- Email: [email protected]
The Significance of Pelvic Phlebolith Displacement
Vol. 106, October
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1971 by The Williams & Wilkins Co.
THE SIGNIFICANCE OF PELVIC PHLEBOLITH DISPLACEMENT JOHN W. FENLON*
AND
CEASAR AUGUSTIN
Prom the ]lfollinckrodt Institute of Radiology, Washington University School of Medicine and Department of Radiology, Homer G. Philips Hospital, St. Louis, Missouri
Phleboliths are visible in pelvic radiographs of 25 to 48 per cent of adult patients. They are bilateral in more than half the cases and are then symmetrical in position (fig. 1). Although much attention has been given to differentiating phleboliths from ureteral stones, little emphasis has been placed on phleboliths as indicators of pelvic disease. Three cases are presented to demonstrate the value of phlebolith displacement on the plain film as a sign of pelvic mass. CASE REPORTS
Case 1. A 42-year-old man was admitted to the hospital for a gunshot wound in the left flank. Pulse was 100 per minute and blood pressure 115/80. There was tenderness in the right lower quadrant. The patient was unable to urinate and gross bloody urine was obtained on catheterization. The hematocrit was 37 per cent. A plain film of the abdomen revealed the phleboliths in the left pelvis displaced medially and a bullet in the middle of the pelvis (fig. 2, A). Excretory urography (IVP) showed the urinary bladder displaced to the right with extravasation of contrast medium into the region of the displaced phleboliths (fig. 2, B). Exploratory laparotomy confirmed an extraperitoneal perforation of the left posterior wall of the bladder with the bullet inside the bladder. About 600 ml. blood mixed with urine was aspirated from the retroperitoneal area of the pelvis. The bladder was repaired and convalescence was uneventful. A subsequent plain film of the pelvis showed return of the phleboliths on the left side to their normal symmetrical position (fig. 2, C). Comment: In this clinical setting, phlebolith displacement on the plain film of the pelvis may be the first sign of urine extravasation or pelvic hematoma and is an indication for contrast examination of the urinary tract. Case 2. A 74-year-old woman was admitted to the hospital with diffuse abdominal pain, weight
loss and progressive constipation. Six years previously she received a full course of irradiation therapy for stage 3 carcinoma of the uterine cervix. She was emaciated and had mild abdominal distention. Medial displacement of the left phleboliths was seen on a plain film of the abdomen (fig. 3, A). Pelvic examination revealed a large hard mass occupying the left two-thirds of the pelvis. Barium enema showed displacement and stretching of the sigmoid colon by the pelvic mass (fig. 3, B). Exploratory laparotomy confirmed epidermoid carcinoma involving the left pelvic wall and crossing the midline. No resection was attempted and subsequent treatment was supportive. Comment: With this history, radiographic demonstration of phlebolith displacement indicating a pelvic mass should suggest metastatic neoplasm. Case 3. A 78-year-old man was admitted to the hospital with weight loss, abdominal pain and vomiting. A prostatic resection for benign prostatic hypertrophy was performed 19 years previously. The patient was slightly dehydrated and had a moderately distended abdomen and slight epigastric tenderness. Hematocrit was 30 per cent, white blood count and differential were normal and the blood urea nitrogen was 25 mg. per cent. A plain film of the abdomen showed displacement of right phleboliths medially by a mass in the right side of the pelvis (fig. 4, A). A retrograde cystogram showed the mass to be a bladder diverticulum (figs. 4, B and C and 5). The patient underwent transurethral resection of the enlarged prostate. Convalescence was uneventful. Comment: Phlebolith displacement indicated the presence of a pelvic mass. However, there was no historical clue to the etiology. During evaluation of the prostate, cystography provided the diagnosis. DISCUSSION
Accepted for publication December 1970. * Current address: Department of Radiology, Veterans Administration Hospital, San Francisco, California 94121.
Radiographic detection of a pelvic mass often is difficult. Large lesions produce an abnormal in595
596
FENLON AND AUGUSTIN
Fm. 1. Normal appearance. Although there are some phleboliths near midline, majority are symmetrically placed laterally in pelvis. Note unusually large number.
crease in soft tissue density. Detection of lesions which do not significantly alter radiographic density is more difficult. The presence of abnormal pelvic calcification may signify a tumor but often is absent. Reliance usually must be placed on the indirert sign of displacement of pelvic structures which have different radiographic densities from soft tissues. Displacement of phleboliths is an indirect sign of a pelvic mass. Since they are normally symmetrical, displacement is a reliable finding. Phleboliths may be shifted in any direction, depending on their relationship to the mass. This finding does not give an etiologic diagnosis. It only indicates the presence of a space-occupying lesion. However, when correlated with the patient's history, this sign may yield valuable information.
Fm. 2. A, plain film reveals left phleboliths, especially superior one (arrow), displaced medially. Increase in soft tissue density lateral to them suggests mass. Note bullet. B, 10-minute IVP shows bladder and distal left ureter (arrow) displaced to right. Extraluminal contrast medium indicates bladder laceration with urine extravasation as cause of phlebolith displacement. C, 3 months after repair of ruptured bladder phleboliths on left side have returned to more symmetrical lateral position.
Fm. 3. A, plain film reveals upper left phleboliths displaced to right of midline by large mass. B, on post-evacuation barium enema mass displaces sigmoid colon upward and to right. Relationship of mass to displaced phleboliths (arrows) is better demonstrated.
PELVIC PHLEBOLITH DISPLACEMENT
597
Fm. 4. A, plain film re,eals phleboliths in right of pelvis displaced medially. Increased density lateral to phleboliths indicates mass. B, retrograde cystogram reveals trabeculation with diverticula. Large diverticulum is present on right side. C, oblique view of diverticulum on right posterolateral aspect of bladder. No special contrast study is necessary. Demonstration of the ureter and bladder requires opacification by IVP1 and the rectosigmoid must be filled with barium. A plain film of the pelvis is all that is needed to evaluate phlebolith position. Under these circumstances phlebolith displacement may be the first indication of a pelvic mass. Hemorrhage and urine extravasation owing to blunt or penetrating trauma are urgent remedial causes of displacement of pelvic structures (case 1). Since attention often is directed elsewhere in cases of multi-organ system trauma, and retroperitoneal hemorrhage sufficient to cause death may escape clinical detection,2 it is important to look carefully for any sign of retroperitoneal hemorrhage in these patients. Phlebo1 Friedenberg, R. M., Ney, C., Lopez, F. A. and Stachenfeld, R. A.: Clinical significance of deviations of the pelvic ureter. J. Urol., 96: 146, 1966. 2 McCarroll, J. IL, Braunstein, P. W., Cooper, W., Helpern, M., Seremetis, M., Wade, P.A. and Weinberg, S. B.: Fatal pedestrian automotive accidents. J.A.M.A., 180: 127, 1962.
Fm. 5. Post-void film shows contrast material trapped in diverticulum and relationship to displaced phleboliths. Diverticulum is cause of phlebolith displacement. lith displacement may be an important finding under these circumstances. Neoplasms are a recognized cause of phlebolith displacement (case 2). 3 The bladder diverticulum 3 Steinbach, H. L.: Identification of pelvic masses by phlebolith displacement. Amer. J. Roentgen., 83: 1063, 1960.
598
FENLON AND AUGUSTIN
in case 3 was an unexpected explanation of the pelvic mass. Pelvic abscess is another cause of phlebolith displacement. SUMMARY AND CONCLUSION
Pelvic phleboliths are natural markers of soft tissue anatomy and can be evaluated on any
plain film of the pelvis. Phlebolith displacement is an indirect sign of a pelvic mass and an indication for further clinical and roentgenographic evaluation. Phlebolith position should be carefully studied, particularly in patients with a history of neoplasm and in those hospitalized for trauma.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1971 by The Williams & Wilkins Co.
THE SIGNIFICANCE OF PELVIC PHLEBOLITH DISPLACEMENT JOHN W. FENLON*
AND
CEASAR AUGUSTIN
Prom the ]lfollinckrodt Institute of Radiology, Washington University School of Medicine and Department of Radiology, Homer G. Philips Hospital, St. Louis, Missouri
Phleboliths are visible in pelvic radiographs of 25 to 48 per cent of adult patients. They are bilateral in more than half the cases and are then symmetrical in position (fig. 1). Although much attention has been given to differentiating phleboliths from ureteral stones, little emphasis has been placed on phleboliths as indicators of pelvic disease. Three cases are presented to demonstrate the value of phlebolith displacement on the plain film as a sign of pelvic mass. CASE REPORTS
Case 1. A 42-year-old man was admitted to the hospital for a gunshot wound in the left flank. Pulse was 100 per minute and blood pressure 115/80. There was tenderness in the right lower quadrant. The patient was unable to urinate and gross bloody urine was obtained on catheterization. The hematocrit was 37 per cent. A plain film of the abdomen revealed the phleboliths in the left pelvis displaced medially and a bullet in the middle of the pelvis (fig. 2, A). Excretory urography (IVP) showed the urinary bladder displaced to the right with extravasation of contrast medium into the region of the displaced phleboliths (fig. 2, B). Exploratory laparotomy confirmed an extraperitoneal perforation of the left posterior wall of the bladder with the bullet inside the bladder. About 600 ml. blood mixed with urine was aspirated from the retroperitoneal area of the pelvis. The bladder was repaired and convalescence was uneventful. A subsequent plain film of the pelvis showed return of the phleboliths on the left side to their normal symmetrical position (fig. 2, C). Comment: In this clinical setting, phlebolith displacement on the plain film of the pelvis may be the first sign of urine extravasation or pelvic hematoma and is an indication for contrast examination of the urinary tract. Case 2. A 74-year-old woman was admitted to the hospital with diffuse abdominal pain, weight
loss and progressive constipation. Six years previously she received a full course of irradiation therapy for stage 3 carcinoma of the uterine cervix. She was emaciated and had mild abdominal distention. Medial displacement of the left phleboliths was seen on a plain film of the abdomen (fig. 3, A). Pelvic examination revealed a large hard mass occupying the left two-thirds of the pelvis. Barium enema showed displacement and stretching of the sigmoid colon by the pelvic mass (fig. 3, B). Exploratory laparotomy confirmed epidermoid carcinoma involving the left pelvic wall and crossing the midline. No resection was attempted and subsequent treatment was supportive. Comment: With this history, radiographic demonstration of phlebolith displacement indicating a pelvic mass should suggest metastatic neoplasm. Case 3. A 78-year-old man was admitted to the hospital with weight loss, abdominal pain and vomiting. A prostatic resection for benign prostatic hypertrophy was performed 19 years previously. The patient was slightly dehydrated and had a moderately distended abdomen and slight epigastric tenderness. Hematocrit was 30 per cent, white blood count and differential were normal and the blood urea nitrogen was 25 mg. per cent. A plain film of the abdomen showed displacement of right phleboliths medially by a mass in the right side of the pelvis (fig. 4, A). A retrograde cystogram showed the mass to be a bladder diverticulum (figs. 4, B and C and 5). The patient underwent transurethral resection of the enlarged prostate. Convalescence was uneventful. Comment: Phlebolith displacement indicated the presence of a pelvic mass. However, there was no historical clue to the etiology. During evaluation of the prostate, cystography provided the diagnosis. DISCUSSION
Accepted for publication December 1970. * Current address: Department of Radiology, Veterans Administration Hospital, San Francisco, California 94121.
Radiographic detection of a pelvic mass often is difficult. Large lesions produce an abnormal in595
596
FENLON AND AUGUSTIN
Fm. 1. Normal appearance. Although there are some phleboliths near midline, majority are symmetrically placed laterally in pelvis. Note unusually large number.
crease in soft tissue density. Detection of lesions which do not significantly alter radiographic density is more difficult. The presence of abnormal pelvic calcification may signify a tumor but often is absent. Reliance usually must be placed on the indirert sign of displacement of pelvic structures which have different radiographic densities from soft tissues. Displacement of phleboliths is an indirect sign of a pelvic mass. Since they are normally symmetrical, displacement is a reliable finding. Phleboliths may be shifted in any direction, depending on their relationship to the mass. This finding does not give an etiologic diagnosis. It only indicates the presence of a space-occupying lesion. However, when correlated with the patient's history, this sign may yield valuable information.
Fm. 2. A, plain film reveals left phleboliths, especially superior one (arrow), displaced medially. Increase in soft tissue density lateral to them suggests mass. Note bullet. B, 10-minute IVP shows bladder and distal left ureter (arrow) displaced to right. Extraluminal contrast medium indicates bladder laceration with urine extravasation as cause of phlebolith displacement. C, 3 months after repair of ruptured bladder phleboliths on left side have returned to more symmetrical lateral position.
Fm. 3. A, plain film reveals upper left phleboliths displaced to right of midline by large mass. B, on post-evacuation barium enema mass displaces sigmoid colon upward and to right. Relationship of mass to displaced phleboliths (arrows) is better demonstrated.
PELVIC PHLEBOLITH DISPLACEMENT
597
Fm. 4. A, plain film re,eals phleboliths in right of pelvis displaced medially. Increased density lateral to phleboliths indicates mass. B, retrograde cystogram reveals trabeculation with diverticula. Large diverticulum is present on right side. C, oblique view of diverticulum on right posterolateral aspect of bladder. No special contrast study is necessary. Demonstration of the ureter and bladder requires opacification by IVP1 and the rectosigmoid must be filled with barium. A plain film of the pelvis is all that is needed to evaluate phlebolith position. Under these circumstances phlebolith displacement may be the first indication of a pelvic mass. Hemorrhage and urine extravasation owing to blunt or penetrating trauma are urgent remedial causes of displacement of pelvic structures (case 1). Since attention often is directed elsewhere in cases of multi-organ system trauma, and retroperitoneal hemorrhage sufficient to cause death may escape clinical detection,2 it is important to look carefully for any sign of retroperitoneal hemorrhage in these patients. Phlebo1 Friedenberg, R. M., Ney, C., Lopez, F. A. and Stachenfeld, R. A.: Clinical significance of deviations of the pelvic ureter. J. Urol., 96: 146, 1966. 2 McCarroll, J. IL, Braunstein, P. W., Cooper, W., Helpern, M., Seremetis, M., Wade, P.A. and Weinberg, S. B.: Fatal pedestrian automotive accidents. J.A.M.A., 180: 127, 1962.
Fm. 5. Post-void film shows contrast material trapped in diverticulum and relationship to displaced phleboliths. Diverticulum is cause of phlebolith displacement. lith displacement may be an important finding under these circumstances. Neoplasms are a recognized cause of phlebolith displacement (case 2). 3 The bladder diverticulum 3 Steinbach, H. L.: Identification of pelvic masses by phlebolith displacement. Amer. J. Roentgen., 83: 1063, 1960.
598
FENLON AND AUGUSTIN
in case 3 was an unexpected explanation of the pelvic mass. Pelvic abscess is another cause of phlebolith displacement. SUMMARY AND CONCLUSION
Pelvic phleboliths are natural markers of soft tissue anatomy and can be evaluated on any
plain film of the pelvis. Phlebolith displacement is an indirect sign of a pelvic mass and an indication for further clinical and roentgenographic evaluation. Phlebolith position should be carefully studied, particularly in patients with a history of neoplasm and in those hospitalized for trauma.