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Hernia into Female Bladder
HERNIA INTO FEMALE BLADDER FRANK J. CUSHMAN Lansing, Michigan
That this condition has occurred before, there is no doubt; but that it has been previously reported, I have not been able to confirm. The object in reporting such a case here is not to offer a method of surgical repair, but rather to sound a warning against the indiscriminate use of fulguration or any other puncturing method employed to treat any anomaly resembling a cyst in the bladder, without first being reasonably certain of the exact nature of the pathology. The fact that I nearly committed such an error prompts me to record the case. A woman, forty-six years of age, was referred for study on account of constant, painless hematuria of three years' duration. Her general condition was good, and aside from a past history of having had a hysterectomy for fibromata of the uterus six years previously, all other factors of the history are irrelevant. A review of the operator's record does not reveal anything unusual about the pathology or the procedure. The positive laboratory findings at the time I saw her were: erythrocytes, 4,100,000; hemoglobin, 70 per cent. The urine was too bloody to expect an accurate kidney function estimation, and of course contained albumen. The results of the other usual laboratory tests were normal. A flat plate did not demonstrate the presence of calculi. A cystoscopy disclosed the blood to be coming from the right side. A pyelogram of the right side was normal. After thorough study of this side during the following cystoscopies, I had to be satisfied with a diagnosis of right hematuria of an idiopathic nature. Perhaps investigation now would disclose a more definite source. The condition on the left side is that which I take the liberty to report, and is as follows. Protruding into the bladder in the region of the left angle of the trigone is a globular mass about 5.5 cm. in diameter. About midway of its anterior-posterior circumference and medially is the orifice of the 107
108
FRANK J . CUSHMAN
left ureter, from which clear urine can be seen to spurt. In the center of the mass is a small umbilicated area, in appearance resembling an atresiated ureteral orifice. The mass dents when the catheter is pressed against it, and upon distention of the bladder with fluid, the mass disappears through the bladder wall leaving a crater in its wake. The border of the crater is not smooth like the orifice of a diverticulum, and is about 2 cm. in diameter. Left pyelogram demonstrates a moderate hydronephrosis. T entative diagnosis : Ureterocele of a duplicated left ureter with atresia of it orifice. Planned to fulgurate through the umbilicated area at the next cystoscopy. At the second cystoscopy a colleague was invited to view the mass. His reply was, "What else could it be but a ureterocele." However, there was enough doubt in both our minds to caution against any procedure at this time. The right pelvis was given a topical treatment and the cystoscopy concluded. At the third cystoscopy the abdomen was greatly distended, but the patient was not so uncomfortable, but that she could stand the procedure. A glance at the mass, before passing the catheter up the right side, disclosed coarse peristaltic waves running through the mass, and, contrary to former occasions, the mass failed to become obliterated even when the intravesical pressure was increased far beyond the point used during the previous cystoscopies. This was the first indication that the protruding mass was of intestinal origin. The findings of the fourth cystoscopy were a repetition of the first and second, and those of the fifth cystoscopy a repetition of the third. With this data at hand, I feel that a diagnosis of hernia into the bladder is a justifiable one; also a profound sense of relief that my first impulse to puncture the protrusion was never carried out. No treatment was advised as the condition was painless, and the only object in interference would be to forestall a possible strangulation. This reason would be laudable if the probability of such an occurrence were not so remote. I believe the hernial opening in the bladder would have a tendency to stretch sufficiently to prevent strangulation. Of course the exact relation between the intestines and the bladder can not be discerned without a laparotomy, but apparently there is a close adhesion between these organs, as the protrusion was present at all cystoscopies, and I feel certain that it is present at all times.
In conclusion my only remark is, that given a similar condition
HERNIA INTO FEMALE BLADDER
109
in this or any other part of the bladder, the diagnosis would depend chiefly on the presence of the peristaltic waves of the herniated intestine. 221 North Capitol Avenue, Lansing, Mich.
That this condition has occurred before, there is no doubt; but that it has been previously reported, I have not been able to confirm. The object in reporting such a case here is not to offer a method of surgical repair, but rather to sound a warning against the indiscriminate use of fulguration or any other puncturing method employed to treat any anomaly resembling a cyst in the bladder, without first being reasonably certain of the exact nature of the pathology. The fact that I nearly committed such an error prompts me to record the case. A woman, forty-six years of age, was referred for study on account of constant, painless hematuria of three years' duration. Her general condition was good, and aside from a past history of having had a hysterectomy for fibromata of the uterus six years previously, all other factors of the history are irrelevant. A review of the operator's record does not reveal anything unusual about the pathology or the procedure. The positive laboratory findings at the time I saw her were: erythrocytes, 4,100,000; hemoglobin, 70 per cent. The urine was too bloody to expect an accurate kidney function estimation, and of course contained albumen. The results of the other usual laboratory tests were normal. A flat plate did not demonstrate the presence of calculi. A cystoscopy disclosed the blood to be coming from the right side. A pyelogram of the right side was normal. After thorough study of this side during the following cystoscopies, I had to be satisfied with a diagnosis of right hematuria of an idiopathic nature. Perhaps investigation now would disclose a more definite source. The condition on the left side is that which I take the liberty to report, and is as follows. Protruding into the bladder in the region of the left angle of the trigone is a globular mass about 5.5 cm. in diameter. About midway of its anterior-posterior circumference and medially is the orifice of the 107
108
FRANK J . CUSHMAN
left ureter, from which clear urine can be seen to spurt. In the center of the mass is a small umbilicated area, in appearance resembling an atresiated ureteral orifice. The mass dents when the catheter is pressed against it, and upon distention of the bladder with fluid, the mass disappears through the bladder wall leaving a crater in its wake. The border of the crater is not smooth like the orifice of a diverticulum, and is about 2 cm. in diameter. Left pyelogram demonstrates a moderate hydronephrosis. T entative diagnosis : Ureterocele of a duplicated left ureter with atresia of it orifice. Planned to fulgurate through the umbilicated area at the next cystoscopy. At the second cystoscopy a colleague was invited to view the mass. His reply was, "What else could it be but a ureterocele." However, there was enough doubt in both our minds to caution against any procedure at this time. The right pelvis was given a topical treatment and the cystoscopy concluded. At the third cystoscopy the abdomen was greatly distended, but the patient was not so uncomfortable, but that she could stand the procedure. A glance at the mass, before passing the catheter up the right side, disclosed coarse peristaltic waves running through the mass, and, contrary to former occasions, the mass failed to become obliterated even when the intravesical pressure was increased far beyond the point used during the previous cystoscopies. This was the first indication that the protruding mass was of intestinal origin. The findings of the fourth cystoscopy were a repetition of the first and second, and those of the fifth cystoscopy a repetition of the third. With this data at hand, I feel that a diagnosis of hernia into the bladder is a justifiable one; also a profound sense of relief that my first impulse to puncture the protrusion was never carried out. No treatment was advised as the condition was painless, and the only object in interference would be to forestall a possible strangulation. This reason would be laudable if the probability of such an occurrence were not so remote. I believe the hernial opening in the bladder would have a tendency to stretch sufficiently to prevent strangulation. Of course the exact relation between the intestines and the bladder can not be discerned without a laparotomy, but apparently there is a close adhesion between these organs, as the protrusion was present at all cystoscopies, and I feel certain that it is present at all times.
In conclusion my only remark is, that given a similar condition
HERNIA INTO FEMALE BLADDER
109
in this or any other part of the bladder, the diagnosis would depend chiefly on the presence of the peristaltic waves of the herniated intestine. 221 North Capitol Avenue, Lansing, Mich.