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Ureteral Sciatic Hernias: Case Report of an Infant with Bilateral Ureteral Herniation into the Sciatic Foramina
Vol. 106, July Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
URETERAL SCIATIC HERNIAS: CASE REPORT OF AN INFANT WITH BILATERAL URETERAL HERNIATION INTO THE SCIATIC FORAMINA WILLIAM W. BOHNERT From the Urology Department, Indiana University Medical Center, Indianapolis, Indiana
Ureteral hernias are rare; 113 cases have been reported. Ureteral herniation into the sciatic foramen is even more rare; 3 cases have been reported previously. A patient with this anomaly is herein described.
urea nitrogen and chest x-ray were normal. On October 1 a ventriculoatrial shunt was placed for increasing hydrocephalus. General surgical and orthopedic consultations were obtained. The boy was discharged from the hospital on October 21. He was readmitted fo the hospital on November 10 for intermittent fever of 104F for 8 days prior to admission. Physical examination revealed the Holter valve was functioning well. All other, :findings were unchanged.
CASE REPORT
B. S., 444407, a 2½-month-old infant was admitted to the Neurosurgical Service on September 24, 1968 because of increasing hydrocephalus. He was born with a lumbar myelomeningocele,
A, anterior posterior view shows ureters in sciatic notch bilaterally. B, right posterior oblique. C, left postedor oblique.
umbilical hernia and bilateral club feet. The myelomeningocele was allowed to epithelialize. He had no evidence of sepsis or meningismus at any time. Physical examination revealed a deformed white boy with a large head (49½ cm.), flaccid lower extremities, well epithelialized lumbar myelomeningocele, a small umbilical hernia and an easily reducible prolapse of the rectum. The complete blood count, urinalysis, blood Accepted for publication November 1970. Current address: 3411 North 5th Avenue, Phoenix, Arizona 85013.
Urine culture yielded in excess of 100,000 colonies of Escherichia coli. Initial blood cultures were negative. He was treated with ampicillin before hospitalization but this was discontinued. He was released on November 15 but was readmitted on the Neurosurgical Service because earlier blood cultures had yielded Staphylococcus aureus. Blood cultures were repeated and were negative. Urologic consultation was requested because of bacilluria. An excretory urogram (IVP) revealed bilateral ureteral sciatic hernias with otherwise normal upper urinary tracts (see figure). Repeat urinalysis was negative. Medica-
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URETERAL SCIATIC HERNIAS
tion was discontinued on December 10 and the patient was released. He was last seen in the outpatient clinic on January 8, 1970 and was doing relatively welL DISCUSSION
Watson reviewed the literature m 1948 and found a total of 102 cases of ureteral hernias. 1 Since that time 11 instances have been reported bringing the number of ureteral hernias reported to 113. 2- 12 1 Watson, L. F.: Hernia; Anatomy, Etiology, Symptoms, Diagnosia, Differential Diagnosis, Prognosis and Treatment, 3rd ed. St. Louis: C. V. Mosby Co., pp. 476 and 576, 1948. 2 Barquin, 0. P. and Madsen, P. 0.: Scrotal herniation of the lower urinary tract. J. Urol., 98: 508, 1967. 3 Beck, W. C., Baurys, W., Brochu, J. and Morton, W. A., Jr.: Herniation of the ureter into the sciatic foramen ("curlicue ureter"). J.A.M.A., 149: 441, 1952. 4 Bondevik, H.: Inguinal prolapse of retroperitoneal fat ("fatty hernia"). Report of a case also involving the ureter. Acta Chir. Scand., 31: 492, 1966. 5 Fotopoulos, J.P. and Burkhead, H. C.: Herniation of the ureter. A review and report of a case. Arch. Surg., 82: 290, 1961. 6 Jewett, H. J. and Harris, A. P.: Scrotal ureter: report of a case. J. Urol., 69: 184, 1953. 7 Lindbom, A.: Unusual ureteral obstruction by herniation of ureter into sciatic foramen. Acta Radio!., 28: 225, 1947. 8 Page, B. H.: Obstruction of ureter in internal hernia. Brit. J. Urol., 27: 254, 1955. 9 Rothchild, T. P.: Ureteral hernia. Report of a case of herniation of the ureter into the sciatic foramen. Arch. Surg., 98: 96, 1969. 10 Schmidt, K.: Holyagnyak merevseg ureterreszlet lagyekservtartalomban. Gyermekgyogyaszat, 15: 48, 1964. 11 Swithin bank, A. H.: Intra thoracic deviation of a ureteric loop. Brit. J. Surg., 45: 379, 1958.
Sciatic hernias are the rarest of all hernias. 1?. Watson's comprehensive review uncovered 35 cases. Thomas notes that only a few cases of sciatic hernias have been reported since that time. 13 In 1947 Lindbom reported the first case of ureteral hernia into the sciatic foramen. 7 In 1952 Beck and associates reported the second case of this unusual entity. 3 Both cases were unilateral lesions in adults associated with obstruction of the ureter. More recently Rothchild reported the first case of bilateral ureteral sciatic herniaso 9 The left side was symptomatic because of ob-· struction requiring operative repair, while the right ureter was not obstructed. The case presented herein represents the fourth case of ureteral sciatic hernia, the second case of bilateral lesions and the first case of this in an infant. Our patient was totally asymptomatic and has had no signs of obstruction on IVP to date. The child will be followed closely because of his numerous congenital defects in our multi-specialty Myelomeningocele Clinic. SUMMARY
The fourth case of ureteral herniation into the sacrosciatic foramen is reported. This is the first such case reported in an infant. The radiologic findings, typical and diagnostic of sacrosciatic herniation, have been termed "curlicue ureter" by Beck and associates. 3 12 Tripathi, V. N. P. and Flint, L. D.: Ureteral herniation. Ann. Surg., 169: 417, 1969. 13 Thomas, G. F.: In: Hernia. Edited by L. M. Nyhus and H. N. Harkins. Philadelphia: J. B. Lippincott Co., p. 450, 1964.
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
URETERAL SCIATIC HERNIAS: CASE REPORT OF AN INFANT WITH BILATERAL URETERAL HERNIATION INTO THE SCIATIC FORAMINA WILLIAM W. BOHNERT From the Urology Department, Indiana University Medical Center, Indianapolis, Indiana
Ureteral hernias are rare; 113 cases have been reported. Ureteral herniation into the sciatic foramen is even more rare; 3 cases have been reported previously. A patient with this anomaly is herein described.
urea nitrogen and chest x-ray were normal. On October 1 a ventriculoatrial shunt was placed for increasing hydrocephalus. General surgical and orthopedic consultations were obtained. The boy was discharged from the hospital on October 21. He was readmitted fo the hospital on November 10 for intermittent fever of 104F for 8 days prior to admission. Physical examination revealed the Holter valve was functioning well. All other, :findings were unchanged.
CASE REPORT
B. S., 444407, a 2½-month-old infant was admitted to the Neurosurgical Service on September 24, 1968 because of increasing hydrocephalus. He was born with a lumbar myelomeningocele,
A, anterior posterior view shows ureters in sciatic notch bilaterally. B, right posterior oblique. C, left postedor oblique.
umbilical hernia and bilateral club feet. The myelomeningocele was allowed to epithelialize. He had no evidence of sepsis or meningismus at any time. Physical examination revealed a deformed white boy with a large head (49½ cm.), flaccid lower extremities, well epithelialized lumbar myelomeningocele, a small umbilical hernia and an easily reducible prolapse of the rectum. The complete blood count, urinalysis, blood Accepted for publication November 1970. Current address: 3411 North 5th Avenue, Phoenix, Arizona 85013.
Urine culture yielded in excess of 100,000 colonies of Escherichia coli. Initial blood cultures were negative. He was treated with ampicillin before hospitalization but this was discontinued. He was released on November 15 but was readmitted on the Neurosurgical Service because earlier blood cultures had yielded Staphylococcus aureus. Blood cultures were repeated and were negative. Urologic consultation was requested because of bacilluria. An excretory urogram (IVP) revealed bilateral ureteral sciatic hernias with otherwise normal upper urinary tracts (see figure). Repeat urinalysis was negative. Medica-
142
143
URETERAL SCIATIC HERNIAS
tion was discontinued on December 10 and the patient was released. He was last seen in the outpatient clinic on January 8, 1970 and was doing relatively welL DISCUSSION
Watson reviewed the literature m 1948 and found a total of 102 cases of ureteral hernias. 1 Since that time 11 instances have been reported bringing the number of ureteral hernias reported to 113. 2- 12 1 Watson, L. F.: Hernia; Anatomy, Etiology, Symptoms, Diagnosia, Differential Diagnosis, Prognosis and Treatment, 3rd ed. St. Louis: C. V. Mosby Co., pp. 476 and 576, 1948. 2 Barquin, 0. P. and Madsen, P. 0.: Scrotal herniation of the lower urinary tract. J. Urol., 98: 508, 1967. 3 Beck, W. C., Baurys, W., Brochu, J. and Morton, W. A., Jr.: Herniation of the ureter into the sciatic foramen ("curlicue ureter"). J.A.M.A., 149: 441, 1952. 4 Bondevik, H.: Inguinal prolapse of retroperitoneal fat ("fatty hernia"). Report of a case also involving the ureter. Acta Chir. Scand., 31: 492, 1966. 5 Fotopoulos, J.P. and Burkhead, H. C.: Herniation of the ureter. A review and report of a case. Arch. Surg., 82: 290, 1961. 6 Jewett, H. J. and Harris, A. P.: Scrotal ureter: report of a case. J. Urol., 69: 184, 1953. 7 Lindbom, A.: Unusual ureteral obstruction by herniation of ureter into sciatic foramen. Acta Radio!., 28: 225, 1947. 8 Page, B. H.: Obstruction of ureter in internal hernia. Brit. J. Urol., 27: 254, 1955. 9 Rothchild, T. P.: Ureteral hernia. Report of a case of herniation of the ureter into the sciatic foramen. Arch. Surg., 98: 96, 1969. 10 Schmidt, K.: Holyagnyak merevseg ureterreszlet lagyekservtartalomban. Gyermekgyogyaszat, 15: 48, 1964. 11 Swithin bank, A. H.: Intra thoracic deviation of a ureteric loop. Brit. J. Surg., 45: 379, 1958.
Sciatic hernias are the rarest of all hernias. 1?. Watson's comprehensive review uncovered 35 cases. Thomas notes that only a few cases of sciatic hernias have been reported since that time. 13 In 1947 Lindbom reported the first case of ureteral hernia into the sciatic foramen. 7 In 1952 Beck and associates reported the second case of this unusual entity. 3 Both cases were unilateral lesions in adults associated with obstruction of the ureter. More recently Rothchild reported the first case of bilateral ureteral sciatic herniaso 9 The left side was symptomatic because of ob-· struction requiring operative repair, while the right ureter was not obstructed. The case presented herein represents the fourth case of ureteral sciatic hernia, the second case of bilateral lesions and the first case of this in an infant. Our patient was totally asymptomatic and has had no signs of obstruction on IVP to date. The child will be followed closely because of his numerous congenital defects in our multi-specialty Myelomeningocele Clinic. SUMMARY
The fourth case of ureteral herniation into the sacrosciatic foramen is reported. This is the first such case reported in an infant. The radiologic findings, typical and diagnostic of sacrosciatic herniation, have been termed "curlicue ureter" by Beck and associates. 3 12 Tripathi, V. N. P. and Flint, L. D.: Ureteral herniation. Ann. Surg., 169: 417, 1969. 13 Thomas, G. F.: In: Hernia. Edited by L. M. Nyhus and H. N. Harkins. Philadelphia: J. B. Lippincott Co., p. 450, 1964.