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Worcestershire Sauce-Induced Hematuria
0022-5347/82/1273-0554$02.00/0 Vol.127, March
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
Printed in U.S.A.
Letters to the Editor scended testes. Complete diagnostic study, including serum testosterone, pituitary gonadotropins and tumor markers, was within normal limits. Approximately 75 per cent of the urologists attending the meeting voted observation as the first mode of treatment. The rest recommended various management modalities, ranging from bilateral orchiopexy, unilateral orchiopexy and orchiectomy with or without vasectomy to bilateral orchiectomy. Since medical and ethical factors are involved in the management of such a patient we believe that it may be of interest to your readers to know about this consensus. Ultimate management of a similar patient must be individualized and views of parents or guardians must be taken into consideration.
CATHETER MANAGEMENT AFTER URETERONEOCYSTOSTOMY IN CHILDREN
To the Editor. The primary goals of an antireflux operation are preservation of renal function, restoration of the anatomy and function of the ureterovesical junction, and elimination of infection. Ideally, once surgical treatment has been elected, one would hope to correct the reflux and restore normal function of the urinary tract in as short a period as possible. The goal of postoperative management should be to provide a comfortable and uncomplicated course. To do this we attempted to minimize bladder spasms and clear infection, and to shorten the postoperative stay to a minimum, which was accomplished by early catheter removal. During the last 3 years 12 children who underwent ureteroneocystostomy had the Foley catheter and ureteral stents removed the morning after the operation. The average postoperative hospitalization was 3.5 days. There were subjectively less bladder spasms, less postoperative infection and a more comfortable postoperative course with a shorter hospital stay. More recently, we elected to do without catheter drainage altogether on the last 2 patients undergoing bilateral reimplantations. Both patients did well and both went home 2 days postoperatively. All followup radiographic studies showed absence of reflux and no hydronephrosis. Although this is a brief report the procedure does seem like a safe and worthwhile method of postoperative management. Respectfully, Robert B. Quattlebaum Savannah Urological Clinic 2515 Habersham Street Savannah, Georgia 31499 RE: CROHN'S DISEASE DEVELOPING IN ILEAL CONDUIT
Thomas C. McLaughlin J. Urol., 125: 420-421, 1981
To the Editor. Buried in our article on ileal conduits is another case of regional enteritis of an ileal conduit. 1 The patient underwent ileal conduit diversion for neurogenic bladder secondary to myelomeningocele. Eight years after the diversion the patient presented with hematuria, vague abdominal and flank pains, and bilateral hydroureteronephrosis secondary to ureteroileal obstruction. The conduitogram suggested a pipe steam conduit. A new ileal conduit was constructed without complication. The original ileal conduit showed chronic regional enteritis. Luckily, the bowel selected for the new conduit was not affected, since we were unaware of the pathology at the time of the operation. Doctor McLaughlin is to be congratulated on making this unusual diagnosis before renal damage occurred and stabilizing the situation without rebuilding the conduit. Respectfully, W Reid Pitts, Jr. Department of Surgery (Urology) James Buchanan Brady Foundation The New York Hospital-Cornell University Medical Center New York, New York 10021
Respectfully, Robert S. Davis· and Louis R. Cos Division of Urology, Box 656 Strong Memorial Hospital 601 Elmwood Avenue Rochester, New York 14642 WORCESTERSHIRE SAUCE-INDUCED HEMATURIA
To the Editor. Hematuria has been associated with drugs, chemicals, infections and parenchymal renal disease. Unique anecdotal reports concern this manifestation with the excessive intake of red currants 1 and soda pop. 2 We recently had the opportunity to study a child with gross and persistent microscopic hematuria associated with ingestion of excessive amounts of worcestershire sauce. The 10-year-old boy was seen after an episode of gross hematuria, followed by persistent microscopic hematuria. He had no history suggestive of post-streptococcal glomerulonephritis nor any other clinical manifestations. A physical examination was completely normal and a battery of laboratory tests was within normal limits, including blood urea nitrogen and creatinine. Of significance, the patient was fond of worcestershire sauce and habitually consumed two 32-ounce bottles monthly. Discontinuance of the worcestershire sauce was accompanied by disappearance of microscopic hematuria within 4 weeks. Worcestershire sauce was first implicated in causing renal damage in 1956, when Douthwaite reported on a patient who presented with massive proteinuria, granular casts, and increasing urea nitrogen and hypertension. 3 • 4 This patient became asymptomatic once the sauce was discontinued. Murphy reported on 5 patients with excessive intake of worcestershire sauce in whom bilateral renal calculi and general aminoaciduria and albuminuria were present in 3 and hypertension in 2. 5• 6 All patients showed some abnormality in the ammonium chloride test, suggesting that the sauce was nephrotoxic at the glomerular and tubular levels. Our patient seems to be the youngest ever observed having this manifestation. We believe that every patient with microscopic hematuria with no other symptomatology and with negative laboratory analysis should have a careful dietary history taken to determine any food idiosyncrasies that may be the cause of this manifestation. One wonders how many times we hastily diagnose subclinical postinfectious glomerulonephritis, when all laboratory analyses, physical examinations and renal function tests are normal. Respectfully, Michelle Rivera and Jose R. Salcedo Department of Nephrology Children's Hospital National Medical Center Washington, D. C. 20010 1. Vicary, P.: Haematuria. Letter to the Editor. Brit. Med. J., 2: 642, 1977. 2. Thompson, D. M.: Hematuria associated with soda pop drinking. Letter to the Editor. J.A.M.A., 239: 193, 1978. 3. Anonymous: Worcestershire sauce and the kidneys. Brit. Med. J., 3: 6, 1971. 4. Douthwaite, A. H.: Pitfalls in medicine. (Croonian lecture.) Brit. Med. J., 2: 958, 1956. 5. Murphy, K. J.: Bilateral renal calculi and aminoaciduria after excessive intake of worcestershire sauce. Lancet, 2: 401, 1967. 6. Murphy, K. J.: Worcestershire sauce and the kidney. Med. J. Aust., 1: 1119, 1971.
1. Pitts, W. R., Jr. and Muecke, E. C.: A 20-year experience with ileal conduits: the fate of the kidneys. J. Urol., 122: 154, 1979. POSTPUBERAL BILATERAL UNDESCENDED TESTIS
To the Editor. At the last meeting of the Northeastern Section of the American Urological Association (Ottawa, Ontario, Canada, September 21-23, 1981) we presented for management opinion the case of a 15-year-old white boy with profound mental retardation secondary to cerebral palsy who was found to have bilateral intra-abdominal unde554
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
Printed in U.S.A.
Letters to the Editor scended testes. Complete diagnostic study, including serum testosterone, pituitary gonadotropins and tumor markers, was within normal limits. Approximately 75 per cent of the urologists attending the meeting voted observation as the first mode of treatment. The rest recommended various management modalities, ranging from bilateral orchiopexy, unilateral orchiopexy and orchiectomy with or without vasectomy to bilateral orchiectomy. Since medical and ethical factors are involved in the management of such a patient we believe that it may be of interest to your readers to know about this consensus. Ultimate management of a similar patient must be individualized and views of parents or guardians must be taken into consideration.
CATHETER MANAGEMENT AFTER URETERONEOCYSTOSTOMY IN CHILDREN
To the Editor. The primary goals of an antireflux operation are preservation of renal function, restoration of the anatomy and function of the ureterovesical junction, and elimination of infection. Ideally, once surgical treatment has been elected, one would hope to correct the reflux and restore normal function of the urinary tract in as short a period as possible. The goal of postoperative management should be to provide a comfortable and uncomplicated course. To do this we attempted to minimize bladder spasms and clear infection, and to shorten the postoperative stay to a minimum, which was accomplished by early catheter removal. During the last 3 years 12 children who underwent ureteroneocystostomy had the Foley catheter and ureteral stents removed the morning after the operation. The average postoperative hospitalization was 3.5 days. There were subjectively less bladder spasms, less postoperative infection and a more comfortable postoperative course with a shorter hospital stay. More recently, we elected to do without catheter drainage altogether on the last 2 patients undergoing bilateral reimplantations. Both patients did well and both went home 2 days postoperatively. All followup radiographic studies showed absence of reflux and no hydronephrosis. Although this is a brief report the procedure does seem like a safe and worthwhile method of postoperative management. Respectfully, Robert B. Quattlebaum Savannah Urological Clinic 2515 Habersham Street Savannah, Georgia 31499 RE: CROHN'S DISEASE DEVELOPING IN ILEAL CONDUIT
Thomas C. McLaughlin J. Urol., 125: 420-421, 1981
To the Editor. Buried in our article on ileal conduits is another case of regional enteritis of an ileal conduit. 1 The patient underwent ileal conduit diversion for neurogenic bladder secondary to myelomeningocele. Eight years after the diversion the patient presented with hematuria, vague abdominal and flank pains, and bilateral hydroureteronephrosis secondary to ureteroileal obstruction. The conduitogram suggested a pipe steam conduit. A new ileal conduit was constructed without complication. The original ileal conduit showed chronic regional enteritis. Luckily, the bowel selected for the new conduit was not affected, since we were unaware of the pathology at the time of the operation. Doctor McLaughlin is to be congratulated on making this unusual diagnosis before renal damage occurred and stabilizing the situation without rebuilding the conduit. Respectfully, W Reid Pitts, Jr. Department of Surgery (Urology) James Buchanan Brady Foundation The New York Hospital-Cornell University Medical Center New York, New York 10021
Respectfully, Robert S. Davis· and Louis R. Cos Division of Urology, Box 656 Strong Memorial Hospital 601 Elmwood Avenue Rochester, New York 14642 WORCESTERSHIRE SAUCE-INDUCED HEMATURIA
To the Editor. Hematuria has been associated with drugs, chemicals, infections and parenchymal renal disease. Unique anecdotal reports concern this manifestation with the excessive intake of red currants 1 and soda pop. 2 We recently had the opportunity to study a child with gross and persistent microscopic hematuria associated with ingestion of excessive amounts of worcestershire sauce. The 10-year-old boy was seen after an episode of gross hematuria, followed by persistent microscopic hematuria. He had no history suggestive of post-streptococcal glomerulonephritis nor any other clinical manifestations. A physical examination was completely normal and a battery of laboratory tests was within normal limits, including blood urea nitrogen and creatinine. Of significance, the patient was fond of worcestershire sauce and habitually consumed two 32-ounce bottles monthly. Discontinuance of the worcestershire sauce was accompanied by disappearance of microscopic hematuria within 4 weeks. Worcestershire sauce was first implicated in causing renal damage in 1956, when Douthwaite reported on a patient who presented with massive proteinuria, granular casts, and increasing urea nitrogen and hypertension. 3 • 4 This patient became asymptomatic once the sauce was discontinued. Murphy reported on 5 patients with excessive intake of worcestershire sauce in whom bilateral renal calculi and general aminoaciduria and albuminuria were present in 3 and hypertension in 2. 5• 6 All patients showed some abnormality in the ammonium chloride test, suggesting that the sauce was nephrotoxic at the glomerular and tubular levels. Our patient seems to be the youngest ever observed having this manifestation. We believe that every patient with microscopic hematuria with no other symptomatology and with negative laboratory analysis should have a careful dietary history taken to determine any food idiosyncrasies that may be the cause of this manifestation. One wonders how many times we hastily diagnose subclinical postinfectious glomerulonephritis, when all laboratory analyses, physical examinations and renal function tests are normal. Respectfully, Michelle Rivera and Jose R. Salcedo Department of Nephrology Children's Hospital National Medical Center Washington, D. C. 20010 1. Vicary, P.: Haematuria. Letter to the Editor. Brit. Med. J., 2: 642, 1977. 2. Thompson, D. M.: Hematuria associated with soda pop drinking. Letter to the Editor. J.A.M.A., 239: 193, 1978. 3. Anonymous: Worcestershire sauce and the kidneys. Brit. Med. J., 3: 6, 1971. 4. Douthwaite, A. H.: Pitfalls in medicine. (Croonian lecture.) Brit. Med. J., 2: 958, 1956. 5. Murphy, K. J.: Bilateral renal calculi and aminoaciduria after excessive intake of worcestershire sauce. Lancet, 2: 401, 1967. 6. Murphy, K. J.: Worcestershire sauce and the kidney. Med. J. Aust., 1: 1119, 1971.
1. Pitts, W. R., Jr. and Muecke, E. C.: A 20-year experience with ileal conduits: the fate of the kidneys. J. Urol., 122: 154, 1979. POSTPUBERAL BILATERAL UNDESCENDED TESTIS
To the Editor. At the last meeting of the Northeastern Section of the American Urological Association (Ottawa, Ontario, Canada, September 21-23, 1981) we presented for management opinion the case of a 15-year-old white boy with profound mental retardation secondary to cerebral palsy who was found to have bilateral intra-abdominal unde554