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Further Observations with Delayed Cystograms
THE .JOURNAL OF UROLOGY
Vol. 71, No. 4, April 1954
Printed in U.S.A.
FURTHER OBSERVATIONS WITH DELAYED CYSTOGRAMS
R. G. BUNGE From the Department of Urology, University Hospitals, State University of Iowa Iowa City, Iowa '
In a previous article,1 observations in children using the delayed cystographic x-ray method of Dr. Charles M. Stewart were reported. Stewart first noticed ureteral reflux in a patient whose immediate cystogram was normal. The delayed cystogram occurred as a result of a technician's error. 2 This present report is concerned with observations on a larger series of patients, but includes the prev10us cases. METHOD
Delayed cystograms were made by filling the bladder slowly by the catheter to comfort (90-120 ml. in adults, 30-90 ml. in children) with warm 10 per cent skiodan solution. No effort was made to overdistend the bladder. The catheter was withdrawn and an x-ray film was exposed immediately, giving the ordinary cystogram. The patient was told to retain the instilled solution. Ambulation was allowed, and after the elapse of 30 minutes another x-ray picture was taken, and again after 60 minutes had elapsed, following the instillation of skiodan. Excretory urograms were obtained in most of the cases either 24 hours before or after cystography to avoid erroneous interpretation. If the patient was too young to co-operate, the urethral catheter was left indwelling and clamped. Cystoscopic examinations were done in all cases, except normal children and pregnant females. RESULTS
Twenty-four normal children and adults were examined (table 1). These ranged in age from 9 months to 74 years. In one, an asymptomatic hydronephrosis was found. Ureteral reflux did not appear in any of the examinations. Thirty-six cases of neurogenic bladder were examined (table 2). Ureteral reflux appeared in 8 cases. In 1 case the reflux was not present on the immediate cystogram, but was apparent on the delayed film. In two cases a rather surprising finding was reflux on the immediate film, but none on subsequent delayed pictures. Patients with bladder residual urine over 450 ml. did not have ureteral reflux. Those with ureteral reflux had residual urines ranging from 30 to 250 ml. Twenty-eight cases of bladder neck obstruction ranging in age from 20 months to 85 years were examined (table 3). Ureteral reflux was detected mostly in the children's group (6 children, 3 adults). In three pediatric cases, reflux did not appear on the ordinary cystograms but was detected on subsequent delayed films. Twenty-four cases of full-term pregnant women were examined (table 4). Five had excretory urograms which revealed the typical upper urinary tract dilatation. Ureteral reflux was not detected in any case. Accepted for publication April 10, 1953. 1 Bunge, R. G.: J. Urol., 70: 729, 1953. 2 Stewart, C. M.: Personal communication. 427
428
R. G. BUNGE TABLE
PATIEKT
NO.
12. 13. 14. 15. 16. 17. 18.
M.T. L.M. A. B. E. M. C. C. M.B. R.R. T.H. M. S. M.Z. J. A. C. K. P. C. G. T. M.B. J.B. C. P. N.H.
19. 20. 21. 22. 23. 24.
W.B. Y. Z. C.D. J. G. J. H. L.A.
11.
AGE IN YEARS
CYSTOGRAMS
BLADDER DIAGNOSIS
IVP
RESIDUAL URINE (cc.)
~l~I~
-- ---
--
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
SEX
I. N orinal subjects
F F
M M M M M M M F
F M M M F M F F
9 mo. 4 5 6 7 7 8 8 8 9 9 12 12 13 14 15 18 19
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
subject subject subject subject subject subject subject subject subject subject subject subject subject subject subject subject subject subject
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Normal Not taken Normal Not taken Not taken Not taken Normal Not taken Not taken Normal Normal Not taken Not taken Normal Poor detail Not taken Not taken Lt. hydronephro-
Normal Normal Normal Normal Normal Normal
subject subject subject subject subject subject
0 0 0 0 0 0
Not taken Normal Normal Normal Normal Normal
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
SlS
M F
19 24
F M F F
31 31 40 74
KEY: 0-No ureteral reflux; L-Left ureteral reflux; R-Right ureteral reflux; BilBilateral ureteral reflux; SP-Suprapubic tube; CR-Complete retention; 0 1-Immediate cystogram; 30 1-Cystogram at 30 minute interval; 60 1-Cystogram at 60 minute interval.
Twenty-three patients with urological disease in whom ureteral reflux would not ordinarily be clinically suspected were examined (table 5). Five adults had ureteral reflux; one was picked up by the delayed technique. Two adult cases with reflux failed to show it under spinal anesthesia. Four children with recurrent urinary infections were shown to have ureteral reflux. In three it was not revealed by the ordinary cystogram. Seven cases, classified as a miscellaneous group, were examined (table 6). The possibility of ureteral reflux was entertained but not substantiated. DISCUSSION
Ureteral reflux is rare in normal children3 and adults, 4 but it is more apt to occur in childhood. This suggests the possibility of maturation of ureteral physiology, since reflux is present normally in lower animals, such as the rabbit. 3
4
Campbell, M. F.: Pediatric Urology, New York: Macmillan Co., 1937, vol. 1, p. 70. Sampson, J. A., Bull. Johns Hopkins Hosp., 14: 334, 1903.
429
DELAYED CYSTOGRAMS TABLE
2. Neurogenic bladders BLADDER
NO.
PATIENT
SEX
AGE IN YEARS
DIAGNOSIS
RESIDUAL URINE
CYSTOGRAMS
lVP
(cc.)
O'
1.
P.R.
M
12
2.
M.G.
M
17
3.
P. T.
M
18
4.
H.B.
F
23
5.
M.W.
F
46
6.
C. S.
M
54
7.
E.E.
F
4
8. 9. 10.
H. C. B.R. R. C.
M M F
62 67 42
11.
S. L.
M
3
12.
D. C.
M
3
13.
C. E.
F
4
14.
G.L.
F
8
15.
L. L.
F
8
16.
J. H.
F
9
F
11
17.* M.C.
30'
60'
---- --
--
18.
J. R.
F
12
19.
P. B.
F
15
20.
D.K.
M
25
21.
W.N.
M
4
22.
K.H.
F
6
23.
D.D.
M
6
Paraplegic 4 months Paraplegic 3 years Paraplegic 6 months Paraplegic 2 years Paraplegic ? years Paraplegic 4 years Transverse myelopathy L-1
Poor detail
0
0
0
180
Normal
R
R
R
?
Normal
R
0
0
Bil. hydronephrosis Poor detail
0
0
0
0
0
0
100
Poor detail
0
0
0
150
Rt. indeterminate, It. normal Normal Poor detail Normal
0
0
0
0 0 0
0 0 0
0 0 0
Rt. normal, lt. L hydronephrosis Normal 0
L
L
0
0
0
Normal
0
0
0
110
Normal
0
0
0
Bil. hydronephrosis Bil. hydronephrosis Lt. hydronephrosis Bil. hydronephrosis Rt. normal, It. hydronephrosis Normal
0
0
0
0
Bil
Bil
L
L
L
Bil
0
0
L
L
L
0
0
0
Bil. hydronephrosis Bil. hydronephrosis Bil. hydronephrosis
0
0
0
Bil
Bil
Bil
0
0
0
20
125 0
Tabes dorsalis Tabes dorsalis Erb's spastic paralysis Meningomyelocele Meningomyelocele Meningomyelocele Meningomyelocele Meningomyelocele Meningomyelocele Meningocele
20 50 1000
Meningomyelocele Meningomyelocele
50
Meningomyelocele Landry-GuillainBarre syndrome N eurogenic bladder, ? cause Encephalomeningomyelitis
30 50
50 250 150
150
300 SP 160 100
430
R. G. BUNGE TABLE
2.-(Continued) BLADDER
NO.
PATIE~T
SEX
AGE IN
YEARS
DIAGNOSIS
RESIDUAL URINE
CYSTOGRAMS
IVP
(cc.)
--
24.
R. N.
M
23
25.
E. F.
F
19
26.
J.K.
F
21
27.
L. R.
F
54
28.
M.W.
F
63
29.
H.H.
M
51
30.
M.B.
F
35
31.
A. F.
M
62
32.
W.W.
F
62
33.
L. G.
M
10
34.
D.D.
M
19
35.
H.W.
M
39
36.
E. S.
M
39
O' 30' 60' - - - - -~
--~
-- --
Ascending myelitis Atonic bladder, ? cause Atonic bladder, ? cause A tonic bladder, ? cause Atonic bladder, ? cause Diabetes mellitus, atonic bladder Spinal cord tumor Multiple sclerosis Intrathecal alcohol Anterior poliomyelitis Anterior poliomyelitis Anterior poliomyelitis Herniated nucleus pulposus
SP
Normal
0
0
Poor detail
0
0
0
30
Normal
0
0
0
500
Normal
0
0
0
600
Normal
0
0
0
20
Normal
0
0
0
450
Normal
0
0
0
700
0
0
0
500
Bil. hydronephrosis Normal
0
0
0
150
Normal
0
0
0
Bil. hydronephrosis Bil. hydronephrosis Normal
0
0
0
0
0
0
0
0
0
0
50 30 SP
0
* Right nephrectomy for hydronephrosis.
The altered function of neurogenically disturbed bladders raises suspicions of altered ureteral physiology. Ureteral reflux is more apt to be present, and large residual bladder urines are not associated with reflux. This is in agreement with the findings of Bors and Comarr whose work we were not aware of at the time this paper was first written. 5 The detection of bilateral hydronephrosis does not allow prediction that ureteral reflux will be present. Ureteral reflux is more apt to occur in bladder neck obstruction of childhood, and there is one important point here: in children who have had their obstruction removed and persistently have pyuria, unsuspected delayed ureteral reflux may be the underlying cause. We have successfully attacked this problem by using Hutch's vesicoureteroplasty. 6 The altered state of the upper urinary tract during pregnancy suggested the possibility of ureteral reflux occurring under the conditions of this investigation (table 4). This was not found to be true; however, it would be highly interesting to employ delayed cystography in a group of "pyelitis of pregnancy" patients. 5 6
Bors, E. and Comarr, E.: J. Urol., 68: 691, 1952. Hutch, J. A.: J. Urol., 68: 457, 1952.
431
DELAYED CYSTOGRAMS TABLE
NO.
PATIENT
SEX
AGE IN YEARS
3. Bladder neck obstruction
DIAGNOSIS
BLADDER RESIDUAL URHrn
CYSTOGRAi\IS IVP
--
-
1.
D.N.
M
20 mo.
2.
P. P.
F
4
3.
J.B.
M
5
4.
w. s.
M
7
5.
G. T.
M
7
6.
M.M.
F
7
7.
J.B.
F
7
8.
R. S.
M
9
9.
W.H.
M
10
10.
N. T.
F
47
11.
U. C.
F
47
12.
E.H.
F
57
13.
J. H.
M
58
14.
A.G.
F
68
15.
F. B.
M
73
16.
H.P.
M
60
17.
J.M.
M
70
18.
F. 0.
M
70
Prostatic valves
225
Congenital bladder neck obstruction Congenital bladder neck obstruction Congenital bladder neck obstruction, postoperative Congenital bladder neck obstruction, postoperative Congenital bladder neck obstruction Congenital bladder neck obstruction, postoperative Congenital bladder neck obstruction Congenital bladder neck obstruction Bladder neck contracture Bladder neck contracture Bladder neck contracture Bladder neck contracture Bladder neck contracture Bladder neck contracture Benign prostatic hypertrophy Benign prostatic hypertrophy Benign prostatic hypertrophy
100
30'
O'
(cc.)
~-
.
-
60' ~
Bil. hydronephrosis Bil. hydronephrosis
0
0
0
0
Bil
Bil
0
Normal
0
Bil
Bil
5
Normal
L
L
Bil
25
Bil. hydronephrosis
0
0
0
75
Poor detail
0
L
0
Bil. hydronephrosis
Bil
Bil
Bil
Normal
0
0
0
250
Bil. hydronephrosis
Bil
Bil
Bil
450
Normal
0
0
0
100
Bil. hydronephrosis Bil. hydronephrosis Bil. hydronephrosis Normal
Bil
Bil
Bil
R
R
R
Bil
Bil
Bil
0
0
0
Normal
0
0
0
400
Not taken
0
0
0
175
Not taken
0
0
0
250
Normal
0
0
0
0
80
SP 100 100 60
TABLE
NO.
PATIENT
AGE IN
SEX
3.-(Continued) :BLADDER RESIDUAL URINE
DIAGNOSIS
YEARS
CYSTOGRAMS
IVP
O'
(cc.)
19.
M.P.
M
73
20.
R.B.
M
73
21.
R.B.
M
73
22.
C.H.
M
75
23.
F.W.
M
79
24. 25.
w. s. E.D.
M M
79 80
26.
J.E.
M
83
27.
T.R.
M
84
28.
H. L.
M
85
Benign prostatic hypertrophy Benign prostatic hypertrophy Benign prostatic hypertrophy Benign prostatic hypertrophy Benign prostatic hypertrophy Median bar Benign prostatic hypertrophy Benign prostatic hypertrophy Carcinoma of the prostate Benign prostatic hypertrophy TABLE
NO.
PATIENT
AGE
TERM
GRAVID
30'
60'
- -- - --
400
Not taken
0
0
0
CR
Not taken
0
0
0
500
Not taken
0
0
0
CR
Not.taken
0
0
0
450
Not taken
0
0
0
250 CR
Not taken Not taken
0 0
0 0
0 0
CR
Not taken
0
0
0
200
Not taken
0
0
0
CR
Normal
0
0
0
4. Pregnancy PARA
I
CYSTOGRAMS URINE
IVP
--~~160'
1. 2..
N. LaM. D.H.
16 17
Near full Full
1 1
0 0
0 0
0 0
0 0
Negative Negative
3. 4. 5.
S. B. H. S. V.B.
19 19 20
Full Full Full
2 1 2
1 0 1
0 0 0
0 0 0
0 0 0
5 wbc/hpf Negative Negative
6. 7.
P. B. D.G.
21 21
Full Full
2 4
1 3
0 0
0 0
0 0
Negative Negative
12. 13.
G.O'C. M.T. M.R. D.L. D.T. R.D.
22 22 22 23 23 23
Full Full Full Full Full Full
4 3 1 2 3 2
3 2 0 1 2 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
Negative Negative Negative Negative Negative Negative
14.
C. C.
25
Full
2
1
0
0
0
Negative
15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
M.D. L. P.
25 25 27 27 27 33 33 34 35 39
Full Full Full Full Full Full Full Full Full Full
2 4 7 4 5 7 8 5 9 7
1 2 6 3 4 6 7 4 6 6
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Negative 10 wbc/hpf Negative 3-5 wbc/hpf Negative Negative Negative 10 wbc/hpf Negative 6 wbc/hpf
8. 9. 10.
11.
v. s.
M.B. M.M. L. F. E.G. G. C. D. C. J.K.
432
Not taken Rt. hydronephrosis Not taken Not taken Bil. hydronephrosis Not taken Rt. hydronephrosis, lt. normal Not taken Not taken Not taken Not taken Not taken Rt. hydronephrosis, lt. normal Bil. hydronephrosis Not taken Not taken Not taken Not taken Not taken Not taken Not taken Not taken Not taken Not taken
433
DELAYED CYSTOGRAMS TABLE
5. Urological disease BLAD-
NO.
1.
PATIENT
0.
s.
SEX
M
~~ .,,&~ 52
0. S. 2.
W. S.
M
67
W. S. 3.
M.M.
F
3
4.
B. B.
F
5
5. 6.
M.P. M.G.
F F
5 9
7.
P. B.
F
9
8. 9.
J.C. B. C.
F F
9 22
10.
C. F.
M
23
11. 12.
M.A. G. P.
F F
27 29
13. 14.
J.M. M.D.
F F
31 34
15.
L. T.
F
33
16.
V. J.
F
39
DIAGl'WSIS
CYSTOGRAMS
DER RESIDUAL URI1\TE
IVP
O'
(cc.)
Bladder neck contracture With spinal anesthesia Trigonal scar gapping ureteral orifices With spinal anesthesia Recurrent urinary tract infection Unexplained chills, fever Pyuria Recurrent urinary tract infection Recurrent urinary tract infection Acute cystitis Congenital hydronephrosis and hydro-ureter Diabetes and chronic pyelonephritis Left renal stone Bilateral nephrolithiasis Recurrent cystitis Recurrent cystitis Scarred left ureteral orifice Diabetes, cystitis
I
30'
-1-
60' --
o Io
L
0
0
0
R
R
R
0
0
0
Bil. hydronephrosis Normal
0
Bil
L
0
R
R
0 20
Normal Normal
0 Bil
0 0
0 0
25
Normal
0
Bil
L
0 20
Normal Bil. hydronephrosis
0 Bil
0 Bil
0 Bil
0
Poor detail
0
0
0
0 0
Bil 0
Bil 0
0 0
0 0
0 0
0 0
0
Not taken Bil. hydronephrosis Normal Bil. hydronephrosis Normal
0
0
0
0
Rt. hydronephro-
0
0
0
Bil. hydronephrosis Normal Bil. hydronephrosis
0
0
0
0 0
0 0
0 0
Normal Poor detail
0 L
0 L
0 L
Bil. hydronephrosis Normal
0
0
0
0
0
0
50
50
20 0
0 0
Bil. hydronephrosis
Normal
SIS
17.
V. J.
F
39
Acute cystitis
0
18. 19.
A. S. H.H.
F M
46 51
0 0
20. 21.
L. E.
w. s.
F M
57 67
22.
B. G.
F
78
23.
Q. S.
F
63
Acute cystitis Bilateral ureterocele, postoperative Bladder stones Three months after resection of bladder tumor near left ureteral orifice Bilateral nephrolithiasis Stress incontinence
25 0
0 0
434
R. G. BUNGE TABLE
NO.
PATIENT
SEX
BLADDER DIAG~OSIS
RESIDUAL URINE
CYSTOGRA:MS IVP
(cc.)
-<
O'
1. 2. 3. 4.
N. C. M.B. M. S. M.Q.
M F M F
5. 6.
M.L. H. C. M.L.
F
1~
1 4 4 16
40 48 81
30'
60'
------
-- --
--
7.
iS ~ r5 ~
6. Miscellaneous group
Megacolon Megacolon Imperforate anus Wertheim operation, carcinoma of cervix Relaxed pelvic floor Right hemiparesis Relaxed pelvic floor
0 0 0 135
Not taken Normal Normal Normal
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0
Normal Not taken Normal
0 0 0
0 0 0
0 0 0
One noteworthy case occurred in the group of patients with urological disease (table 5). Case 7 was previously presented. She had a "normal urinary tract" until ureteral reflux was demonstrated by delayed cystography. An interesting follow-up period has occurred. The parents were informed that the child's difficulty arose from the ureteral reflux when the bladder became full. Arrangements were made to have the child void frequently while in school and at home. Fluids were restricted after the evening meal. On this regimen she has been free of upper urinary tract infection. I quote from a recent parental letter: "To date, she has had no recurrences, except for one recurrence in March which took place immediately after we arrived in Florida after a three-day trip. The same thing happened a year ago last winter when we went to Florida." There is little doubt that under the enforced delay in emptying the bladder, ureteral reflux occurred when the bladder capacity reached a critical level as indicated by the delayed cystograms. Dr. Charles M. Stewart informed me recently of a similar case under his care. These are two cases of "automotive pyelitis," which, of course, might well occur under any situation of delay in emptying the bladder. Recall that both these cases had "normal urinary tracts" until delayed cystography uncovered the reflux. Delayed cystography adds a new tool to dynamic clinical ureteral physiology, and great credit is due to Dr. Charles M. Stewart for bringing it to our attention.
Vol. 71, No. 4, April 1954
Printed in U.S.A.
FURTHER OBSERVATIONS WITH DELAYED CYSTOGRAMS
R. G. BUNGE From the Department of Urology, University Hospitals, State University of Iowa Iowa City, Iowa '
In a previous article,1 observations in children using the delayed cystographic x-ray method of Dr. Charles M. Stewart were reported. Stewart first noticed ureteral reflux in a patient whose immediate cystogram was normal. The delayed cystogram occurred as a result of a technician's error. 2 This present report is concerned with observations on a larger series of patients, but includes the prev10us cases. METHOD
Delayed cystograms were made by filling the bladder slowly by the catheter to comfort (90-120 ml. in adults, 30-90 ml. in children) with warm 10 per cent skiodan solution. No effort was made to overdistend the bladder. The catheter was withdrawn and an x-ray film was exposed immediately, giving the ordinary cystogram. The patient was told to retain the instilled solution. Ambulation was allowed, and after the elapse of 30 minutes another x-ray picture was taken, and again after 60 minutes had elapsed, following the instillation of skiodan. Excretory urograms were obtained in most of the cases either 24 hours before or after cystography to avoid erroneous interpretation. If the patient was too young to co-operate, the urethral catheter was left indwelling and clamped. Cystoscopic examinations were done in all cases, except normal children and pregnant females. RESULTS
Twenty-four normal children and adults were examined (table 1). These ranged in age from 9 months to 74 years. In one, an asymptomatic hydronephrosis was found. Ureteral reflux did not appear in any of the examinations. Thirty-six cases of neurogenic bladder were examined (table 2). Ureteral reflux appeared in 8 cases. In 1 case the reflux was not present on the immediate cystogram, but was apparent on the delayed film. In two cases a rather surprising finding was reflux on the immediate film, but none on subsequent delayed pictures. Patients with bladder residual urine over 450 ml. did not have ureteral reflux. Those with ureteral reflux had residual urines ranging from 30 to 250 ml. Twenty-eight cases of bladder neck obstruction ranging in age from 20 months to 85 years were examined (table 3). Ureteral reflux was detected mostly in the children's group (6 children, 3 adults). In three pediatric cases, reflux did not appear on the ordinary cystograms but was detected on subsequent delayed films. Twenty-four cases of full-term pregnant women were examined (table 4). Five had excretory urograms which revealed the typical upper urinary tract dilatation. Ureteral reflux was not detected in any case. Accepted for publication April 10, 1953. 1 Bunge, R. G.: J. Urol., 70: 729, 1953. 2 Stewart, C. M.: Personal communication. 427
428
R. G. BUNGE TABLE
PATIEKT
NO.
12. 13. 14. 15. 16. 17. 18.
M.T. L.M. A. B. E. M. C. C. M.B. R.R. T.H. M. S. M.Z. J. A. C. K. P. C. G. T. M.B. J.B. C. P. N.H.
19. 20. 21. 22. 23. 24.
W.B. Y. Z. C.D. J. G. J. H. L.A.
11.
AGE IN YEARS
CYSTOGRAMS
BLADDER DIAGNOSIS
IVP
RESIDUAL URINE (cc.)
~l~I~
-- ---
--
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
SEX
I. N orinal subjects
F F
M M M M M M M F
F M M M F M F F
9 mo. 4 5 6 7 7 8 8 8 9 9 12 12 13 14 15 18 19
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
subject subject subject subject subject subject subject subject subject subject subject subject subject subject subject subject subject subject
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Normal Not taken Normal Not taken Not taken Not taken Normal Not taken Not taken Normal Normal Not taken Not taken Normal Poor detail Not taken Not taken Lt. hydronephro-
Normal Normal Normal Normal Normal Normal
subject subject subject subject subject subject
0 0 0 0 0 0
Not taken Normal Normal Normal Normal Normal
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
SlS
M F
19 24
F M F F
31 31 40 74
KEY: 0-No ureteral reflux; L-Left ureteral reflux; R-Right ureteral reflux; BilBilateral ureteral reflux; SP-Suprapubic tube; CR-Complete retention; 0 1-Immediate cystogram; 30 1-Cystogram at 30 minute interval; 60 1-Cystogram at 60 minute interval.
Twenty-three patients with urological disease in whom ureteral reflux would not ordinarily be clinically suspected were examined (table 5). Five adults had ureteral reflux; one was picked up by the delayed technique. Two adult cases with reflux failed to show it under spinal anesthesia. Four children with recurrent urinary infections were shown to have ureteral reflux. In three it was not revealed by the ordinary cystogram. Seven cases, classified as a miscellaneous group, were examined (table 6). The possibility of ureteral reflux was entertained but not substantiated. DISCUSSION
Ureteral reflux is rare in normal children3 and adults, 4 but it is more apt to occur in childhood. This suggests the possibility of maturation of ureteral physiology, since reflux is present normally in lower animals, such as the rabbit. 3
4
Campbell, M. F.: Pediatric Urology, New York: Macmillan Co., 1937, vol. 1, p. 70. Sampson, J. A., Bull. Johns Hopkins Hosp., 14: 334, 1903.
429
DELAYED CYSTOGRAMS TABLE
2. Neurogenic bladders BLADDER
NO.
PATIENT
SEX
AGE IN YEARS
DIAGNOSIS
RESIDUAL URINE
CYSTOGRAMS
lVP
(cc.)
O'
1.
P.R.
M
12
2.
M.G.
M
17
3.
P. T.
M
18
4.
H.B.
F
23
5.
M.W.
F
46
6.
C. S.
M
54
7.
E.E.
F
4
8. 9. 10.
H. C. B.R. R. C.
M M F
62 67 42
11.
S. L.
M
3
12.
D. C.
M
3
13.
C. E.
F
4
14.
G.L.
F
8
15.
L. L.
F
8
16.
J. H.
F
9
F
11
17.* M.C.
30'
60'
---- --
--
18.
J. R.
F
12
19.
P. B.
F
15
20.
D.K.
M
25
21.
W.N.
M
4
22.
K.H.
F
6
23.
D.D.
M
6
Paraplegic 4 months Paraplegic 3 years Paraplegic 6 months Paraplegic 2 years Paraplegic ? years Paraplegic 4 years Transverse myelopathy L-1
Poor detail
0
0
0
180
Normal
R
R
R
?
Normal
R
0
0
Bil. hydronephrosis Poor detail
0
0
0
0
0
0
100
Poor detail
0
0
0
150
Rt. indeterminate, It. normal Normal Poor detail Normal
0
0
0
0 0 0
0 0 0
0 0 0
Rt. normal, lt. L hydronephrosis Normal 0
L
L
0
0
0
Normal
0
0
0
110
Normal
0
0
0
Bil. hydronephrosis Bil. hydronephrosis Lt. hydronephrosis Bil. hydronephrosis Rt. normal, It. hydronephrosis Normal
0
0
0
0
Bil
Bil
L
L
L
Bil
0
0
L
L
L
0
0
0
Bil. hydronephrosis Bil. hydronephrosis Bil. hydronephrosis
0
0
0
Bil
Bil
Bil
0
0
0
20
125 0
Tabes dorsalis Tabes dorsalis Erb's spastic paralysis Meningomyelocele Meningomyelocele Meningomyelocele Meningomyelocele Meningomyelocele Meningomyelocele Meningocele
20 50 1000
Meningomyelocele Meningomyelocele
50
Meningomyelocele Landry-GuillainBarre syndrome N eurogenic bladder, ? cause Encephalomeningomyelitis
30 50
50 250 150
150
300 SP 160 100
430
R. G. BUNGE TABLE
2.-(Continued) BLADDER
NO.
PATIE~T
SEX
AGE IN
YEARS
DIAGNOSIS
RESIDUAL URINE
CYSTOGRAMS
IVP
(cc.)
--
24.
R. N.
M
23
25.
E. F.
F
19
26.
J.K.
F
21
27.
L. R.
F
54
28.
M.W.
F
63
29.
H.H.
M
51
30.
M.B.
F
35
31.
A. F.
M
62
32.
W.W.
F
62
33.
L. G.
M
10
34.
D.D.
M
19
35.
H.W.
M
39
36.
E. S.
M
39
O' 30' 60' - - - - -~
--~
-- --
Ascending myelitis Atonic bladder, ? cause Atonic bladder, ? cause A tonic bladder, ? cause Atonic bladder, ? cause Diabetes mellitus, atonic bladder Spinal cord tumor Multiple sclerosis Intrathecal alcohol Anterior poliomyelitis Anterior poliomyelitis Anterior poliomyelitis Herniated nucleus pulposus
SP
Normal
0
0
Poor detail
0
0
0
30
Normal
0
0
0
500
Normal
0
0
0
600
Normal
0
0
0
20
Normal
0
0
0
450
Normal
0
0
0
700
0
0
0
500
Bil. hydronephrosis Normal
0
0
0
150
Normal
0
0
0
Bil. hydronephrosis Bil. hydronephrosis Normal
0
0
0
0
0
0
0
0
0
0
50 30 SP
0
* Right nephrectomy for hydronephrosis.
The altered function of neurogenically disturbed bladders raises suspicions of altered ureteral physiology. Ureteral reflux is more apt to be present, and large residual bladder urines are not associated with reflux. This is in agreement with the findings of Bors and Comarr whose work we were not aware of at the time this paper was first written. 5 The detection of bilateral hydronephrosis does not allow prediction that ureteral reflux will be present. Ureteral reflux is more apt to occur in bladder neck obstruction of childhood, and there is one important point here: in children who have had their obstruction removed and persistently have pyuria, unsuspected delayed ureteral reflux may be the underlying cause. We have successfully attacked this problem by using Hutch's vesicoureteroplasty. 6 The altered state of the upper urinary tract during pregnancy suggested the possibility of ureteral reflux occurring under the conditions of this investigation (table 4). This was not found to be true; however, it would be highly interesting to employ delayed cystography in a group of "pyelitis of pregnancy" patients. 5 6
Bors, E. and Comarr, E.: J. Urol., 68: 691, 1952. Hutch, J. A.: J. Urol., 68: 457, 1952.
431
DELAYED CYSTOGRAMS TABLE
NO.
PATIENT
SEX
AGE IN YEARS
3. Bladder neck obstruction
DIAGNOSIS
BLADDER RESIDUAL URHrn
CYSTOGRAi\IS IVP
--
-
1.
D.N.
M
20 mo.
2.
P. P.
F
4
3.
J.B.
M
5
4.
w. s.
M
7
5.
G. T.
M
7
6.
M.M.
F
7
7.
J.B.
F
7
8.
R. S.
M
9
9.
W.H.
M
10
10.
N. T.
F
47
11.
U. C.
F
47
12.
E.H.
F
57
13.
J. H.
M
58
14.
A.G.
F
68
15.
F. B.
M
73
16.
H.P.
M
60
17.
J.M.
M
70
18.
F. 0.
M
70
Prostatic valves
225
Congenital bladder neck obstruction Congenital bladder neck obstruction Congenital bladder neck obstruction, postoperative Congenital bladder neck obstruction, postoperative Congenital bladder neck obstruction Congenital bladder neck obstruction, postoperative Congenital bladder neck obstruction Congenital bladder neck obstruction Bladder neck contracture Bladder neck contracture Bladder neck contracture Bladder neck contracture Bladder neck contracture Bladder neck contracture Benign prostatic hypertrophy Benign prostatic hypertrophy Benign prostatic hypertrophy
100
30'
O'
(cc.)
~-
.
-
60' ~
Bil. hydronephrosis Bil. hydronephrosis
0
0
0
0
Bil
Bil
0
Normal
0
Bil
Bil
5
Normal
L
L
Bil
25
Bil. hydronephrosis
0
0
0
75
Poor detail
0
L
0
Bil. hydronephrosis
Bil
Bil
Bil
Normal
0
0
0
250
Bil. hydronephrosis
Bil
Bil
Bil
450
Normal
0
0
0
100
Bil. hydronephrosis Bil. hydronephrosis Bil. hydronephrosis Normal
Bil
Bil
Bil
R
R
R
Bil
Bil
Bil
0
0
0
Normal
0
0
0
400
Not taken
0
0
0
175
Not taken
0
0
0
250
Normal
0
0
0
0
80
SP 100 100 60
TABLE
NO.
PATIENT
AGE IN
SEX
3.-(Continued) :BLADDER RESIDUAL URINE
DIAGNOSIS
YEARS
CYSTOGRAMS
IVP
O'
(cc.)
19.
M.P.
M
73
20.
R.B.
M
73
21.
R.B.
M
73
22.
C.H.
M
75
23.
F.W.
M
79
24. 25.
w. s. E.D.
M M
79 80
26.
J.E.
M
83
27.
T.R.
M
84
28.
H. L.
M
85
Benign prostatic hypertrophy Benign prostatic hypertrophy Benign prostatic hypertrophy Benign prostatic hypertrophy Benign prostatic hypertrophy Median bar Benign prostatic hypertrophy Benign prostatic hypertrophy Carcinoma of the prostate Benign prostatic hypertrophy TABLE
NO.
PATIENT
AGE
TERM
GRAVID
30'
60'
- -- - --
400
Not taken
0
0
0
CR
Not taken
0
0
0
500
Not taken
0
0
0
CR
Not.taken
0
0
0
450
Not taken
0
0
0
250 CR
Not taken Not taken
0 0
0 0
0 0
CR
Not taken
0
0
0
200
Not taken
0
0
0
CR
Normal
0
0
0
4. Pregnancy PARA
I
CYSTOGRAMS URINE
IVP
--~~160'
1. 2..
N. LaM. D.H.
16 17
Near full Full
1 1
0 0
0 0
0 0
0 0
Negative Negative
3. 4. 5.
S. B. H. S. V.B.
19 19 20
Full Full Full
2 1 2
1 0 1
0 0 0
0 0 0
0 0 0
5 wbc/hpf Negative Negative
6. 7.
P. B. D.G.
21 21
Full Full
2 4
1 3
0 0
0 0
0 0
Negative Negative
12. 13.
G.O'C. M.T. M.R. D.L. D.T. R.D.
22 22 22 23 23 23
Full Full Full Full Full Full
4 3 1 2 3 2
3 2 0 1 2 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
Negative Negative Negative Negative Negative Negative
14.
C. C.
25
Full
2
1
0
0
0
Negative
15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
M.D. L. P.
25 25 27 27 27 33 33 34 35 39
Full Full Full Full Full Full Full Full Full Full
2 4 7 4 5 7 8 5 9 7
1 2 6 3 4 6 7 4 6 6
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Negative 10 wbc/hpf Negative 3-5 wbc/hpf Negative Negative Negative 10 wbc/hpf Negative 6 wbc/hpf
8. 9. 10.
11.
v. s.
M.B. M.M. L. F. E.G. G. C. D. C. J.K.
432
Not taken Rt. hydronephrosis Not taken Not taken Bil. hydronephrosis Not taken Rt. hydronephrosis, lt. normal Not taken Not taken Not taken Not taken Not taken Rt. hydronephrosis, lt. normal Bil. hydronephrosis Not taken Not taken Not taken Not taken Not taken Not taken Not taken Not taken Not taken Not taken
433
DELAYED CYSTOGRAMS TABLE
5. Urological disease BLAD-
NO.
1.
PATIENT
0.
s.
SEX
M
~~ .,,&~ 52
0. S. 2.
W. S.
M
67
W. S. 3.
M.M.
F
3
4.
B. B.
F
5
5. 6.
M.P. M.G.
F F
5 9
7.
P. B.
F
9
8. 9.
J.C. B. C.
F F
9 22
10.
C. F.
M
23
11. 12.
M.A. G. P.
F F
27 29
13. 14.
J.M. M.D.
F F
31 34
15.
L. T.
F
33
16.
V. J.
F
39
DIAGl'WSIS
CYSTOGRAMS
DER RESIDUAL URI1\TE
IVP
O'
(cc.)
Bladder neck contracture With spinal anesthesia Trigonal scar gapping ureteral orifices With spinal anesthesia Recurrent urinary tract infection Unexplained chills, fever Pyuria Recurrent urinary tract infection Recurrent urinary tract infection Acute cystitis Congenital hydronephrosis and hydro-ureter Diabetes and chronic pyelonephritis Left renal stone Bilateral nephrolithiasis Recurrent cystitis Recurrent cystitis Scarred left ureteral orifice Diabetes, cystitis
I
30'
-1-
60' --
o Io
L
0
0
0
R
R
R
0
0
0
Bil. hydronephrosis Normal
0
Bil
L
0
R
R
0 20
Normal Normal
0 Bil
0 0
0 0
25
Normal
0
Bil
L
0 20
Normal Bil. hydronephrosis
0 Bil
0 Bil
0 Bil
0
Poor detail
0
0
0
0 0
Bil 0
Bil 0
0 0
0 0
0 0
0 0
0
Not taken Bil. hydronephrosis Normal Bil. hydronephrosis Normal
0
0
0
0
Rt. hydronephro-
0
0
0
Bil. hydronephrosis Normal Bil. hydronephrosis
0
0
0
0 0
0 0
0 0
Normal Poor detail
0 L
0 L
0 L
Bil. hydronephrosis Normal
0
0
0
0
0
0
50
50
20 0
0 0
Bil. hydronephrosis
Normal
SIS
17.
V. J.
F
39
Acute cystitis
0
18. 19.
A. S. H.H.
F M
46 51
0 0
20. 21.
L. E.
w. s.
F M
57 67
22.
B. G.
F
78
23.
Q. S.
F
63
Acute cystitis Bilateral ureterocele, postoperative Bladder stones Three months after resection of bladder tumor near left ureteral orifice Bilateral nephrolithiasis Stress incontinence
25 0
0 0
434
R. G. BUNGE TABLE
NO.
PATIENT
SEX
BLADDER DIAG~OSIS
RESIDUAL URINE
CYSTOGRA:MS IVP
(cc.)
-<
O'
1. 2. 3. 4.
N. C. M.B. M. S. M.Q.
M F M F
5. 6.
M.L. H. C. M.L.
F
1~
1 4 4 16
40 48 81
30'
60'
------
-- --
--
7.
iS ~ r5 ~
6. Miscellaneous group
Megacolon Megacolon Imperforate anus Wertheim operation, carcinoma of cervix Relaxed pelvic floor Right hemiparesis Relaxed pelvic floor
0 0 0 135
Not taken Normal Normal Normal
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0
Normal Not taken Normal
0 0 0
0 0 0
0 0 0
One noteworthy case occurred in the group of patients with urological disease (table 5). Case 7 was previously presented. She had a "normal urinary tract" until ureteral reflux was demonstrated by delayed cystography. An interesting follow-up period has occurred. The parents were informed that the child's difficulty arose from the ureteral reflux when the bladder became full. Arrangements were made to have the child void frequently while in school and at home. Fluids were restricted after the evening meal. On this regimen she has been free of upper urinary tract infection. I quote from a recent parental letter: "To date, she has had no recurrences, except for one recurrence in March which took place immediately after we arrived in Florida after a three-day trip. The same thing happened a year ago last winter when we went to Florida." There is little doubt that under the enforced delay in emptying the bladder, ureteral reflux occurred when the bladder capacity reached a critical level as indicated by the delayed cystograms. Dr. Charles M. Stewart informed me recently of a similar case under his care. These are two cases of "automotive pyelitis," which, of course, might well occur under any situation of delay in emptying the bladder. Recall that both these cases had "normal urinary tracts" until delayed cystography uncovered the reflux. Delayed cystography adds a new tool to dynamic clinical ureteral physiology, and great credit is due to Dr. Charles M. Stewart for bringing it to our attention.