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Pyocystis
--
Vol. 117, June
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1977 by The Williams & Wilkins Co.
PYOCYSTIS RAYMOND W. WEINBERG* From the Godfrey Huggins School of Medicine, University of Rhodesia, Salisbury, Rhodesia
ABSTRACT
A case of pyocystis occurring in a woman after supravesical urinary diversion for complicated neuropathic bladder is reported. Treatment consisted of a vaginal vesicostomy. Indications for the precedure and the problems associated with it are discussed with special emphasis on sexual intercourse. Pyocystis, empyema cystis, 1 vesical empyema2 and pyovesiculosis3 are all varied terms used to describe the pus-filled bladder that may develop after supravesical urinary diversion when the bladder is left behind. The purpose of this paper is to review the condition and to report such a case but, especially, to highlight a special problem, namely sexual intercourse, which has never been discussed specifically. Pyocystis may occur in one-fifth4 to one-third5 of the cases in children. It is more common in female than in male subjects, probably because the short urethra in the female subject predisposes easily to ascending infection. Once infected the bladder has no way of draining itself since it does not have the stimulus of the urine coming down from the kidneys into it to cause it to contract, empty and, thus, wash itself out. Instead it merely becomes a grossly infected functionless bag eventually resulting in pyocystis, a simple explanation compared with other theories. 6 This condition is not only an embarrassment to the patient because of the malodorous discharge that may periodically come from the bladder through the urethra but it may become life threatening as a result of the absorbtive septicemic effects of this bladder. 2 Pyocystis may be prevented by total cystectomy at the time of diversion but the over-all operative mortality will be increased considerably7 and its removal may be difficult. 2 Postoperative total cystectomy, which may be simple, could be done but, "it is a major operation requiring prolonged anaesthesia" that could result in complications and morbidity. 8 Another method of management is bladder irrigation, which may be done by the nursing staff or the patient. Of course, selfcatheterization will be considerably easier in the female patient. Bladder irrigation may solve the problem in a short time if it is done regularly and conscientiously but, on the other :hand, it may be difficult to eradicate even with vigorous, enthusiastic treatment. Vaginal vesicostomy is a procedure that has been developed only recently but has been used with success. 6 • 8 It is performed easily and simply and in no way compares with the morbidity and mortality of cystectomy. However, the arguments against its routine use are well presented. 8 Perineal vesicostomy has been described for use in male subjects but it is apparently difficult and requires frequent followup to check the patency of the opening. 9 Chemical sclerosing by instillation is another form of treatment for pyocystis. 6 Herein a case is reported to illustrate the typical features of this condition. CASE REPORT
A 52-year-old white woman was hospitalized because of a fracture of the right humerus. History included right nephrectomy for a dysplastic kidney 14 years previously and, 5 years Accepted for publication December 17, 1976. *Current address: St. Joseph Ziekenhuis, Kapellen 2080, Antwerp, Belgium.
before that, laminectomy for a spinal cord tumor, which resulted in partial paraplegia. Bladder control had been variable and reasonable but during the last few months it had become extremely difficult, with bouts of pyrexia and uncontrollable urinary infection. The urinary infection was brought under control with multiple antibiotics and bladder irrigations. However, it recurred after the patient was discharged from the hospital. An excretory urogram revealed gross left hydronephrosis with hydroureter. A cystogram showed total left vesicoureteral reflux and cystoscopy revealed a grossly infected bladder with a gaping left ureteral orince. Supravesical urinary diversion with an ileal conduit was done. Convalescence was uneventful. Bladder washouts were performed and the patient was discharged from the hospital with a clean bladder. Eight months later she presented with periodic bouts of passing a malodorous discharge from the vagina, which was caused by pyocystis. Cystoscopy revealed an edematous hemorrhagic infected bladder containing foul-smelling purulent material. When a vaginal vesicostomy was advised the patient's immediate reaction was how would this interfere with sexual relations, which were adequate at that time. After considerable discussion the vaginal vesicostomy was done according to the method of Spence and Allen. 2 Since there were no guide lines reported in the literature the surgical procedure was done cautiously in the hope that an adequate drainage opening had been made but had not extended so far up the vesic
There is no doubt from the literature and this case that when the bladder washout regimen fails a vaginal vesicostomy is the ideal method of management in the female patient with pyocystis. It is simple to perform and the postoperative course is easy for the patient. The patients are satisfied since this stops the continuous leaking malodorous profuse discharge that is socially embarrassing. There is no doubt that vaginal vesicostomy should be offered immediately after pyocystis is diagnosed. To persist for weeks or months trying to eradicate the infection seems pointless when such a simple procedure is available. Because of the simplicity of the procedure the possibility now arises with reference to its routine use. However, this would seem to be unnecessary because most bladders will
798
FYDCYSTIS
on the It is better to act earlier rather than later. The question of how this procedure will interfere with sexual intercourse, v,hich was raised by this patient, should be discussed preoperatively. There is nothing in the literature on this subject. "One patient subsequently experienced sexual intercourse without apparent difficulty." 2 All one can say to the patient is that a small but efficient drainage hole will be made but it may have to be enlarged should drainage be inefficient. There should be no hesitation in enlarging the stoma by extending it up the vesicovaginal septum since it is a simple procedure for the patient and the surgeon.
3.
4. 5. 6. 7.
8.
REFERENCES
1. Herwig, K. R.: Ernpyema cystis treated by intermittent self-
catheterization. J. Urol., 113: 719, 1975. 2. Spence, H. M. and Allen, T. D.: Vaginal vesicostomy for em-
9.
pyen1a of the defuEcticnalizei bladder. u. I\1. F,: infectio!ls. In: F. Campbell J. H. Harrison. ····---·,·····-· W. B. Co., chapt. 43, p. 1828, 1970. Eckstein, H.B. and Mohindra, P.: The defunctioned neurogenic bladder: a clinical study. Dev. Med. Child Neurol., suppl. 22, pp. 46-50, 1970. Smith, E. D.: Follow-up studies on 150 ilea! conduits in children, J. Pediat. Surg., 7: 1, 1972. Ray, P., Taguchi, Y. and MacKinnon, K. J .. The pyocystis syndrome. Brit. J. Urol., 43: 583, 1971. Jaffe, B. M., Bricker, E. I\IL and Butcher, H. R., Jr.: Surgical complications of ilea! segment urinary diversion. Ann. Surg., 167: 367, 1968. Stevens, P. S. and Eckstein, H.B.: The management ofpyocystis following ileal conduit urinary diversion in children. Brit. J. Urol., 47: 631, 1975. Orecklin, J. R. and Goodwin, W. E.: Perinea! vesicostomy: an alternative to cystectomy in male patients with a permanently defunctionalized bladder. J. Urol., lll: 151, 1974. va,rn';.,,,,oa,
Vol. 117, June
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1977 by The Williams & Wilkins Co.
PYOCYSTIS RAYMOND W. WEINBERG* From the Godfrey Huggins School of Medicine, University of Rhodesia, Salisbury, Rhodesia
ABSTRACT
A case of pyocystis occurring in a woman after supravesical urinary diversion for complicated neuropathic bladder is reported. Treatment consisted of a vaginal vesicostomy. Indications for the precedure and the problems associated with it are discussed with special emphasis on sexual intercourse. Pyocystis, empyema cystis, 1 vesical empyema2 and pyovesiculosis3 are all varied terms used to describe the pus-filled bladder that may develop after supravesical urinary diversion when the bladder is left behind. The purpose of this paper is to review the condition and to report such a case but, especially, to highlight a special problem, namely sexual intercourse, which has never been discussed specifically. Pyocystis may occur in one-fifth4 to one-third5 of the cases in children. It is more common in female than in male subjects, probably because the short urethra in the female subject predisposes easily to ascending infection. Once infected the bladder has no way of draining itself since it does not have the stimulus of the urine coming down from the kidneys into it to cause it to contract, empty and, thus, wash itself out. Instead it merely becomes a grossly infected functionless bag eventually resulting in pyocystis, a simple explanation compared with other theories. 6 This condition is not only an embarrassment to the patient because of the malodorous discharge that may periodically come from the bladder through the urethra but it may become life threatening as a result of the absorbtive septicemic effects of this bladder. 2 Pyocystis may be prevented by total cystectomy at the time of diversion but the over-all operative mortality will be increased considerably7 and its removal may be difficult. 2 Postoperative total cystectomy, which may be simple, could be done but, "it is a major operation requiring prolonged anaesthesia" that could result in complications and morbidity. 8 Another method of management is bladder irrigation, which may be done by the nursing staff or the patient. Of course, selfcatheterization will be considerably easier in the female patient. Bladder irrigation may solve the problem in a short time if it is done regularly and conscientiously but, on the other :hand, it may be difficult to eradicate even with vigorous, enthusiastic treatment. Vaginal vesicostomy is a procedure that has been developed only recently but has been used with success. 6 • 8 It is performed easily and simply and in no way compares with the morbidity and mortality of cystectomy. However, the arguments against its routine use are well presented. 8 Perineal vesicostomy has been described for use in male subjects but it is apparently difficult and requires frequent followup to check the patency of the opening. 9 Chemical sclerosing by instillation is another form of treatment for pyocystis. 6 Herein a case is reported to illustrate the typical features of this condition. CASE REPORT
A 52-year-old white woman was hospitalized because of a fracture of the right humerus. History included right nephrectomy for a dysplastic kidney 14 years previously and, 5 years Accepted for publication December 17, 1976. *Current address: St. Joseph Ziekenhuis, Kapellen 2080, Antwerp, Belgium.
before that, laminectomy for a spinal cord tumor, which resulted in partial paraplegia. Bladder control had been variable and reasonable but during the last few months it had become extremely difficult, with bouts of pyrexia and uncontrollable urinary infection. The urinary infection was brought under control with multiple antibiotics and bladder irrigations. However, it recurred after the patient was discharged from the hospital. An excretory urogram revealed gross left hydronephrosis with hydroureter. A cystogram showed total left vesicoureteral reflux and cystoscopy revealed a grossly infected bladder with a gaping left ureteral orince. Supravesical urinary diversion with an ileal conduit was done. Convalescence was uneventful. Bladder washouts were performed and the patient was discharged from the hospital with a clean bladder. Eight months later she presented with periodic bouts of passing a malodorous discharge from the vagina, which was caused by pyocystis. Cystoscopy revealed an edematous hemorrhagic infected bladder containing foul-smelling purulent material. When a vaginal vesicostomy was advised the patient's immediate reaction was how would this interfere with sexual relations, which were adequate at that time. After considerable discussion the vaginal vesicostomy was done according to the method of Spence and Allen. 2 Since there were no guide lines reported in the literature the surgical procedure was done cautiously in the hope that an adequate drainage opening had been made but had not extended so far up the vesic
There is no doubt from the literature and this case that when the bladder washout regimen fails a vaginal vesicostomy is the ideal method of management in the female patient with pyocystis. It is simple to perform and the postoperative course is easy for the patient. The patients are satisfied since this stops the continuous leaking malodorous profuse discharge that is socially embarrassing. There is no doubt that vaginal vesicostomy should be offered immediately after pyocystis is diagnosed. To persist for weeks or months trying to eradicate the infection seems pointless when such a simple procedure is available. Because of the simplicity of the procedure the possibility now arises with reference to its routine use. However, this would seem to be unnecessary because most bladders will
798
FYDCYSTIS
on the It is better to act earlier rather than later. The question of how this procedure will interfere with sexual intercourse, v,hich was raised by this patient, should be discussed preoperatively. There is nothing in the literature on this subject. "One patient subsequently experienced sexual intercourse without apparent difficulty." 2 All one can say to the patient is that a small but efficient drainage hole will be made but it may have to be enlarged should drainage be inefficient. There should be no hesitation in enlarging the stoma by extending it up the vesicovaginal septum since it is a simple procedure for the patient and the surgeon.
3.
4. 5. 6. 7.
8.
REFERENCES
1. Herwig, K. R.: Ernpyema cystis treated by intermittent self-
catheterization. J. Urol., 113: 719, 1975. 2. Spence, H. M. and Allen, T. D.: Vaginal vesicostomy for em-
9.
pyen1a of the defuEcticnalizei bladder. u. I\1. F,: infectio!ls. In: F. Campbell J. H. Harrison. ····---·,·····-· W. B. Co., chapt. 43, p. 1828, 1970. Eckstein, H.B. and Mohindra, P.: The defunctioned neurogenic bladder: a clinical study. Dev. Med. Child Neurol., suppl. 22, pp. 46-50, 1970. Smith, E. D.: Follow-up studies on 150 ilea! conduits in children, J. Pediat. Surg., 7: 1, 1972. Ray, P., Taguchi, Y. and MacKinnon, K. J .. The pyocystis syndrome. Brit. J. Urol., 43: 583, 1971. Jaffe, B. M., Bricker, E. I\IL and Butcher, H. R., Jr.: Surgical complications of ilea! segment urinary diversion. Ann. Surg., 167: 367, 1968. Stevens, P. S. and Eckstein, H.B.: The management ofpyocystis following ileal conduit urinary diversion in children. Brit. J. Urol., 47: 631, 1975. Orecklin, J. R. and Goodwin, W. E.: Perinea! vesicostomy: an alternative to cystectomy in male patients with a permanently defunctionalized bladder. J. Urol., lll: 151, 1974. va,rn';.,,,,oa,