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Foreign Body Migration to the Genitourinary Tract
0022-534 7/87 /1374-0751$02.00/0 THE JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
FOREIGN BODY MIGRATION TO THE GENITOURINARY TRACT ROBERT MARX
AND
DENNIS VENABLE
From the Department of Urology, Louisiana State University Medical Center-Shreveport, Shreveport, Louisiana
ABSTRACT
Foreign body migration from the gastrointestinal tract to any of several sites within the genitourinary tract has been well documented. We report 3 such cases involving the upper and lower urinary tract to highlight the varied presentations, manifestations and prognosis associated with this entity. Foreign bodies within the genitourinary tract have been noted to reach the kidney by 3 commonly recognized routes: 1) external trauma, including those foreign bodies associated with surgical procedures, that is drains, needles and sutures, 2) retrograde passage from the bladder to the kidney and 3) migration from the gastrointestinal tract to the kidney. Excluding missile penetration of the kidney and self-instrumentation of the urethra, the most common route is migration from the gastrointestinal tract. 1 • 2 We describe 3 cases of migration of foreign bodies to the genitourinary tract and discuss the possible routes of entry. CASE REPORTS
Case 1. A 7-year-old boy presented to the pediatrician in November 1982 with general malaise associated with neck, back and stomach pain. No nausea, vomiting, diarrhea, chills, fever or flank pain was noted. Medical history was noncontributory and no past genitourinary disease was noted. Physical examination was completely within normal limits. The urine was negative by dipstick for albumin, sugar and ketones but it was positive for occult blood. Microscopic evaluation of urinary sediment showed few white cells and 3 to 5 red cells per high power field. No casts or bacteria were present. Urological consultation was obtained to assess the microhematuria. Plain films of the abdomen and excretory urography (IVP) revealed a metallic foreign body (needle) within the substance of the right kidney (fig. 1). Lateral and oblique views, and subsequent computerized tomography (CT) (fig. 2) confirmed the intrarenal parenchymal location of the needle. Since the patient had become and remained asymptomatic, and the foreign body was not associated with infection or stone formation, conservative management with observation only was elected. Followup at 2 years revealed no change in the position of the needle or calculous formation. Urine has remained free of infection and the hematuria has resolved. The probable route of entry in this case followed oral ingestion with subsequent perforation of the duodenum and migration to the right kidney. Case 2. A 32-year-old man with documented schizophrenia presented with fever, nausea, vomiting and vague abdominal pain followed by hematemesis. Gastroscopy revealed no active bleeding sites. Later that evening massive upper gastrointestinal hemorrhage necessitated emergency laparotomy. The patient experienced cardiac arrest just before anesthetic induction. Emergency left thoracotomy followed by cross-clamping of the aorta and internal cardiac massage temporarily resuscitated the patient. Surgical exploration of the abdomen revealed a large phlegmonous mass surrounding the second portion of the duodenum. Dissection of the mass from the duodenum revealed a fistula from the duodenum to the right renal vein containing a toothpick. Despite control of bleeding and repair of the fistula, the patient experienced irreversible shock and died. Accepted for publication November 10, 1986. Read at annual meeting of Southeastern Section, American Urological Association, El Dorado Beach, Puerto Rico, March 16-19, 1986.
Case 3. A 52-year-old man presented with pneumaturia and 2-year history of recurrent urinary tract infections. Urine cultures confirmed polymicrobial infection. An IVP revealed irregularity in the posterior dome of the bladder. Cystoscopy showed an inflammatory lesion in this area of the bladder, which contained necrotic debris centrally. Cold cup biopsy was consistent only with inflammatory changes. A barium enema revealed extensive diverticular disease of the sigmoid colon. Voided urine contained barium following this study, which confirmed the diagnosis of a colovesical fistula. The patient underwent exploratory laparotomy with sigmoid colon resection and closure of the fistulous communication with the bladder. A 2 X 1 cm. foreign body within the fistulous tract was determined by gross examination and subsequent pathological section to be bone. Convalescence was uneventful. We hypothesize that the ingested foreign body (bone fragment) was retained within a sigmoid diverticulum and, subsequently, it eroded into and through the bladder wall.
FIG. 1. Case 1. IVP suggests that foreign body may lie in area of parenchyma of right kidney.
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MARX AND VENABLE
FIG. 2. Case 1. Renal CT confirmed superficial parenchymal location of foreign body (arrowhead). No communication with collecting system could be seen.
DISCUSSION
Foreign body migration from the gastrointestinal tract to the genitourinary tract is a rare but well documented occurrence. 1-5 Fortunately, most ingested foreign objects pass harmlessly through the alimentary tract and are eliminated in the feces. 6 In the series by Henderson and Gaston of 800 patients documented to have swallowed foreign bodies gastrointestinal perforations were found in only 1 per cent. 7 Other series estimate that up to 20 per cent of such ingested foreign bodies fail to pass spontaneously. 8 Accidental foreign body ingestion occurs most commonly among the 2 patient populations of the young and the elderly. Elderly, edentulous patients who wear dentures are at risk for swallowing foreign objects secondary to decreased sensitivity of the palate and gingival surfaces. 7 ' 8 Maleki and Evans found that 75 per cent of their patients with foreign body perforation wore dentures. 8 Other conditions favoring ingestion of foreign objects in the adult population include ethanol ingestion, mental disease or retardation and rapid eating. 8 - 12 The route of entry in case 1 was presumed to be ingestion with subsequent perforation of the duodenum and migration to the right kidney. What makes this case unique is the possibility of ingestion of contaminated Halloween candy. Although we cannot rule out ingestion of the needle at a much earlier age the presentation of the child shortly after Halloween leads one to speculate that he may have ingested Halloween candy contaminated by the needle. Further questioning of the patient and his family revealed no additional information as to the origin of the foreign body, except to confirm that he had been "trick or treating" on the previous Halloween. Several instances of candy and cookie contamination with similar foreign bodies occurred at that time locally and nationally. Ingested foreign objects that are most likely to perforate the gastrointestinal tract are narrow, pointed, indigestible metallic foreign bodies, such as hairpins, needles and wire.13 This type of foreign body accounted for 45 per cent of the perforations in a large review. 14 Fish and chicken bones accounted for 36 per cent, and toothpicks and wood splinters caused 9 per cent of perforations in that same review. 14 While the site of perforation of an ingested foreign body may
occur at any level of the alimentary tract, it occurs most frequently in the ileocecal region. 14' 15 The second portion of the duodenum appears to be the most likely site of perforation in those cases associated with subsequent intrarenal migration.1· 3 • 4 The angulation of the retroperitonealized, relatively fixed duodenum is not easily negotiated by long, stiff, sharp objects, explaining its susceptibility to perforation. 2· 3 Foreign bodies associated with the left kidney occur only 10 to 20 per cent as commonly as those associated with the right kidney and usually they result from penetration of the left colon. 2· 3 The latter are associated frequently with abscess formation, secondary to spillage of infected fecal material into the perirenal space, or directly into the left renal collecting system or bladder. 2· 3 In contrast, perforation of the relatively sterile duodenal contents may produce only a mild inflammatory response and in such instances may assume an indolent course. 3• 16 Bearing these facts in mind, a right perinephric abscess associated with a foreign body will be associated more likely with perforation of the right colon rather than the duodenum. 3 • 5 Therapy should be individualized, depending on the presence or absence of associated infectious or vascular complications. 8 • 9 • 17 Intrarenal foreign bodies exposed to the collecting system and urine as well as intravesical foreign bodies would likely be calculogenic, and consideration should be given to elective removal. Inert metallic foreign bodies that have migrated to a renal parenchymal location and are not associated with symptoms or secondary complications may be managed conservatively. REFERENCES
1. Osmond, J. D., Jr.: Foreign bodies in the kidney: a review of the literature and reports of 4 additional cases. Radiology, 60: 375, 1953. 2. Gondos, B.: Foreign body in the left kidney and ureter. J. Urol., 73: 35, 1955. 3. Baird, J.M. and Spence, H. M.: Ingested foreign bodies migrating to the kidney from the gastrointestinal tract. J. Urol., 99: 675, 1968. 4. Nelson, 0. A., Kretz, A. W., McCormack, J. L., Docter, J.M. and Douglass, C. W.: A bobby pin in the kidney pelvis. J. Urol., 69: 618, 1953. 5. Landers, M. B., Jr.: Toothpick in a perinephric abscess. Amer. J. Surg., 71: 427, 1946. 6. Cockerill, F. R., III, Wilson, W.R. and Van Scoy, R. E.: Traveling toothpicks. Mayo Clin. Proc., 58: 613, 1983. 7. Henderson, F. F. and Gaston, E. A.: Ingested foreign bodies in the gastrointestinal tract. Arch. Surg., 36: 66, 1938. 8. Maleki, M. and Evans, W. E.: Foreign-body perforation of the inte~tinal tract: :report of 12 cases and review of the literature. Arch. Surg., 101: 475, 1970. 9. Justiniani, F. R., Wigoda, L. and Ortega, R. S.: Duodenocaval fistula due to toothpick perforation. J.A.M.A., 227: 788, 1974. 10. Jernigan, P. A. and Mullin, G. T., Jr.: Intestinal fistula from a toothpick. Minn. Med., 62: 321, 1979. 11. Eldridge, W. W., Jr.: Foreign bodies in the gastrointestinal tract. J.A.M.A., 178: 665, 1961. 12. Schwartz, J. T. and Graham, D. Y.: Toothpick perforation of the intestines. Ann. Surg., 185: 64, 1977. 13. Budnick, L. D.: Toothpick-related injuries in the United States, 1979 through 1982. J.A.M.A., 252: 796, 1984. 14. MacManus, J. E.: Perforations of the intestine by ingested foreign bodies: report of 2 cases and review of the literature. Amer. J. Surg., 53: 393, 1941. 15. Carp, L.: Foreign bodies in the intestine. Ann. Surg., 85: 575, 1927. 16. Macaulay, D. and Moore, T.: A foreign body in the kidney. Brit. Med. J., 1: 205, 1955. 17. Fry, D., Flint, L. M. and Richardson, J. D.: Aorticoduodenal fistula secondary to a toothpick. J. Kentucky Med. Ass., 76: 441, 1978.
Copyright© 1987 by The Williams & Wilkins Co.
FOREIGN BODY MIGRATION TO THE GENITOURINARY TRACT ROBERT MARX
AND
DENNIS VENABLE
From the Department of Urology, Louisiana State University Medical Center-Shreveport, Shreveport, Louisiana
ABSTRACT
Foreign body migration from the gastrointestinal tract to any of several sites within the genitourinary tract has been well documented. We report 3 such cases involving the upper and lower urinary tract to highlight the varied presentations, manifestations and prognosis associated with this entity. Foreign bodies within the genitourinary tract have been noted to reach the kidney by 3 commonly recognized routes: 1) external trauma, including those foreign bodies associated with surgical procedures, that is drains, needles and sutures, 2) retrograde passage from the bladder to the kidney and 3) migration from the gastrointestinal tract to the kidney. Excluding missile penetration of the kidney and self-instrumentation of the urethra, the most common route is migration from the gastrointestinal tract. 1 • 2 We describe 3 cases of migration of foreign bodies to the genitourinary tract and discuss the possible routes of entry. CASE REPORTS
Case 1. A 7-year-old boy presented to the pediatrician in November 1982 with general malaise associated with neck, back and stomach pain. No nausea, vomiting, diarrhea, chills, fever or flank pain was noted. Medical history was noncontributory and no past genitourinary disease was noted. Physical examination was completely within normal limits. The urine was negative by dipstick for albumin, sugar and ketones but it was positive for occult blood. Microscopic evaluation of urinary sediment showed few white cells and 3 to 5 red cells per high power field. No casts or bacteria were present. Urological consultation was obtained to assess the microhematuria. Plain films of the abdomen and excretory urography (IVP) revealed a metallic foreign body (needle) within the substance of the right kidney (fig. 1). Lateral and oblique views, and subsequent computerized tomography (CT) (fig. 2) confirmed the intrarenal parenchymal location of the needle. Since the patient had become and remained asymptomatic, and the foreign body was not associated with infection or stone formation, conservative management with observation only was elected. Followup at 2 years revealed no change in the position of the needle or calculous formation. Urine has remained free of infection and the hematuria has resolved. The probable route of entry in this case followed oral ingestion with subsequent perforation of the duodenum and migration to the right kidney. Case 2. A 32-year-old man with documented schizophrenia presented with fever, nausea, vomiting and vague abdominal pain followed by hematemesis. Gastroscopy revealed no active bleeding sites. Later that evening massive upper gastrointestinal hemorrhage necessitated emergency laparotomy. The patient experienced cardiac arrest just before anesthetic induction. Emergency left thoracotomy followed by cross-clamping of the aorta and internal cardiac massage temporarily resuscitated the patient. Surgical exploration of the abdomen revealed a large phlegmonous mass surrounding the second portion of the duodenum. Dissection of the mass from the duodenum revealed a fistula from the duodenum to the right renal vein containing a toothpick. Despite control of bleeding and repair of the fistula, the patient experienced irreversible shock and died. Accepted for publication November 10, 1986. Read at annual meeting of Southeastern Section, American Urological Association, El Dorado Beach, Puerto Rico, March 16-19, 1986.
Case 3. A 52-year-old man presented with pneumaturia and 2-year history of recurrent urinary tract infections. Urine cultures confirmed polymicrobial infection. An IVP revealed irregularity in the posterior dome of the bladder. Cystoscopy showed an inflammatory lesion in this area of the bladder, which contained necrotic debris centrally. Cold cup biopsy was consistent only with inflammatory changes. A barium enema revealed extensive diverticular disease of the sigmoid colon. Voided urine contained barium following this study, which confirmed the diagnosis of a colovesical fistula. The patient underwent exploratory laparotomy with sigmoid colon resection and closure of the fistulous communication with the bladder. A 2 X 1 cm. foreign body within the fistulous tract was determined by gross examination and subsequent pathological section to be bone. Convalescence was uneventful. We hypothesize that the ingested foreign body (bone fragment) was retained within a sigmoid diverticulum and, subsequently, it eroded into and through the bladder wall.
FIG. 1. Case 1. IVP suggests that foreign body may lie in area of parenchyma of right kidney.
751
752
MARX AND VENABLE
FIG. 2. Case 1. Renal CT confirmed superficial parenchymal location of foreign body (arrowhead). No communication with collecting system could be seen.
DISCUSSION
Foreign body migration from the gastrointestinal tract to the genitourinary tract is a rare but well documented occurrence. 1-5 Fortunately, most ingested foreign objects pass harmlessly through the alimentary tract and are eliminated in the feces. 6 In the series by Henderson and Gaston of 800 patients documented to have swallowed foreign bodies gastrointestinal perforations were found in only 1 per cent. 7 Other series estimate that up to 20 per cent of such ingested foreign bodies fail to pass spontaneously. 8 Accidental foreign body ingestion occurs most commonly among the 2 patient populations of the young and the elderly. Elderly, edentulous patients who wear dentures are at risk for swallowing foreign objects secondary to decreased sensitivity of the palate and gingival surfaces. 7 ' 8 Maleki and Evans found that 75 per cent of their patients with foreign body perforation wore dentures. 8 Other conditions favoring ingestion of foreign objects in the adult population include ethanol ingestion, mental disease or retardation and rapid eating. 8 - 12 The route of entry in case 1 was presumed to be ingestion with subsequent perforation of the duodenum and migration to the right kidney. What makes this case unique is the possibility of ingestion of contaminated Halloween candy. Although we cannot rule out ingestion of the needle at a much earlier age the presentation of the child shortly after Halloween leads one to speculate that he may have ingested Halloween candy contaminated by the needle. Further questioning of the patient and his family revealed no additional information as to the origin of the foreign body, except to confirm that he had been "trick or treating" on the previous Halloween. Several instances of candy and cookie contamination with similar foreign bodies occurred at that time locally and nationally. Ingested foreign objects that are most likely to perforate the gastrointestinal tract are narrow, pointed, indigestible metallic foreign bodies, such as hairpins, needles and wire.13 This type of foreign body accounted for 45 per cent of the perforations in a large review. 14 Fish and chicken bones accounted for 36 per cent, and toothpicks and wood splinters caused 9 per cent of perforations in that same review. 14 While the site of perforation of an ingested foreign body may
occur at any level of the alimentary tract, it occurs most frequently in the ileocecal region. 14' 15 The second portion of the duodenum appears to be the most likely site of perforation in those cases associated with subsequent intrarenal migration.1· 3 • 4 The angulation of the retroperitonealized, relatively fixed duodenum is not easily negotiated by long, stiff, sharp objects, explaining its susceptibility to perforation. 2· 3 Foreign bodies associated with the left kidney occur only 10 to 20 per cent as commonly as those associated with the right kidney and usually they result from penetration of the left colon. 2· 3 The latter are associated frequently with abscess formation, secondary to spillage of infected fecal material into the perirenal space, or directly into the left renal collecting system or bladder. 2· 3 In contrast, perforation of the relatively sterile duodenal contents may produce only a mild inflammatory response and in such instances may assume an indolent course. 3• 16 Bearing these facts in mind, a right perinephric abscess associated with a foreign body will be associated more likely with perforation of the right colon rather than the duodenum. 3 • 5 Therapy should be individualized, depending on the presence or absence of associated infectious or vascular complications. 8 • 9 • 17 Intrarenal foreign bodies exposed to the collecting system and urine as well as intravesical foreign bodies would likely be calculogenic, and consideration should be given to elective removal. Inert metallic foreign bodies that have migrated to a renal parenchymal location and are not associated with symptoms or secondary complications may be managed conservatively. REFERENCES
1. Osmond, J. D., Jr.: Foreign bodies in the kidney: a review of the literature and reports of 4 additional cases. Radiology, 60: 375, 1953. 2. Gondos, B.: Foreign body in the left kidney and ureter. J. Urol., 73: 35, 1955. 3. Baird, J.M. and Spence, H. M.: Ingested foreign bodies migrating to the kidney from the gastrointestinal tract. J. Urol., 99: 675, 1968. 4. Nelson, 0. A., Kretz, A. W., McCormack, J. L., Docter, J.M. and Douglass, C. W.: A bobby pin in the kidney pelvis. J. Urol., 69: 618, 1953. 5. Landers, M. B., Jr.: Toothpick in a perinephric abscess. Amer. J. Surg., 71: 427, 1946. 6. Cockerill, F. R., III, Wilson, W.R. and Van Scoy, R. E.: Traveling toothpicks. Mayo Clin. Proc., 58: 613, 1983. 7. Henderson, F. F. and Gaston, E. A.: Ingested foreign bodies in the gastrointestinal tract. Arch. Surg., 36: 66, 1938. 8. Maleki, M. and Evans, W. E.: Foreign-body perforation of the inte~tinal tract: :report of 12 cases and review of the literature. Arch. Surg., 101: 475, 1970. 9. Justiniani, F. R., Wigoda, L. and Ortega, R. S.: Duodenocaval fistula due to toothpick perforation. J.A.M.A., 227: 788, 1974. 10. Jernigan, P. A. and Mullin, G. T., Jr.: Intestinal fistula from a toothpick. Minn. Med., 62: 321, 1979. 11. Eldridge, W. W., Jr.: Foreign bodies in the gastrointestinal tract. J.A.M.A., 178: 665, 1961. 12. Schwartz, J. T. and Graham, D. Y.: Toothpick perforation of the intestines. Ann. Surg., 185: 64, 1977. 13. Budnick, L. D.: Toothpick-related injuries in the United States, 1979 through 1982. J.A.M.A., 252: 796, 1984. 14. MacManus, J. E.: Perforations of the intestine by ingested foreign bodies: report of 2 cases and review of the literature. Amer. J. Surg., 53: 393, 1941. 15. Carp, L.: Foreign bodies in the intestine. Ann. Surg., 85: 575, 1927. 16. Macaulay, D. and Moore, T.: A foreign body in the kidney. Brit. Med. J., 1: 205, 1955. 17. Fry, D., Flint, L. M. and Richardson, J. D.: Aorticoduodenal fistula secondary to a toothpick. J. Kentucky Med. Ass., 76: 441, 1978.