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Leech in urinary bladder causing hematuria
Journal of Pediatric Urology (2008) 4, 70e73
Leech in urinary bladder causing hematuria Shadrul Alam a,*, Mrigen Kumar Das Choudhary a, Kabirul Islam b a b
Department of Paediatric Surgery, Sylhet MAG Osmani Medical College, Bangladesh Department of Paediatric Surgery, Dhaka Medical College, Bangladesh
Received 15 October 2004; accepted 15 February 2007 Available online 22 May 2007
KEYWORDS Leech in urinary bladder; Hematuria; Treatment with normal saline
Abstract Objective: To estimate efficacy of normal saline in the management of hematuria caused by accidental entry of a leech per urethra into the urinary bladder. Methods: An intervention study was carried out in the Department of Pediatric Surgery of Sylhet MAG Osmani Medical College between January 1998 and December 2003. A total of 43 boys (mean age 8 years, SD 2.6) were enrolled. In all cases, a leech had entered the urinary bladder through the urethra causing hematuria. All patients were equipped with a self-retaining Foley catheter. They were managed by infusing 50 ml of normal saline into the urinary bladder through the catheter that was then clamped for 3 h. Results: After removing the catheter, in all cases the whole leech was spontaneously expelled intact, dead or alive, within 2e24 h during the subsequent act of micturition. Hematuria gradually diminished to a clear flow within the next 6 h in 27 cases, 12 h in 14 cases and 24 h in two cases. All patients were followed up for 2 weeks, and none developed recurrent hematuria. Conclusion: Catheterization and irrigation of the urinary bladder with normal saline is a relatively simple, safe and inexpensive method of removing the leech and controlling hematuria. ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction The class Hirudinea comprises leeches, which are perhaps the most specialized annelids. About 300 species of leeches are known to occur in the tropical and temperate parts of
* Corresponding author. 86/2 (4th Floor), Nijum Residential Area, Jigatola, Dhanmondhi, Dhaka e 1209, Bangladesh. Tel.: þ88 01711 364377; fax: þ88 01911 528300. E-mail addresses: [email protected], [email protected] (S. Alam).
the globe. The common aquatic species are Hirudinaria granulose, Hirudinaria viridis, Hirudinaria javanica and Hirudinaria manilensis. The species Hemadipsa zeylonica is a land leech. All these species are very common in Bangladesh, especially in the rural areas where ponds, lakes, tanks, swamps and sluggish streams are numerous. The leech is a sanguinivorous hermaphrodite. The body is soft, elongated, vermiform, dorsoventrally flattened, bilaterally symmetrical and segmented, and well suited for a parasitic life. Each end bears a hollow muscular organ, the anterior and posterior suckers. Both suckers serve as a organs of locomotion and also provide firm adhesion to
1477-5131/$30 ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2007.02.004
Leech in urinary bladder causing hematuria
71
the host’s body at the time of feeding. The leech either swims by vertical undulations, grips objects (weeds, logs, stones) with its suckers, or moves by looping. It has a bloodsucking (sanguivorous) habit, feeding on the blood of fish, frogs, cattle and other domestic animals, and men visiting the water source where it lives. This parasite commonly infests the body surface of the host to suck blood, and has the habit of entering into the anatomical orifices such as the urethra, anus, vagina, nose and throat [1]. Aquatic leeches will even crawl up the external opening of the male and female sex organs and attach inside the urethra of a male or the vagina of a female, causing serious loss of blood. Hemorrhage from the bite area tends to be prolonged because the leech secretes a powerful anticoagulant (hirudin). In the case of the urinary bladder, hemostasis is further prevented due to steady urinary flow; retention of urine due to clot formation has also been reported [2]. The objective of this study was to estimate the efficacy of normal saline in the management of hematuria due to accidental entry of a leech per urethra into the urinary bladder.
Materials and methods This intervention study was carried out at the Department of Pediatric Surgery of Sylhet MAG Osmani Medical College, Sylhet, Bangladesh. A total of 45 boys, in whom a leech had entered accidentally into the urinary bladder through the urethra, were studied between January 1998 and December 2003. They had hematuria as well as dysuria. Two of these boys seemed to have associated pneumonia, which was treated with ampicillin and cloxacillin, and were excluded from our study. Diagnosis of leech in urinary bladder was supported by finding an intravesical, still or moving, linear, echogenic foreign body on ultrasonography. All 43 patients were equipped with a Foley catheter and treated by infusing 50 ml of normal saline into the urinary bladder. The saline was kept in the bladder for 2e3 h, and then released. The catheter was removed, followed by a waiting period of 2e12 h for expulsion of the leech. All patients were followed up for 14 days for recurrence of bleeding or any other morbidity. Diagnosis was confirmed in all cases by inspection of the leech after expulsion.
which 36/43 were mobile (Fig. 2). Regardless of the size of the leech, the whole leech, dead or alive, was spontaneously expelled intact in all cases during the next act of micturition after removing the catheter (Fig. 3). The majority of cases required 3e12 h for expulsion of the leech after application of normal saline (Table 2). Hematuria gradually diminished to a clear flow within the next 6 h in 58% of cases, and by 24 h in the rest (Table 3). All patients were followed up for 2 weeks, and none of them developed recurrent hematuria. Subsequently, parents were instructed to return to our outpatient department if necessary. To date, no complication or morbidity has been observed in any patient.
Discussion Medically important leeches are annelid worms that attach to their hosts with chitinous cutting jaws and draw blood using muscular suckers. The body surface is slippery and difficult to grasp because of a wide distribution of slime glands. A feeding leech firmly adheres to the body of its victim by its posterior sucker, and then the cup-shaped anterior sucker (Fig. 4) is suitably placed on a soft site of the host’s skin. The three blade-like and teeth-bearing jaws protrude through the mouth, moving like saws, and make the characteristic triradiate or ‘Y’ shaped painless incision in the skin of the host, which is anesthetized by a substance of unknown origin. Ultimately, the blood coming out from the wound is sucked into the pharynx by alternate contraction and expansion of the pharyngeal muscles. A leech can suck at a single meal several times its own weight in blood, which lasts the animal for several months or a year [3]. Healing of the wound is slow, and bacterial infections are not uncommon. Ubiquitous aquatic leeches that parasitize fish, frogs and turtles readily attach to the skin of human beings and eagerly suck blood. Several species of aquatic leeches in Africa, Asia and southern Europe can enter through the mouth, nose and genitourinary tract, and attach to mucosal surfaces at sites as deep as the esophagus and trachea. In
Results The age of the patients ranged from 4 to 16 years (mean 8 years, SD 2.6). The commonest age group was 7e10 years (Table 1). All 43 patients presented with hematuria (Fig. 1). Ultrasonography showed an intravesical foreign body, of
Table 1
Age distribution (n Z 43)
Age (years)
n
%
4e7 7e10 10e13 13e16
9 27 5 2
21 63 12 5
Figure 1 Hematuria caused by leech that entered into the urinary bladder through urethra.
72
S. Alam et al.
Figure 2
Ultrasonography showed an intravesical mobile foreign body.
the present study, there were 43 boys with leech infestation, of whom 63% were in the 7e10-year age group. The exact cause of increased leech infestation at this age is not known, but it may be due to the habit of children at this age of learning to swim, bathing or playing in ponds, lakes, tanks, swamps and sluggish streams in the rural areas of our country. Hematuria, hemoptysis, hematemesis, epistaxis and rectal bleeding may take place depending on the site of infestation [4]. Bleeding may be intense. Even accidental swallowing of a leech with drinking water has been reported. A leech shows a preference for mucous membranes, probably due to its attraction to moist and humid areas. Aquatic leeches will easily attach to the external opening of the urethra of a male or the vagina of a female. In our study, the leeches used the urethral opening of the boys that entered ultimately into the urinary bladder, and the only complaint was hematuria in all cases, which is similar to the series of Saha and Saha [5]. The leech looses body water in a hypertonic peripheral environment, and application of common salt to its body
surface to dislodge it is usual practice. Removal from surface areas can be assisted by application of salt, alcohol, vinegar or a flame to the leech [6]. Internally attached leeches may detach on exposure to gurgled saline or may be removed by forceps. Various ways of removing a leech from the urinary bladder have been described, such as suprapubic exploration and cystoscopic removal. In our series, a relatively simple method of catheterization and normal saline infusion resulted in control of symptoms, and the intact leech was expelled during the subsequent uneventful micturition after catheter removal. Hematuria also stopped spontaneously within 3e6 h of normal saline infusion, which is comparable to the findings reported in other studies [1,5]. In conclusion, we recommend normal saline infusion of the urinary bladder for treatment of accidental entry of a leech through the urethra. This is simple, safe, inexpensive, and can be practiced by medical personnel anywhere, rural or urban.
Table 2 Time required for expulsion of leeches after application of normal saline (n Z 43) Time (h)
n
%
3e6 6e12 12e18 18e24
16 21 4 2
37 49 9 5
Table 3
Figure 3 Whole leech was expelled intact during the subsequent act of micturition.
Hematuria clearance time (n Z 43)
Time (h)
n
%
3e6 6e12 12e18 18e24
25 15 2 1
58 35 5 2
Leech in urinary bladder causing hematuria
Figure 4
73
Whole leech showing anterior and posterior suckers.
Acknowledgement Prof. Parimal Deb, a renowned zoologist of Bangladesh, came forward with his knowledge, which was of enormous help for this publication. Our heartfelt thanks to him.
References [1] Ghosh D, Saha S, Das S, Samanta N, Konar H. Leech in urinary bladder. J Indian Assoc Pediatr Surg 2002;7:46e9.
[2] Hamid MS, Mohd Nor GR. Severe urological complications of leech bite in tropics. Br J Urol 1996;77:164e5. [3] James HM, Andrew S. Ectoparasite infestations, arthropod bites and stings. In: Braunwald E, Fauci AS, Kasper DS, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s principles of internal medicine. 15th ed. Boston: McGraw-Hill; 2003. p. 2622e9. [4] Singh M, Naim AF. Respiratory obstruction and haematemesis due to leech. Lancet 1979;22:1374. [5] Saha S, Saha I. Unusual foreign body causing bleeding per urethra. J Indian Med Assoc 1977;69:286e7. [6] Adams LA. The emergency management of a medicinal leech bite. Ann Emerg Med 1989;18:316e9.
Leech in urinary bladder causing hematuria Shadrul Alam a,*, Mrigen Kumar Das Choudhary a, Kabirul Islam b a b
Department of Paediatric Surgery, Sylhet MAG Osmani Medical College, Bangladesh Department of Paediatric Surgery, Dhaka Medical College, Bangladesh
Received 15 October 2004; accepted 15 February 2007 Available online 22 May 2007
KEYWORDS Leech in urinary bladder; Hematuria; Treatment with normal saline
Abstract Objective: To estimate efficacy of normal saline in the management of hematuria caused by accidental entry of a leech per urethra into the urinary bladder. Methods: An intervention study was carried out in the Department of Pediatric Surgery of Sylhet MAG Osmani Medical College between January 1998 and December 2003. A total of 43 boys (mean age 8 years, SD 2.6) were enrolled. In all cases, a leech had entered the urinary bladder through the urethra causing hematuria. All patients were equipped with a self-retaining Foley catheter. They were managed by infusing 50 ml of normal saline into the urinary bladder through the catheter that was then clamped for 3 h. Results: After removing the catheter, in all cases the whole leech was spontaneously expelled intact, dead or alive, within 2e24 h during the subsequent act of micturition. Hematuria gradually diminished to a clear flow within the next 6 h in 27 cases, 12 h in 14 cases and 24 h in two cases. All patients were followed up for 2 weeks, and none developed recurrent hematuria. Conclusion: Catheterization and irrigation of the urinary bladder with normal saline is a relatively simple, safe and inexpensive method of removing the leech and controlling hematuria. ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction The class Hirudinea comprises leeches, which are perhaps the most specialized annelids. About 300 species of leeches are known to occur in the tropical and temperate parts of
* Corresponding author. 86/2 (4th Floor), Nijum Residential Area, Jigatola, Dhanmondhi, Dhaka e 1209, Bangladesh. Tel.: þ88 01711 364377; fax: þ88 01911 528300. E-mail addresses: [email protected], [email protected] (S. Alam).
the globe. The common aquatic species are Hirudinaria granulose, Hirudinaria viridis, Hirudinaria javanica and Hirudinaria manilensis. The species Hemadipsa zeylonica is a land leech. All these species are very common in Bangladesh, especially in the rural areas where ponds, lakes, tanks, swamps and sluggish streams are numerous. The leech is a sanguinivorous hermaphrodite. The body is soft, elongated, vermiform, dorsoventrally flattened, bilaterally symmetrical and segmented, and well suited for a parasitic life. Each end bears a hollow muscular organ, the anterior and posterior suckers. Both suckers serve as a organs of locomotion and also provide firm adhesion to
1477-5131/$30 ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2007.02.004
Leech in urinary bladder causing hematuria
71
the host’s body at the time of feeding. The leech either swims by vertical undulations, grips objects (weeds, logs, stones) with its suckers, or moves by looping. It has a bloodsucking (sanguivorous) habit, feeding on the blood of fish, frogs, cattle and other domestic animals, and men visiting the water source where it lives. This parasite commonly infests the body surface of the host to suck blood, and has the habit of entering into the anatomical orifices such as the urethra, anus, vagina, nose and throat [1]. Aquatic leeches will even crawl up the external opening of the male and female sex organs and attach inside the urethra of a male or the vagina of a female, causing serious loss of blood. Hemorrhage from the bite area tends to be prolonged because the leech secretes a powerful anticoagulant (hirudin). In the case of the urinary bladder, hemostasis is further prevented due to steady urinary flow; retention of urine due to clot formation has also been reported [2]. The objective of this study was to estimate the efficacy of normal saline in the management of hematuria due to accidental entry of a leech per urethra into the urinary bladder.
Materials and methods This intervention study was carried out at the Department of Pediatric Surgery of Sylhet MAG Osmani Medical College, Sylhet, Bangladesh. A total of 45 boys, in whom a leech had entered accidentally into the urinary bladder through the urethra, were studied between January 1998 and December 2003. They had hematuria as well as dysuria. Two of these boys seemed to have associated pneumonia, which was treated with ampicillin and cloxacillin, and were excluded from our study. Diagnosis of leech in urinary bladder was supported by finding an intravesical, still or moving, linear, echogenic foreign body on ultrasonography. All 43 patients were equipped with a Foley catheter and treated by infusing 50 ml of normal saline into the urinary bladder. The saline was kept in the bladder for 2e3 h, and then released. The catheter was removed, followed by a waiting period of 2e12 h for expulsion of the leech. All patients were followed up for 14 days for recurrence of bleeding or any other morbidity. Diagnosis was confirmed in all cases by inspection of the leech after expulsion.
which 36/43 were mobile (Fig. 2). Regardless of the size of the leech, the whole leech, dead or alive, was spontaneously expelled intact in all cases during the next act of micturition after removing the catheter (Fig. 3). The majority of cases required 3e12 h for expulsion of the leech after application of normal saline (Table 2). Hematuria gradually diminished to a clear flow within the next 6 h in 58% of cases, and by 24 h in the rest (Table 3). All patients were followed up for 2 weeks, and none of them developed recurrent hematuria. Subsequently, parents were instructed to return to our outpatient department if necessary. To date, no complication or morbidity has been observed in any patient.
Discussion Medically important leeches are annelid worms that attach to their hosts with chitinous cutting jaws and draw blood using muscular suckers. The body surface is slippery and difficult to grasp because of a wide distribution of slime glands. A feeding leech firmly adheres to the body of its victim by its posterior sucker, and then the cup-shaped anterior sucker (Fig. 4) is suitably placed on a soft site of the host’s skin. The three blade-like and teeth-bearing jaws protrude through the mouth, moving like saws, and make the characteristic triradiate or ‘Y’ shaped painless incision in the skin of the host, which is anesthetized by a substance of unknown origin. Ultimately, the blood coming out from the wound is sucked into the pharynx by alternate contraction and expansion of the pharyngeal muscles. A leech can suck at a single meal several times its own weight in blood, which lasts the animal for several months or a year [3]. Healing of the wound is slow, and bacterial infections are not uncommon. Ubiquitous aquatic leeches that parasitize fish, frogs and turtles readily attach to the skin of human beings and eagerly suck blood. Several species of aquatic leeches in Africa, Asia and southern Europe can enter through the mouth, nose and genitourinary tract, and attach to mucosal surfaces at sites as deep as the esophagus and trachea. In
Results The age of the patients ranged from 4 to 16 years (mean 8 years, SD 2.6). The commonest age group was 7e10 years (Table 1). All 43 patients presented with hematuria (Fig. 1). Ultrasonography showed an intravesical foreign body, of
Table 1
Age distribution (n Z 43)
Age (years)
n
%
4e7 7e10 10e13 13e16
9 27 5 2
21 63 12 5
Figure 1 Hematuria caused by leech that entered into the urinary bladder through urethra.
72
S. Alam et al.
Figure 2
Ultrasonography showed an intravesical mobile foreign body.
the present study, there were 43 boys with leech infestation, of whom 63% were in the 7e10-year age group. The exact cause of increased leech infestation at this age is not known, but it may be due to the habit of children at this age of learning to swim, bathing or playing in ponds, lakes, tanks, swamps and sluggish streams in the rural areas of our country. Hematuria, hemoptysis, hematemesis, epistaxis and rectal bleeding may take place depending on the site of infestation [4]. Bleeding may be intense. Even accidental swallowing of a leech with drinking water has been reported. A leech shows a preference for mucous membranes, probably due to its attraction to moist and humid areas. Aquatic leeches will easily attach to the external opening of the urethra of a male or the vagina of a female. In our study, the leeches used the urethral opening of the boys that entered ultimately into the urinary bladder, and the only complaint was hematuria in all cases, which is similar to the series of Saha and Saha [5]. The leech looses body water in a hypertonic peripheral environment, and application of common salt to its body
surface to dislodge it is usual practice. Removal from surface areas can be assisted by application of salt, alcohol, vinegar or a flame to the leech [6]. Internally attached leeches may detach on exposure to gurgled saline or may be removed by forceps. Various ways of removing a leech from the urinary bladder have been described, such as suprapubic exploration and cystoscopic removal. In our series, a relatively simple method of catheterization and normal saline infusion resulted in control of symptoms, and the intact leech was expelled during the subsequent uneventful micturition after catheter removal. Hematuria also stopped spontaneously within 3e6 h of normal saline infusion, which is comparable to the findings reported in other studies [1,5]. In conclusion, we recommend normal saline infusion of the urinary bladder for treatment of accidental entry of a leech through the urethra. This is simple, safe, inexpensive, and can be practiced by medical personnel anywhere, rural or urban.
Table 2 Time required for expulsion of leeches after application of normal saline (n Z 43) Time (h)
n
%
3e6 6e12 12e18 18e24
16 21 4 2
37 49 9 5
Table 3
Figure 3 Whole leech was expelled intact during the subsequent act of micturition.
Hematuria clearance time (n Z 43)
Time (h)
n
%
3e6 6e12 12e18 18e24
25 15 2 1
58 35 5 2
Leech in urinary bladder causing hematuria
Figure 4
73
Whole leech showing anterior and posterior suckers.
Acknowledgement Prof. Parimal Deb, a renowned zoologist of Bangladesh, came forward with his knowledge, which was of enormous help for this publication. Our heartfelt thanks to him.
References [1] Ghosh D, Saha S, Das S, Samanta N, Konar H. Leech in urinary bladder. J Indian Assoc Pediatr Surg 2002;7:46e9.
[2] Hamid MS, Mohd Nor GR. Severe urological complications of leech bite in tropics. Br J Urol 1996;77:164e5. [3] James HM, Andrew S. Ectoparasite infestations, arthropod bites and stings. In: Braunwald E, Fauci AS, Kasper DS, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s principles of internal medicine. 15th ed. Boston: McGraw-Hill; 2003. p. 2622e9. [4] Singh M, Naim AF. Respiratory obstruction and haematemesis due to leech. Lancet 1979;22:1374. [5] Saha S, Saha I. Unusual foreign body causing bleeding per urethra. J Indian Med Assoc 1977;69:286e7. [6] Adams LA. The emergency management of a medicinal leech bite. Ann Emerg Med 1989;18:316e9.