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RE: RENAL COLIC DURING PREGNANCY
0022-5347/99/16110230$03.Oan, k JOURNAL OF U R O ~ Y Copyright Q 1999 by M m c m UROUXICAL ASS~CUTION,hc.
vol. 161,230-232,January 1999 Printed in V . S . A
Letters to the Editor 36.8 years) who complained of a mean 6.8-year history of perineal pain as well as urinary frequency, urgency and dysuria also had chronic constipation. Physical examination demonstrated normal B. G. Parulknr. T. B. Hopkins, M.R. Wollin, P.J . Howard, Jr. findings. Perineal hypoesthesia was present in all patients. Anal and A. La1 reflex was weak in 8 cases, and external urethral sphincter and J. Urol.. 159: 365-368, 1998 levator ani activity was decreased in 6 and 12, respectively. In contrast, external anal sphincter electromyography was normal. PuTo the Editor. Ureteral colic during pregnancy is a difficult man- dendal nerve terminal motor latency was significantly increased in agement problem, as demonstrated by this article. While fully endorsing the early evaluation of such patients, we believe that the all patients. Characteristic pain distribution, sensory changes exreliance on ultrasound imaging proposed by the authors is unreliable pressed a s perineal hypoesthesia, motor changes manifesting as weak anal reflexes and decreased electromyography activity of the and does not provide the definitive diagnosis required. The authors suggest that 95% sensitivity was achieved using ul- external urethral sphincter and levator ani muscles as well as intrasound in this study. However, as they comment, this rate does not creased pudendal nerve terminal motor latency suggested neuropainclude the 20 of 72 patients who underwent no further investigation thy of the distal part of the pudendal nerve. The pudendal canal despite a good history of renal colic following a negative scan. It is syndrome was diagnosed. Pudendal nerve block relieved the pain for possible that excretory urography (IVP)in these 20 patients may only 2 or 3 days. Pudendal canal decompression was successful in 9 have detected some stones otherwise missed. In 3 of 5 patients of the 12 patients. Symptoms disappeared and perineal hypoesthesubsequent IVP showed no stone despite ultrasound suspicion but sia, anal reflex, electromyography activity of the external urethral more significantly, IVP revealed stones in 2 patients that were sphincter and levator ani, and pudendal nerve terminal motor lamissed by ultrasound. While ultrasound studies detect hydmnephro- tency improved. Mean followup was 23.6 months (range 16 to 36). sis, this finding is common during uncomplicated pregnancy. Also, What causes entrapment of the pudendal nerve with resultant ureteral stones need not always cause hydronephrosis. prostatodynia? The levator ani muscle, which is the muscle of defeAlthough we recognize the potential risk of exposing the fetus to cation, contracts on straining and becomes elevated and laterally rahation, the significant morbidity associated with obstruction due retracted. An increase in intra-abdominal pressure beyond normal to stones, particularly renal parenchymal loss, septicemia and pre- physiological limits, which seems to occur with chronic straining a t mature labor, surely poses a greater threat to the mother and, hence, stool in constipation as experienced by our 12 patients, is concenthe fetus. IVP still represents the gold standard for stone disease. As such, it should be the investigation of choice in patients with a trated at the levator ani muscle, and leads to its subluxation and history of renal colic during pregnancy so that management, be it sagging. The muscle then lies a t a lower level than normal and consequently it pulls on the pudendal nerve. The distal part of the conservative or surgical, may be more accurately planned. nerve, which extends from the ischial spine to the levator ani muscle, Respectfully, is exposed to stretching because the way in which it winds around M. Costa, R. Calleja and N . A. Burgess the sacrospinous ligament seems to fix the nerve a t this point. Norfolk and Nomich Health Care N.H.S. Trust Repeated nerve stretching due to intermittent contraction of the Nonuick, Norfolk NR13SR sagging levator ani at defecation may lead to neuropraxia or axonotEngland mesis. Since it is entrapped in the pudendal canal and subjected to continuous stretching, the pudendal nerve may undergo edema with Reply by Authors. We agree that IVP may represent the gold subsequent compression inside the canal leading to nerve ischemia, standard for stone disease. IVPdelineates anatomy and the presence adding to nerve damage. Eventually pudendal entrapment neuropor absence of stones better than ultrasound. However, in our expe- athy develops, which seems to affect the nerve branches in different rience with pregnant women ultrasound helps to plan appropriate grades. In the reported 12 cases of prostatodynia this neuropathy treatment without the need for subjecting the fetus to radiation. The involved mainly the perineal nerve and to a lesser extent the inferior need for intervention depends not on imaging studies, but on the rectal nerve, as evident from sensory and motor changes. In light of clinical course. To subject the fetus to radiation to achieve anatom- these etiological considerations, pudendal canal fasciotomy is the ical clarity seems to us unnecessary. With experienced ultrasonog- appropriate procedure to decompress the pudendal nerve and set it raphers ultrasound imaging is reliable. Of 42 clinically significant free within the ischiorectal fossa, so as not to expose it to further stones 40 were identified. None of the 20 patients in whom no stones stretching by the contracting and sagging levator ani muscle. were identified had any symptoms suggestive of stones, nor were In regard to chronic prostatitis, the 2 to 6 small rectourogenital stones detected in 3 months postpartum. We believe that ultrasound veins that communicate unidirectionally from the hemorrhoidal to is the least morbid imaging study that in our hands has helped to the vesicoprostatic plexus1 have opened a new route for drug adminplan appropriate therapy. None of our patients had any significant istration. By injection of the select therapeutic agent into the anal morbidity secondary to undergoing ultrasound as the primary mosubmucosa just above the pectinate line the agent reaches and treats dality for assessing renal colic. all organs in the pelvic floor. The advantages of this direct approach are enhanced drug efficacy and satisfactory results even with decreased drug amounts, while a t the same time the systemic circulation is spared the complications of high serum levels after intraveRE: a-BLOCKERS FOR THE TREATMENT OF CHRONIC nous administration. When in an earlier study I4carbon labeled PROSTATITIS IN COMBINATION WITH ANTIBIOTICS misonidazole (a radiation sensitizer) was injected into the anal submucosa, drug concentration was 3 and as high as 8 times the serum G. A. Barbalias, G. Nikiforidis and E. N . Liatsikos level 15 minutes &r injection in the prostate and bladder, respecJ. Urol.,169: 883-887, 1998 tively.3 The study of the treatment of chronic prostatitis with anal submucoTo t h Editor. I read the study of the new approach to prostatodynia and prostatitis with great interest. Having worked in this field sal injection of gentamicin, to which the causative Escherichia coli extensively, I would like to mention our experience with treatment organisms were sensitive, included 11 patients. When the treatment modalities for prostatodynial and chronic prostatitis* that derive comprising 10 injections was completed, cultures were negative in all satisfactory results from etiology related alternative approaches. patients and all were symptom-free. No recurrence was noted for up to In a recent study of pmstatodynia all 12 patients (a mean age of 3 years. It is important to stress that all 11 patients had initially 230
RE: RENAL COLIC DURING PREGNANCY A CASE FOR CONSERVATIVE TREATMENT
vol. 161,230-232,January 1999 Printed in V . S . A
Letters to the Editor 36.8 years) who complained of a mean 6.8-year history of perineal pain as well as urinary frequency, urgency and dysuria also had chronic constipation. Physical examination demonstrated normal B. G. Parulknr. T. B. Hopkins, M.R. Wollin, P.J . Howard, Jr. findings. Perineal hypoesthesia was present in all patients. Anal and A. La1 reflex was weak in 8 cases, and external urethral sphincter and J. Urol.. 159: 365-368, 1998 levator ani activity was decreased in 6 and 12, respectively. In contrast, external anal sphincter electromyography was normal. PuTo the Editor. Ureteral colic during pregnancy is a difficult man- dendal nerve terminal motor latency was significantly increased in agement problem, as demonstrated by this article. While fully endorsing the early evaluation of such patients, we believe that the all patients. Characteristic pain distribution, sensory changes exreliance on ultrasound imaging proposed by the authors is unreliable pressed a s perineal hypoesthesia, motor changes manifesting as weak anal reflexes and decreased electromyography activity of the and does not provide the definitive diagnosis required. The authors suggest that 95% sensitivity was achieved using ul- external urethral sphincter and levator ani muscles as well as intrasound in this study. However, as they comment, this rate does not creased pudendal nerve terminal motor latency suggested neuropainclude the 20 of 72 patients who underwent no further investigation thy of the distal part of the pudendal nerve. The pudendal canal despite a good history of renal colic following a negative scan. It is syndrome was diagnosed. Pudendal nerve block relieved the pain for possible that excretory urography (IVP)in these 20 patients may only 2 or 3 days. Pudendal canal decompression was successful in 9 have detected some stones otherwise missed. In 3 of 5 patients of the 12 patients. Symptoms disappeared and perineal hypoesthesubsequent IVP showed no stone despite ultrasound suspicion but sia, anal reflex, electromyography activity of the external urethral more significantly, IVP revealed stones in 2 patients that were sphincter and levator ani, and pudendal nerve terminal motor lamissed by ultrasound. While ultrasound studies detect hydmnephro- tency improved. Mean followup was 23.6 months (range 16 to 36). sis, this finding is common during uncomplicated pregnancy. Also, What causes entrapment of the pudendal nerve with resultant ureteral stones need not always cause hydronephrosis. prostatodynia? The levator ani muscle, which is the muscle of defeAlthough we recognize the potential risk of exposing the fetus to cation, contracts on straining and becomes elevated and laterally rahation, the significant morbidity associated with obstruction due retracted. An increase in intra-abdominal pressure beyond normal to stones, particularly renal parenchymal loss, septicemia and pre- physiological limits, which seems to occur with chronic straining a t mature labor, surely poses a greater threat to the mother and, hence, stool in constipation as experienced by our 12 patients, is concenthe fetus. IVP still represents the gold standard for stone disease. As such, it should be the investigation of choice in patients with a trated at the levator ani muscle, and leads to its subluxation and history of renal colic during pregnancy so that management, be it sagging. The muscle then lies a t a lower level than normal and consequently it pulls on the pudendal nerve. The distal part of the conservative or surgical, may be more accurately planned. nerve, which extends from the ischial spine to the levator ani muscle, Respectfully, is exposed to stretching because the way in which it winds around M. Costa, R. Calleja and N . A. Burgess the sacrospinous ligament seems to fix the nerve a t this point. Norfolk and Nomich Health Care N.H.S. Trust Repeated nerve stretching due to intermittent contraction of the Nonuick, Norfolk NR13SR sagging levator ani at defecation may lead to neuropraxia or axonotEngland mesis. Since it is entrapped in the pudendal canal and subjected to continuous stretching, the pudendal nerve may undergo edema with Reply by Authors. We agree that IVP may represent the gold subsequent compression inside the canal leading to nerve ischemia, standard for stone disease. IVPdelineates anatomy and the presence adding to nerve damage. Eventually pudendal entrapment neuropor absence of stones better than ultrasound. However, in our expe- athy develops, which seems to affect the nerve branches in different rience with pregnant women ultrasound helps to plan appropriate grades. In the reported 12 cases of prostatodynia this neuropathy treatment without the need for subjecting the fetus to radiation. The involved mainly the perineal nerve and to a lesser extent the inferior need for intervention depends not on imaging studies, but on the rectal nerve, as evident from sensory and motor changes. In light of clinical course. To subject the fetus to radiation to achieve anatom- these etiological considerations, pudendal canal fasciotomy is the ical clarity seems to us unnecessary. With experienced ultrasonog- appropriate procedure to decompress the pudendal nerve and set it raphers ultrasound imaging is reliable. Of 42 clinically significant free within the ischiorectal fossa, so as not to expose it to further stones 40 were identified. None of the 20 patients in whom no stones stretching by the contracting and sagging levator ani muscle. were identified had any symptoms suggestive of stones, nor were In regard to chronic prostatitis, the 2 to 6 small rectourogenital stones detected in 3 months postpartum. We believe that ultrasound veins that communicate unidirectionally from the hemorrhoidal to is the least morbid imaging study that in our hands has helped to the vesicoprostatic plexus1 have opened a new route for drug adminplan appropriate therapy. None of our patients had any significant istration. By injection of the select therapeutic agent into the anal morbidity secondary to undergoing ultrasound as the primary mosubmucosa just above the pectinate line the agent reaches and treats dality for assessing renal colic. all organs in the pelvic floor. The advantages of this direct approach are enhanced drug efficacy and satisfactory results even with decreased drug amounts, while a t the same time the systemic circulation is spared the complications of high serum levels after intraveRE: a-BLOCKERS FOR THE TREATMENT OF CHRONIC nous administration. When in an earlier study I4carbon labeled PROSTATITIS IN COMBINATION WITH ANTIBIOTICS misonidazole (a radiation sensitizer) was injected into the anal submucosa, drug concentration was 3 and as high as 8 times the serum G. A. Barbalias, G. Nikiforidis and E. N . Liatsikos level 15 minutes &r injection in the prostate and bladder, respecJ. Urol.,169: 883-887, 1998 tively.3 The study of the treatment of chronic prostatitis with anal submucoTo t h Editor. I read the study of the new approach to prostatodynia and prostatitis with great interest. Having worked in this field sal injection of gentamicin, to which the causative Escherichia coli extensively, I would like to mention our experience with treatment organisms were sensitive, included 11 patients. When the treatment modalities for prostatodynial and chronic prostatitis* that derive comprising 10 injections was completed, cultures were negative in all satisfactory results from etiology related alternative approaches. patients and all were symptom-free. No recurrence was noted for up to In a recent study of pmstatodynia all 12 patients (a mean age of 3 years. It is important to stress that all 11 patients had initially 230
RE: RENAL COLIC DURING PREGNANCY A CASE FOR CONSERVATIVE TREATMENT