- Email: [email protected]
Report of a Case of Extreme Dilatation of the Ureters
REPORT OF A CASE OF EXTREME DILATATION OF THE URETERS T. F. LAURIE Syracuse, New York
Received for publication, August 18, 1022
The following case is deemed of sufficient interest to warrant it being reported: Man, aged thirty-seven when seen first April 3, 1918. Chief complaint Frequency of urination with occasional burning. Has had this "bladder trouble" for the past ton years beginning ·with rather slight symptoms gradually increasing up to tho present. He now urinates about every hour during the day and about every two hours during the night. The desire to urinate when it comes is rather urgent. During his illness he has consulted various physicians and for fifteen months preceding the time I saw him he was under the care of a competent urologist. Immediately preceding the time I rnw him he had consulted a general surgeon in Brooklyn who had made a diagnosis of bilateral renal tuberculosis. Previous history. Infantile paralysis at two and a half years of age which probably involved the muscles of the back and abdomen along with the muscles of the right leg and thigh. At the age of fourteen he noticed that his spine was beginning to curve. Examination. Short in stature with a very marked scoliosis of the lower dorsal and lumbar spines with some rotation. Right leg and thigh atrophied. Total loss of function of the quadriceps extensor. Neither kidney palpable; rectal; prnstatc flat, not tender; vesicles, not felt. Cystoscopic. Bladder: residual, none; capacity 4 ounces; mucous membrane normal, smooth and glistening, slight congestion at apex of trigone. Ureteral orifices much enlarged, the right one appearing about 1 cm. across and the left one half that size. Catheters introduced easily to each kidney. With the ureteral orifices dilated as they were it 1 Read before the American Urological Association, Atlantic City, New Jersey, April, 1922.
491
492
T. F. LAURIE
was evident that whatever fluid was introduced into the bladder would go to the kidneys and thus come down the catheters, therefore the cystoscope was removed and a catheter introduced into the bladder and through it sodium bromide injected. An X-ray plate was made which is here shown.
Fm. 1
The urine has been repeatedly negative for tubercle bacilli both by stain and guinea-pig inoculation and revealed a very small amount of pus in one specimen out of many examined. The important facts concerning this case are that he had infantile paralysis at two and a half years of age; that he has a curvature of the spine which began at age fourteen; that in the urinary tract he h~s no
EXTREME DILATATION OF URETERS
493
apparent obstruction to urinary outflow and no interference with the mechanism of urination; the bladder is markedly contracted, the ureters and pelves markedly dilated. There is at present no signs of infection. The chief interest in this patient lies in the etiology. It is quite apparent nothing can be done for him. Dilatation of the ureters such as is presented here may be due to the following causes: 1. Mechanical obstruction: (a) congenital, (b) acquired. 2. Infection. 3. Disturbances of innervation. There is no evidence of obstruction anywhere along the urinary tract so that this as a cause can be ruled out. It is possible that he may have had a severe infection at the time of his first urinary symptoms, that he survived the infection and that the whole condition as here presented is the result, namely, the dilated ureters and pelves, and the contracted, rigid thick walled bladder. The possibility of disturbance of innervation must be considered as a very strong etiologic factor. In all the cases reported in the literature, with paralysis as a possible cause, none of them gives a history of having had infantile paralysis. Lack of intimate knowledge of the innervation and mechanism of urination prevents certainty in this field. Neurologists who have seen this patient and those with whom I have talked on the subject assure me that it is quite impossible for infantile paralysis to have caused this condition, yet they all admit that the urinary tract is frequently affected in this disease particularly when there is involvement of the abdominal and thigh muscles. Just how the urinary tract is involved no one seems to know. It is possible that the uretero-vesical valve was affected to a point of insufficiency and that this continued insufficiency produced the condition here shown. There are cases mentioned by various authors in which no etiologic factor can be found and this may be one of them, however the above comment is worthy of consideration.
Received for publication, August 18, 1022
The following case is deemed of sufficient interest to warrant it being reported: Man, aged thirty-seven when seen first April 3, 1918. Chief complaint Frequency of urination with occasional burning. Has had this "bladder trouble" for the past ton years beginning ·with rather slight symptoms gradually increasing up to tho present. He now urinates about every hour during the day and about every two hours during the night. The desire to urinate when it comes is rather urgent. During his illness he has consulted various physicians and for fifteen months preceding the time I saw him he was under the care of a competent urologist. Immediately preceding the time I rnw him he had consulted a general surgeon in Brooklyn who had made a diagnosis of bilateral renal tuberculosis. Previous history. Infantile paralysis at two and a half years of age which probably involved the muscles of the back and abdomen along with the muscles of the right leg and thigh. At the age of fourteen he noticed that his spine was beginning to curve. Examination. Short in stature with a very marked scoliosis of the lower dorsal and lumbar spines with some rotation. Right leg and thigh atrophied. Total loss of function of the quadriceps extensor. Neither kidney palpable; rectal; prnstatc flat, not tender; vesicles, not felt. Cystoscopic. Bladder: residual, none; capacity 4 ounces; mucous membrane normal, smooth and glistening, slight congestion at apex of trigone. Ureteral orifices much enlarged, the right one appearing about 1 cm. across and the left one half that size. Catheters introduced easily to each kidney. With the ureteral orifices dilated as they were it 1 Read before the American Urological Association, Atlantic City, New Jersey, April, 1922.
491
492
T. F. LAURIE
was evident that whatever fluid was introduced into the bladder would go to the kidneys and thus come down the catheters, therefore the cystoscope was removed and a catheter introduced into the bladder and through it sodium bromide injected. An X-ray plate was made which is here shown.
Fm. 1
The urine has been repeatedly negative for tubercle bacilli both by stain and guinea-pig inoculation and revealed a very small amount of pus in one specimen out of many examined. The important facts concerning this case are that he had infantile paralysis at two and a half years of age; that he has a curvature of the spine which began at age fourteen; that in the urinary tract he h~s no
EXTREME DILATATION OF URETERS
493
apparent obstruction to urinary outflow and no interference with the mechanism of urination; the bladder is markedly contracted, the ureters and pelves markedly dilated. There is at present no signs of infection. The chief interest in this patient lies in the etiology. It is quite apparent nothing can be done for him. Dilatation of the ureters such as is presented here may be due to the following causes: 1. Mechanical obstruction: (a) congenital, (b) acquired. 2. Infection. 3. Disturbances of innervation. There is no evidence of obstruction anywhere along the urinary tract so that this as a cause can be ruled out. It is possible that he may have had a severe infection at the time of his first urinary symptoms, that he survived the infection and that the whole condition as here presented is the result, namely, the dilated ureters and pelves, and the contracted, rigid thick walled bladder. The possibility of disturbance of innervation must be considered as a very strong etiologic factor. In all the cases reported in the literature, with paralysis as a possible cause, none of them gives a history of having had infantile paralysis. Lack of intimate knowledge of the innervation and mechanism of urination prevents certainty in this field. Neurologists who have seen this patient and those with whom I have talked on the subject assure me that it is quite impossible for infantile paralysis to have caused this condition, yet they all admit that the urinary tract is frequently affected in this disease particularly when there is involvement of the abdominal and thigh muscles. Just how the urinary tract is involved no one seems to know. It is possible that the uretero-vesical valve was affected to a point of insufficiency and that this continued insufficiency produced the condition here shown. There are cases mentioned by various authors in which no etiologic factor can be found and this may be one of them, however the above comment is worthy of consideration.