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Vesicoureteral Reflux in Male Adults with Bladder Neck Obstruction
:
TIIE JOURNAL OF UROLOGY
' Vol.[89, No. 3 March 1963 Copyright © 1963 by The Williams & Wilkins Co. Printed in U.S.A.
VESICOURETERAL REFLUX IN MALE ADULTS WITH BLADDER ~ECK OBSTRUCTIO~ MANUEL M. MORILLO, AHMAD ORANDI, MANUEL FERNANDES DRAPER
AND
JOHN W.
From the Cornell Division of Surgery (Urology), Bellevue Hospital Center, New York, N. Y.
Regurgitation of vesical contents in men with bladder neck obstruction has been recognized ' clinically and radiographically for many years. A review of the literature discloses that very little has been offered concerning its actual incidence and potential complications. Zemblinoff1in 1883 was the first to demonstrate with experimental animals that regurgitation of vesical contents is possible. Many fascinating papers have been written about reflux and the vesicoureteral valve in animals and cadavers. 2-s Kretschmer 9 in 1916 observed ureteral reflux by means of cystograms in children under anesthesia. Reflux was further shown to occur in 3 adults in his series with disease of the vcsical outlet. In 1924, Bumpus10 reviewed 527 cystograms of Accepted for publication September 18, 1962. Presented (and awarded third prize) at the residents' essay contest meeting of New York Section of American Urological Association, Inc., New York, N. Y., April 25, 1962. 1 Zemblinoff: Dissertation Russ, 1883. Reviewed by J. Alksne: Folia Urol., 1: 338-365, 1907. 2 Lewin, L. and Goldschmidt, H.: Versuche ueber die Beziehungen zwischen Blase, Harnleiter, und Nierbecken. Virch. Arch. f. path. Anat.,
patients with prostatic hypertrophy and reflux was present in only 4.74 per cent. Many excellent papers have been published during the past 15 years concerning vesicoureteral reflux in children11-14 and many operations devised for its correction15-i7 hoping to prevent the serious sequelae produced by pyelonephritis and back pressure. Our work was begun with the idea of determining the incidence of reflux in men with obstruction of the bladder neck. However, as the study progressed, it was noted that several patients with reflux had serious clinical complications. MATERIAL
One hundred consecutive patients from the urological services of Bellevue Hospital, Cornell Division, and St. Luke's Hospital, New York, N. Y., were chosen for this study. Of these, 79 had benign prostatic hypertrophy, 11 bladder neck contracture and 10 prostatic carcinoma. In all, bladder neck obstruction was confirmed by cystoscopy. Cystograms were made on every patient.
134: 33-71, 1893. 3 Guyon, F. and Albarran: Anatomie et physiologie pathologiques de la retention d'urine. Arch. de Med. Exper, 2: 181-221, 1890. 4 Young, H. H.: Hydraulic pressure in genitourinary practice especially in contracture of bladder. Bull. Johns Hopkins Hosp., 9: 100-113,
1898.
5 Sampson, J. A.: Ascending renal infection with special reference to the reflux of urine from the bladder into the ureters. Bull. Johns Hopkins Hosp., 14: 334-350, 1903. 6 Draper, J. W. and Braasch, W.: The function of the uretero-vesical valve. J.A.M.A., 60: 20-24,
1913.
7 Caulk, J. R.: l\!Iegaloureter. The importance of the ureterovesical valve. J. Urol., 9: 315-330,
1923.
8 Graves, R. C. and Davidoff, L. M.: Studies on the ureter and bladder with special reference to regurgitation of the vesical contents. J. Urol.,
10: 185-231, 1923; 12: 93-103, 1924; 14: 1-17, 1925. 9 Kretschmer, H. L.: Cystography. Its value
and limitations in surgery of the bladder. Surg., Gynec. & Obst., 23: 709-717, 1916. 10 Bumpus, H. C., Jr.: Urinar:v reflux. J. Urol., 12: 341-34(i, 1925. 389
TECHNIQUE
After obtaining a flat film of the abdomen (KlTB), a catheter was inserted in the bladder 11 Keyes, E. L. and Ferguson, R. S.: Urologyo New York: D. Appleton-Century Co., 1938, p.
134. 12 Lo,vsley, 0. S. and Kirwin, T. J.: Clinical Urology. Baltimore: The Williams & Wilkins Co., 1940, vol. 2, p. 1158. 13 Gibson, H. M.: Ureteral reflux in the normal child. J. Urol., 62: 40, 1949. 14 Campbell, M. F.: Urology. Philadelphia: W. B. Saunders Co., 1954, vol. 2, p. 1459. "Hill, J. E., Dodson, A. I., Jr. and Hooper, J. W., Jr.: Experimental ureteroneocystostomy using nipple anastomosis technique. J. Urol., 74:
596, 1955. 16 Grey, D. N., Flynn, P. and Goodwin, W. E. · Experimental methods of ureteroneocystostomy; experiences with the ureteral intussusception to produce a nipple or valve. J. Urol., 77: 154, 1957. 17 Paquin, A. J., Jr.: Ureterovesical anastomosis; the description and evaluation of a technique. J. Urol., 82: 573, 1959.
390 TABLE
MORILLO, ORANDI, FERNANDES AND DRAPER
1. Vesicoureteral reflux in male adults with
bladder neck obstruction
Cytograms done . No reflux. Reflux. Reflux complicated by septicemia.
100
87 13 4
which was filled by gravity at 15 cm. pressure with 20 per cent hypaque solution until the patient expressed the desire to void or until the viscus was full. The catheter was then withdrawn and the distal urethra occluded by means of a penile clamp. Anteroposterior and oblique views were taken, then a voiding cystourethrogram and postvoiding films whenever feasible. In the majority of cases, a delayed cystogram was made.18 RESULTS
One hundred cystograms were obtained (table 1). Reflux in varying degrees was demonstrated in 13 of the 100 patients. Of these, reflux was present bilaterally in 4 patients, on the right side only in 4 patients, and on the left side only in 5 patients. The amount of reflux ranged from just a trickle of dye in the lower ureter to a complete pyeloureterogram (fig. 1). All of these showed low pressure reflux, i.e. demonstrable after bladder filling by gravity. All the patients with reflux who were able to urinate showed reflux on the voiding film as well. None of these patients showed reflux only on voiding. In one case (No. 7) reflux still could not be demonstrated 9 months after transurethral resection of the bladder neck (fig. 2). Gram-negative septicemia developed in four of the 13 cases with reflux. CASE REPORTS
Case 10, R. B., No. 44-70-00, a 66-year-old patient, underwent elective cholecystectomy and 8 hours following surgery urinary retention developed. A Foley catheter was inserted with difficulty (met obstruction at bladder neck). A few hours later he had chills, his temperature rose to 104.2F, his blood pressure dropped to shock levels and he became oliguric and eventually anuric. The blood urea nitrogen rose to 200 mg. per cent. Urine and blood cultures grew Bacillus proteus. The patient was treated by massive doses of antibiotics, vasopressors, cor18 Stewart, C. M.: Delayed cystograms. J. Urol., 70: 588, 1953; 74: 749, 1955.
ticosteroids, peritoneal dialysis and suprapubic cystostomy. On the tenth day, the temperature and blood pressure became normal. Three weeks later a cystogram showed right reflux. The patient was discharged on cystostomy drainage and 5 months later underwent transurethral prostatic resection, followed by a smooth postoperative course. This patient was treated with antibiotics during and following transurethral prostatectomy. Case 11, M.S., No. 35-80-11, a 58-year-old patient, underwent transurethral resection of a bladder neck contracture. Three days later, while in clot retention, he had shaking chills and his temperature rose to 105F. He also became hypotensive. He was treated by antibiotics, vasopressors, corticoids, etc., and responded well in 48 hours. Three weeks after surgery, the catheter was removed. That evening he had shaking chills, a temperature of 105F and hypotension. Catheterization recovered 300 cc grossly infected urine. Treated as before, the patient responded well in 3 days. Urine culture grew Aerobacter aerogenes; several blood cultures were negative. A cystogram revealed right reflux. Case 12, E.C., No. 50409-57, a 66-year-old patient, was admitted with urinary retention, chills and fever (103F). He had severe right flank pain for 3 days prior to admission. The fever and flank pain abated in 24 hours on catheter drainage and antibiotic therapy. One week later a cystogram revealed right reflux and cystoscopy confirmed the diagnosis of benign prostatic hypertrophy. Four hours after the procedure the patient had chills, fever (104F) and hypotension. He was treated with vasopressors, steroids and chloramphenicol and responded well in 2 days. Urine and blood cultures grew E. coli and B. proteus. A suprapubic cystostomy 2 days later ,vas followed 6 weeks later by a second stage suprapubic prostatectomy. This procedure was complicated by fever ranging from 101 to 102F for 10 days postoperatively. A continuous bladder irrigation with saline was used the first 3 postoperative days. Blood cultures were negative postoperatively. Case 13, M.K., No. 60464-60, a 74-year-old patient, underwent suprapubic cystostomy because of elevated blood urea nitrogen and daily elevations of fever to 102F which did not improve on urethral catheter drainage. Urine and blood
REFLUX WITH BLADDER NECK OBSTRUCTION
391
Frn. 1. A, example of minimal reflux. B, example of marked reflux
FIG. 2. A, preoperative cystogram of bladder neck contracture. B, l month following transurethral resection of bladder neck. C, 9 months following transurethral resection of bladder neck.
cultures grew B. proteus resistant to all drugs. He continued to have fever for 10 weeks. A cystogram showed bilateral reflux. This procedure was followed by severe chills, temperature of I05F and hypotension. He was treated by antibiotics,
vasopressors and steroids and responded well to therapy in 5 clays. Three months later, he underwent transurethral resection of the prostate followed by slight temperature elevation for 3 days. During and after the surgical procedure
392
MORILLO, ORANDI, FERNANDES AND DRAPER
the patient received the same antibiotics that proved successful for the septicemic bout which followed the cystogram. DISCUSSION
It has been demonstrated that vesicoureteral reflux in men is not a normal finding. 19 Our series shows that the incidence of reflux is much higher than was suspected in the past10 and also that septicemia develops in many of these patients. Eleven of the 13 patients with reflux had infected urine (table 2). The majority of those with reflux did not have any severe complication following instrumentation or surgery on the bladder neck. Eight of them were given antibiotics during and after surgery; none of these patients had septicemia. However, 2 patients without septicemia had temperature elevations ranging from 101.6 to 103F for 4 to 10 days following surgery. The cause of the fever could not be determined. None of these patients had chills, flank pain, hypotension or positive blood cultures. In contradistinction, none of the 87 cases with bladder neck obstruction without reflux had unexplainable fever or septicemia, clinically or bacteriologically. The history of this group of patients showed that 3 cases (Nos. 3, 9, 12) had acute urinary retention accompanied by flank pain and fever. In none of these cases a history of previous kidney infection or any symptom which could be attributed to pyelonephritis was elicited. It is curious to notice in table 2 that the only patients who had chills and fever following urethral instrumentation were those who had septicemia. Hence, it would seem that many of the urethral chills so commonly seen may be due to the passage of bacteria into the bloodstream, not actually from the urethra but from the kidney, although the former remains an important route of entrance of infection. Two cases (Nos. 10 and 12) had gram-negative septicemia following urethral instrumentation; in case 10, the septicemia followed insertion of a urethral catheter. Septicemia developed in the other patient (No. 12) 4 hours after cystoscopy. The same patient had a 19 Leadbetter, G. W., Jr., Duxbury, J. H. and preyfuss, J. R.: Absence of vesicoureteral reflux m 20nor~al male adults. J. Urol., 84:. 69, 1960. Wmter, C. C.: New test for ves1coureteral reflux; external technique using radioisotopes. J. Urol., 81: 105, 1959.
temperature of 101 to 102F for 10 days after suprapubic prostatectomy in spite of antibiotics (continuous bladder irrigation with saline was used in this case) . One patient (case 11) had 2 bouts of septicemia, the first one while in clot retention and the second one following removal of the urethral catheter with poor voiding and high residuum. This patient without explanation had a temperature of 104F for a few hours a week before surgery. Case 13 had daily temperature elevations to 102 or 103F for about 10 weeks with 2 positive blood cultures. The same patient had fever following bladder neck surgery. Blood cultures were neo·ab tive. There was no correlation between the condition of the upper urinary tracts of these patients, as shown by excretory urogram, and the severity of reflux, or between the degree of bladder neck obstruction (manifested by trabeculation and amount of residual urine) and reflux. We saw patients with 3000 cc residual urine and huge bladder diverticula who had no signs of reflux. On the other hand, some patients with bladder neck contracture or a small prostatic adenoma with very little residual urine did have reflux. The 10 patients with prostatic carcinoma showed no reflux. Only one of the patients with reflux had a truly patulous ureteral orifice. There does not seem to be any relationship between the severity of the reflux, as shown by cystogram, and the severity of the septicemia. Curiously, all the patients with reflux and septicemia had reflux on the right side, except one, who had it on the left as well. Reflux does not seem to produce back pain unless associated with pyelonephritis. Eight of the 13 cases with reflux did not have clinical manifestations of pyelonephritis or septicemia although most of them had infected urine. In sharp contrast, the majority of children with vesicoureteral reflux do have the aforementioned complications. Do adults present better resistance to infection due to local vaccination? This phenomenon can not be explained in the light of our present knowledge of the subject. From all the facts mentioned one can surmise how difficult it would be to suspect reflux in this group of patients, based only on the history (although 3 cases had urinary retention with fever and flank pain), physical examination,
TABLE
Case No.
Diag.
Symptoms
Reflux
Urine Culture
2. Patients with reflux
HypoChills, Fever, tension PostPostInstrum.en- Instrumentation tation
Blood Culture
Operation
Post-op Post-op HypoFever tension
Post-op Blood Culture
Antibiotic
WITHOUT SEPTICEMIA
BPH
2
BPH
Bilat.
No
Sterile
No
No
TUR TUR
3
BPH
Left
Retention, fever, flank pain
E. coli
No
No
Cystostomy, TUR
1
Bilat.
No
Sterile
No
No
No
No
No
No
Yes
No
Yes
Yes Sterile
Yes
~i>1
BPH BPH
Bilat.
No
E. coli
No
No
TUR
No
No
Yes
5
Left
No
Aerobact. aerogenes
No
No
TUR
No
No
No
6
BPH
Left
No
E. coli
No
No
No
No
Yes
7
Bladder neck contracture
Left*
No
Aerobact. aerogenes
No
No
TUR TUR
No
No
Yes
8
BPH BPH
Right
No
E.coli
No
No
TUR
No
No
Yes
Left
Retention fever, flank
E. coli
No
Nu
Supra pubic prostatectomy
Yes
No
4
9
~
~ ~ i:,:j
Sterile
Yes
~
t:I t:I
trj ~
ztrj 0
P'i 0
i:,:j
[/)_
~
COMPLICATED BY SEPTICEMIA
0
10
BPH
Right
No
B. proteus
Yes
Yes
Proteus
Cystostomy TUR
Yes
11
Bladder neck contracture
Right
No
Aerobact. aerogenes
Yes
No
Sterilet
TUR
Yes
12
BPH
Right
Retention, fever, flank pain
B. proteus E.coli
Yes
Yes
Proteus
2 stage suprapubic prosta tectomy
Yes
No
Aerobact. aerogenes
Yes
Cystostomy TUR
Yes
13
BPH
Bilat.
* Reflux disappeared 9 months after surgery. t See cases No. 11, M.S., No. 35-80-11.
Yes
Aerobact. aerogenes
Yes
Sterile
Yes
Yes
Sterile
Yes
No
Sterile
Yes
No
Sterile
Yes
~
0
z
i
~
co ~
394
MORILLO, ORANDI, FERNANDES AND DRAPER
pyelography and cystoscopic findings without a cystogram SUMMARY
A historical sketch of vesicoureteral reflux has been presented. One hundred cystograms were done in men with bladder neck obstruction; 13 per cent showed some degree of reflux. Four of the 13 patients with reflu.,'C had gram-negative septicemia following urethral instrumentation or bladder neck surgery. This is attributed to the passage of infected vesical contents into the bloodstream via the kidney. None of the 87 cases without reflux had septicemia. CONCLUSIONS
In view of the high incidence of reflux demonstrated by improved cystographic technique and the serious complications that might arise from it, a cystogram would seem advisable in diagnostic studies of all adults with bladder neck obstruction. Our cases seem to indicate that some of the urethral chills seen after urethral instru-
mentation may be due to regurgitation of infected material into the bloodstream via the kidney in patients with vesicoureteral reflux. The urethral chill may be a clue to the diagnosis of reflu.,'C. Cystograms should be obtained in patients who have urethral chills. Patients with obstruction of the bladder neck and reflux should be treated by appropriate antibiotics during and after bladder instrumentation or prostatic surgery. If transurethral surgery is to be performed, bladder overdistention and high pressure irrigation should be carefully avoided. The dangers of bladder irrigation are therefore obvious. We have not been able to follow all the patients with reflux. However, one patient no longer experienced reflux 9 months following surgical correction of the obstructed bladder neck. The authors express gratitude to Mrs. Ethel Ferguson, Mr. Robert Theologus and Miss Magdalena Schneider for invaluable help in preparation of this paper.
TIIE JOURNAL OF UROLOGY
' Vol.[89, No. 3 March 1963 Copyright © 1963 by The Williams & Wilkins Co. Printed in U.S.A.
VESICOURETERAL REFLUX IN MALE ADULTS WITH BLADDER ~ECK OBSTRUCTIO~ MANUEL M. MORILLO, AHMAD ORANDI, MANUEL FERNANDES DRAPER
AND
JOHN W.
From the Cornell Division of Surgery (Urology), Bellevue Hospital Center, New York, N. Y.
Regurgitation of vesical contents in men with bladder neck obstruction has been recognized ' clinically and radiographically for many years. A review of the literature discloses that very little has been offered concerning its actual incidence and potential complications. Zemblinoff1in 1883 was the first to demonstrate with experimental animals that regurgitation of vesical contents is possible. Many fascinating papers have been written about reflux and the vesicoureteral valve in animals and cadavers. 2-s Kretschmer 9 in 1916 observed ureteral reflux by means of cystograms in children under anesthesia. Reflux was further shown to occur in 3 adults in his series with disease of the vcsical outlet. In 1924, Bumpus10 reviewed 527 cystograms of Accepted for publication September 18, 1962. Presented (and awarded third prize) at the residents' essay contest meeting of New York Section of American Urological Association, Inc., New York, N. Y., April 25, 1962. 1 Zemblinoff: Dissertation Russ, 1883. Reviewed by J. Alksne: Folia Urol., 1: 338-365, 1907. 2 Lewin, L. and Goldschmidt, H.: Versuche ueber die Beziehungen zwischen Blase, Harnleiter, und Nierbecken. Virch. Arch. f. path. Anat.,
patients with prostatic hypertrophy and reflux was present in only 4.74 per cent. Many excellent papers have been published during the past 15 years concerning vesicoureteral reflux in children11-14 and many operations devised for its correction15-i7 hoping to prevent the serious sequelae produced by pyelonephritis and back pressure. Our work was begun with the idea of determining the incidence of reflux in men with obstruction of the bladder neck. However, as the study progressed, it was noted that several patients with reflux had serious clinical complications. MATERIAL
One hundred consecutive patients from the urological services of Bellevue Hospital, Cornell Division, and St. Luke's Hospital, New York, N. Y., were chosen for this study. Of these, 79 had benign prostatic hypertrophy, 11 bladder neck contracture and 10 prostatic carcinoma. In all, bladder neck obstruction was confirmed by cystoscopy. Cystograms were made on every patient.
134: 33-71, 1893. 3 Guyon, F. and Albarran: Anatomie et physiologie pathologiques de la retention d'urine. Arch. de Med. Exper, 2: 181-221, 1890. 4 Young, H. H.: Hydraulic pressure in genitourinary practice especially in contracture of bladder. Bull. Johns Hopkins Hosp., 9: 100-113,
1898.
5 Sampson, J. A.: Ascending renal infection with special reference to the reflux of urine from the bladder into the ureters. Bull. Johns Hopkins Hosp., 14: 334-350, 1903. 6 Draper, J. W. and Braasch, W.: The function of the uretero-vesical valve. J.A.M.A., 60: 20-24,
1913.
7 Caulk, J. R.: l\!Iegaloureter. The importance of the ureterovesical valve. J. Urol., 9: 315-330,
1923.
8 Graves, R. C. and Davidoff, L. M.: Studies on the ureter and bladder with special reference to regurgitation of the vesical contents. J. Urol.,
10: 185-231, 1923; 12: 93-103, 1924; 14: 1-17, 1925. 9 Kretschmer, H. L.: Cystography. Its value
and limitations in surgery of the bladder. Surg., Gynec. & Obst., 23: 709-717, 1916. 10 Bumpus, H. C., Jr.: Urinar:v reflux. J. Urol., 12: 341-34(i, 1925. 389
TECHNIQUE
After obtaining a flat film of the abdomen (KlTB), a catheter was inserted in the bladder 11 Keyes, E. L. and Ferguson, R. S.: Urologyo New York: D. Appleton-Century Co., 1938, p.
134. 12 Lo,vsley, 0. S. and Kirwin, T. J.: Clinical Urology. Baltimore: The Williams & Wilkins Co., 1940, vol. 2, p. 1158. 13 Gibson, H. M.: Ureteral reflux in the normal child. J. Urol., 62: 40, 1949. 14 Campbell, M. F.: Urology. Philadelphia: W. B. Saunders Co., 1954, vol. 2, p. 1459. "Hill, J. E., Dodson, A. I., Jr. and Hooper, J. W., Jr.: Experimental ureteroneocystostomy using nipple anastomosis technique. J. Urol., 74:
596, 1955. 16 Grey, D. N., Flynn, P. and Goodwin, W. E. · Experimental methods of ureteroneocystostomy; experiences with the ureteral intussusception to produce a nipple or valve. J. Urol., 77: 154, 1957. 17 Paquin, A. J., Jr.: Ureterovesical anastomosis; the description and evaluation of a technique. J. Urol., 82: 573, 1959.
390 TABLE
MORILLO, ORANDI, FERNANDES AND DRAPER
1. Vesicoureteral reflux in male adults with
bladder neck obstruction
Cytograms done . No reflux. Reflux. Reflux complicated by septicemia.
100
87 13 4
which was filled by gravity at 15 cm. pressure with 20 per cent hypaque solution until the patient expressed the desire to void or until the viscus was full. The catheter was then withdrawn and the distal urethra occluded by means of a penile clamp. Anteroposterior and oblique views were taken, then a voiding cystourethrogram and postvoiding films whenever feasible. In the majority of cases, a delayed cystogram was made.18 RESULTS
One hundred cystograms were obtained (table 1). Reflux in varying degrees was demonstrated in 13 of the 100 patients. Of these, reflux was present bilaterally in 4 patients, on the right side only in 4 patients, and on the left side only in 5 patients. The amount of reflux ranged from just a trickle of dye in the lower ureter to a complete pyeloureterogram (fig. 1). All of these showed low pressure reflux, i.e. demonstrable after bladder filling by gravity. All the patients with reflux who were able to urinate showed reflux on the voiding film as well. None of these patients showed reflux only on voiding. In one case (No. 7) reflux still could not be demonstrated 9 months after transurethral resection of the bladder neck (fig. 2). Gram-negative septicemia developed in four of the 13 cases with reflux. CASE REPORTS
Case 10, R. B., No. 44-70-00, a 66-year-old patient, underwent elective cholecystectomy and 8 hours following surgery urinary retention developed. A Foley catheter was inserted with difficulty (met obstruction at bladder neck). A few hours later he had chills, his temperature rose to 104.2F, his blood pressure dropped to shock levels and he became oliguric and eventually anuric. The blood urea nitrogen rose to 200 mg. per cent. Urine and blood cultures grew Bacillus proteus. The patient was treated by massive doses of antibiotics, vasopressors, cor18 Stewart, C. M.: Delayed cystograms. J. Urol., 70: 588, 1953; 74: 749, 1955.
ticosteroids, peritoneal dialysis and suprapubic cystostomy. On the tenth day, the temperature and blood pressure became normal. Three weeks later a cystogram showed right reflux. The patient was discharged on cystostomy drainage and 5 months later underwent transurethral prostatic resection, followed by a smooth postoperative course. This patient was treated with antibiotics during and following transurethral prostatectomy. Case 11, M.S., No. 35-80-11, a 58-year-old patient, underwent transurethral resection of a bladder neck contracture. Three days later, while in clot retention, he had shaking chills and his temperature rose to 105F. He also became hypotensive. He was treated by antibiotics, vasopressors, corticoids, etc., and responded well in 48 hours. Three weeks after surgery, the catheter was removed. That evening he had shaking chills, a temperature of 105F and hypotension. Catheterization recovered 300 cc grossly infected urine. Treated as before, the patient responded well in 3 days. Urine culture grew Aerobacter aerogenes; several blood cultures were negative. A cystogram revealed right reflux. Case 12, E.C., No. 50409-57, a 66-year-old patient, was admitted with urinary retention, chills and fever (103F). He had severe right flank pain for 3 days prior to admission. The fever and flank pain abated in 24 hours on catheter drainage and antibiotic therapy. One week later a cystogram revealed right reflux and cystoscopy confirmed the diagnosis of benign prostatic hypertrophy. Four hours after the procedure the patient had chills, fever (104F) and hypotension. He was treated with vasopressors, steroids and chloramphenicol and responded well in 2 days. Urine and blood cultures grew E. coli and B. proteus. A suprapubic cystostomy 2 days later ,vas followed 6 weeks later by a second stage suprapubic prostatectomy. This procedure was complicated by fever ranging from 101 to 102F for 10 days postoperatively. A continuous bladder irrigation with saline was used the first 3 postoperative days. Blood cultures were negative postoperatively. Case 13, M.K., No. 60464-60, a 74-year-old patient, underwent suprapubic cystostomy because of elevated blood urea nitrogen and daily elevations of fever to 102F which did not improve on urethral catheter drainage. Urine and blood
REFLUX WITH BLADDER NECK OBSTRUCTION
391
Frn. 1. A, example of minimal reflux. B, example of marked reflux
FIG. 2. A, preoperative cystogram of bladder neck contracture. B, l month following transurethral resection of bladder neck. C, 9 months following transurethral resection of bladder neck.
cultures grew B. proteus resistant to all drugs. He continued to have fever for 10 weeks. A cystogram showed bilateral reflux. This procedure was followed by severe chills, temperature of I05F and hypotension. He was treated by antibiotics,
vasopressors and steroids and responded well to therapy in 5 clays. Three months later, he underwent transurethral resection of the prostate followed by slight temperature elevation for 3 days. During and after the surgical procedure
392
MORILLO, ORANDI, FERNANDES AND DRAPER
the patient received the same antibiotics that proved successful for the septicemic bout which followed the cystogram. DISCUSSION
It has been demonstrated that vesicoureteral reflux in men is not a normal finding. 19 Our series shows that the incidence of reflux is much higher than was suspected in the past10 and also that septicemia develops in many of these patients. Eleven of the 13 patients with reflux had infected urine (table 2). The majority of those with reflux did not have any severe complication following instrumentation or surgery on the bladder neck. Eight of them were given antibiotics during and after surgery; none of these patients had septicemia. However, 2 patients without septicemia had temperature elevations ranging from 101.6 to 103F for 4 to 10 days following surgery. The cause of the fever could not be determined. None of these patients had chills, flank pain, hypotension or positive blood cultures. In contradistinction, none of the 87 cases with bladder neck obstruction without reflux had unexplainable fever or septicemia, clinically or bacteriologically. The history of this group of patients showed that 3 cases (Nos. 3, 9, 12) had acute urinary retention accompanied by flank pain and fever. In none of these cases a history of previous kidney infection or any symptom which could be attributed to pyelonephritis was elicited. It is curious to notice in table 2 that the only patients who had chills and fever following urethral instrumentation were those who had septicemia. Hence, it would seem that many of the urethral chills so commonly seen may be due to the passage of bacteria into the bloodstream, not actually from the urethra but from the kidney, although the former remains an important route of entrance of infection. Two cases (Nos. 10 and 12) had gram-negative septicemia following urethral instrumentation; in case 10, the septicemia followed insertion of a urethral catheter. Septicemia developed in the other patient (No. 12) 4 hours after cystoscopy. The same patient had a 19 Leadbetter, G. W., Jr., Duxbury, J. H. and preyfuss, J. R.: Absence of vesicoureteral reflux m 20nor~al male adults. J. Urol., 84:. 69, 1960. Wmter, C. C.: New test for ves1coureteral reflux; external technique using radioisotopes. J. Urol., 81: 105, 1959.
temperature of 101 to 102F for 10 days after suprapubic prostatectomy in spite of antibiotics (continuous bladder irrigation with saline was used in this case) . One patient (case 11) had 2 bouts of septicemia, the first one while in clot retention and the second one following removal of the urethral catheter with poor voiding and high residuum. This patient without explanation had a temperature of 104F for a few hours a week before surgery. Case 13 had daily temperature elevations to 102 or 103F for about 10 weeks with 2 positive blood cultures. The same patient had fever following bladder neck surgery. Blood cultures were neo·ab tive. There was no correlation between the condition of the upper urinary tracts of these patients, as shown by excretory urogram, and the severity of reflux, or between the degree of bladder neck obstruction (manifested by trabeculation and amount of residual urine) and reflux. We saw patients with 3000 cc residual urine and huge bladder diverticula who had no signs of reflux. On the other hand, some patients with bladder neck contracture or a small prostatic adenoma with very little residual urine did have reflux. The 10 patients with prostatic carcinoma showed no reflux. Only one of the patients with reflux had a truly patulous ureteral orifice. There does not seem to be any relationship between the severity of the reflux, as shown by cystogram, and the severity of the septicemia. Curiously, all the patients with reflux and septicemia had reflux on the right side, except one, who had it on the left as well. Reflux does not seem to produce back pain unless associated with pyelonephritis. Eight of the 13 cases with reflux did not have clinical manifestations of pyelonephritis or septicemia although most of them had infected urine. In sharp contrast, the majority of children with vesicoureteral reflux do have the aforementioned complications. Do adults present better resistance to infection due to local vaccination? This phenomenon can not be explained in the light of our present knowledge of the subject. From all the facts mentioned one can surmise how difficult it would be to suspect reflux in this group of patients, based only on the history (although 3 cases had urinary retention with fever and flank pain), physical examination,
TABLE
Case No.
Diag.
Symptoms
Reflux
Urine Culture
2. Patients with reflux
HypoChills, Fever, tension PostPostInstrum.en- Instrumentation tation
Blood Culture
Operation
Post-op Post-op HypoFever tension
Post-op Blood Culture
Antibiotic
WITHOUT SEPTICEMIA
BPH
2
BPH
Bilat.
No
Sterile
No
No
TUR TUR
3
BPH
Left
Retention, fever, flank pain
E. coli
No
No
Cystostomy, TUR
1
Bilat.
No
Sterile
No
No
No
No
No
No
Yes
No
Yes
Yes Sterile
Yes
~i>1
BPH BPH
Bilat.
No
E. coli
No
No
TUR
No
No
Yes
5
Left
No
Aerobact. aerogenes
No
No
TUR
No
No
No
6
BPH
Left
No
E. coli
No
No
No
No
Yes
7
Bladder neck contracture
Left*
No
Aerobact. aerogenes
No
No
TUR TUR
No
No
Yes
8
BPH BPH
Right
No
E.coli
No
No
TUR
No
No
Yes
Left
Retention fever, flank
E. coli
No
Nu
Supra pubic prostatectomy
Yes
No
4
9
~
~ ~ i:,:j
Sterile
Yes
~
t:I t:I
trj ~
ztrj 0
P'i 0
i:,:j
[/)_
~
COMPLICATED BY SEPTICEMIA
0
10
BPH
Right
No
B. proteus
Yes
Yes
Proteus
Cystostomy TUR
Yes
11
Bladder neck contracture
Right
No
Aerobact. aerogenes
Yes
No
Sterilet
TUR
Yes
12
BPH
Right
Retention, fever, flank pain
B. proteus E.coli
Yes
Yes
Proteus
2 stage suprapubic prosta tectomy
Yes
No
Aerobact. aerogenes
Yes
Cystostomy TUR
Yes
13
BPH
Bilat.
* Reflux disappeared 9 months after surgery. t See cases No. 11, M.S., No. 35-80-11.
Yes
Aerobact. aerogenes
Yes
Sterile
Yes
Yes
Sterile
Yes
No
Sterile
Yes
No
Sterile
Yes
~
0
z
i
~
co ~
394
MORILLO, ORANDI, FERNANDES AND DRAPER
pyelography and cystoscopic findings without a cystogram SUMMARY
A historical sketch of vesicoureteral reflux has been presented. One hundred cystograms were done in men with bladder neck obstruction; 13 per cent showed some degree of reflux. Four of the 13 patients with reflu.,'C had gram-negative septicemia following urethral instrumentation or bladder neck surgery. This is attributed to the passage of infected vesical contents into the bloodstream via the kidney. None of the 87 cases without reflux had septicemia. CONCLUSIONS
In view of the high incidence of reflux demonstrated by improved cystographic technique and the serious complications that might arise from it, a cystogram would seem advisable in diagnostic studies of all adults with bladder neck obstruction. Our cases seem to indicate that some of the urethral chills seen after urethral instru-
mentation may be due to regurgitation of infected material into the bloodstream via the kidney in patients with vesicoureteral reflux. The urethral chill may be a clue to the diagnosis of reflu.,'C. Cystograms should be obtained in patients who have urethral chills. Patients with obstruction of the bladder neck and reflux should be treated by appropriate antibiotics during and after bladder instrumentation or prostatic surgery. If transurethral surgery is to be performed, bladder overdistention and high pressure irrigation should be carefully avoided. The dangers of bladder irrigation are therefore obvious. We have not been able to follow all the patients with reflux. However, one patient no longer experienced reflux 9 months following surgical correction of the obstructed bladder neck. The authors express gratitude to Mrs. Ethel Ferguson, Mr. Robert Theologus and Miss Magdalena Schneider for invaluable help in preparation of this paper.