruction in 19.52. In 19.53 a cholecysteetomy was done, and in 19.54 a right herniorrhaphy. Convalescence from each of these operations was uneventful. Phvsical evaluation disclosed a tall, wellprese~ved, elderly white man, whose chief complaint centered around his distress on urination. Examination of the abdomen disclosed scars from previous surgery as mentioned above, but there were no palpable masses or areas of tenderness. The genitalia were negative to inspection and palpation. Evaluation of the prostate, per rectum, revealed a gland which was symmetrical in outline, of a benign consistency and enlarged to about a grade 1 degree. A freshly voided urine specimen on analysis had a hazy appearance, the specific gravity was 1.01.5; albumin, 2 plus; sugar, negative; on microscopic examination many pus cells per high power field were observed. My initial impression was that the patient had prostatocystitis, and cystoscopy was deferred because of the marked pyuria and bladder tenesmus. He was placed on gantrisin and told to return in one week. I did not hear from him again until 3 weeks later when a member of the family called stating that his bladder was distended and that he was unable to urinate. Immediate entrance to the Good Samaritan Hospital was obtained. Catherization recovered 600 cc residual urine, and catheter drainage was maintained. Further laboratory studies in the hospital showed urine which gave a 3 plus reaction for
FOREIGN BODY IN BLADDER
albumin, and many pus cells per high power fiPld ..A complete blood eount and differential studies were within normal limits. The blood urea on admission was 31 mg. per cent but by mean.~ of catheter drainage and copious intake of oral fiuids, the blood urea receded to 21 mg. per cent. An x-rn.y of the abdomen disclosed advanced degenerative arthritic changes of the lumbosacral spine, sacroiliac and hip joints bilaterally Since the sponge was of a non-x-ray type, no evidence of its existence was noted on this film. 1Vith the use of ga.ntrisin tablets 2 q.i.d. the urine became grosdy clear, the albumin rraction showed only a tn1r:e and the pus cell count was reduced to 6-8 per high power field. A eystol'Xamination was pnformed under pentotha.1 a.nesthrsia on October :30, 1958. Visualization of tbe interior of the bladder immediately clisclosecl a dirty grayish-white object lying on tlw posterior bladder wall U1()asuring about 7 by 4 by :3 cm. It had a ball-like appearance and a fine thread-like mesh. Using a Lowsley grasping a portion of this matrrial was remov<·d a.nd it had all of the charnderistics of a of surgical sponge. The bladder wall showed a mild degree of tmbeculation and a very subsiding inflammatory change . >i'owhere, either on the foreign body described or within the bladder, was there any e,·idenc:c of any stones or alkaline incrustations. Obscrn,tion of the urethra showed a slight posterior commissnral hypertrophy with about 1 intrnurethral hypertrophy of the
FIG. 1. Ball-like surgical sponge removed from bl,l.(lder :1fter there about J vears. Note ah .. ,cmce of and the \vell-visualizecl threads.
lateral lobes but the obstruction to the of the posterior urethra was minim.al. Three later, a done and the foreign sponge (fig. The closed, drainage bf)ing obtained urethral ea.theter. The catheter was removed, the ma]ly. He has been without DISCUSSION
and a right herniorrhaphy ability the sponge was bladder during the herniorrlmphy. Yet communication with tbc surgeon who this proc:eclure indicated that the hernial was a routine one with 110 c,videncc of bbddct the hernial sac. The surgeon was a compet: nt. 011c with many yearn nf A most interesting feature that this patient Imel 110 ,-;ymptnm,; unh1 which was morl' than J yearn after surgical procedure, , a bcrniorrhaphy. He was quite active aU this time in a dry cleaning t,stablishnwnt. ..\nothrr finding 1vas thr, complde absern·c of any material either on the sponge or witbi.ii t.he bladder itself. As ,1 matter of the muc;osa showed very little eYidcucc of chrcmic irritation or infiarrn1rntio11 at the time totorny. One can conjecture that the ~pong,: an in11oeuo11s substance until n. bladdf:r developed and with tbc a,;.sociated tern'SElUS sponge changed position to tause obstruc:twn the vesical outlet, To be asymptomatic for at, least four with a surgical sponge in the bladder no evidencr of c:alcifica.tion or chronic augurs wdl for the cnJlvtion nf n, :-lie, nocuous described study of onr patient's urine on the pH value~ and have been interesting but he IYiLS very tive when his health was
LlJJCOOJWt':.<.
402
JOSEPH T, MARCONIS
One cannot be overly repetitious in cautioning anyone doing surgery to be fussy about the sponge count and to always use x-ray opaque surgical sponges.
the bladder itself. This case lends some supporting clinical weight to the tolerance of the bladder for innocuous artificial replacement devices as, for example, plastic ureteral valves.
413 W. Market St., Pottsville, Pa. SUMMARY
A case study of a surgical sponge being in the bladder as a foreign body for at least four years was presented. The unusual feature of this case was that the patient was without urinary symptoms over this period of time although actively employed. In addition, when the sponge was removed by cystotomy, the bladder showed very slight irritative changes and there was absolutely no calcification present on the sponge or within
REFERENCES CAMPBELL, M. F.: Urology. Philadelphia: W. B. Saunders Co., 1954. FITZPATRICK, R. J.: Unusual foreign body (Steinmann pin) in bladder. J.A.M.A., 170: 127-128, 1959. KOHLER, F. P. AND MURPHY, J. J.: Experimental evaluation of a plastic mechanical ureteral valve. J. Urol., 84: 293-296, 1960. ZEITLIN, A. B., COTTRELL, T. L. AND LLOYD, F. A.: Hair as a lower urinary tract foreign body. J. Urol., 77: 840-842, 1957.