LUTS in a female attributable to an unusual vesical foreign body

Introduction

A bladder calculus following vesical foreign bodies is uncommon and usually presents with lower urinary tract symptoms (LUTS).¹Sozen S, Kupeli B, Ogunzulgen A I, et al. Gazi Medical Journal 2000;11:179-181.   Many of these intravesical foreign bodies are either left inadvertently after open bladder operations or migrate from adjacent structures, and in many cases were diagnosed while investigating for unrelated conditions; though there are reports where a foreign body was accidentally or even intentionally inserted into the bladder by the patient. The case report given below presents an unusual self inserted foreign body in a female presenting with bladder calculus and diverticulum, and LUTS. Self inserted foreign body in bladder, mostly in females, represents one of the causes of bladder stones,²Nasir SS, Singh B, Qazi WS. JK Practitioner 2004;11:268-269.   and should be suspected in a female patient with chronic LUTS even in the absence of trauma or intervention.

Case history

A 35-year old female patient presented to the out patient department with difficulty in passing urine characterized by irritative and obstructive lower urinary symptoms and double micturition for more than one and a half years. Though she had a history of fever 3 weeks prior to presentation, she denied any history of genitourinary trauma. A plain abdominal x-ray revealed a foreign body in the bladder (Figure 1). The patient reported having urethral itching prior to the onset of symptoms, and used a small knitting needle to scratch the urethra which resulted in accidental loss of the needle into the bladder. However, she mentioned that she was hesitant to seek medical attention at that time due to embarrassment. Also, she said that the symptoms were not that bothersome earlier and only recently increased in severity, affecting her daily life. Her psychiatric evaluation revealed no significant deviation, and she was marked to have sound cognitive domains.

Examination

Examination revealed a febrile middle-aged female (temperature-38.4^oC) with marked suprapubic tenderness, and a bimanually hard pelvic mass was revealed on digital rectal examination. This made an impression of bladder outflow obstruction from vesical calculus secondary to foreign body that was also attributable to the LUTS presentation in the patient. A huge vesical calculus was revealed on abdominopelvic ultrasound that was consistent with the plain abdominal x-ray revealing a radio-opaque shadow in the region of the bladder with metallic dense shadow within it (Figure 1). A right posterior lateral bladder diverticulum, with a filling defect and mucosal irregularity, was found to be present on intravenous urogram.

Biochemical evaluation of the patient revealed normal electrolytes, except for elevated urea (12 mmol/l) that was normalized after hydration and bladder drainage. Urine microscopy and culture was performed that revealed presence of many white blood cells (WBCs) and no red blood cell (RBC), and no organism was isolated. After a detailed discussion with the patient, cystourethroscopy was performed which revealed a foreign body embedded in a massive vesical calculus with a posterior lateral bladder diverticulum.

Treatment

The patient was treated with intravenous (IV) antibiotics, IV fluids and analgesics before she underwent a cystostomy and removal of the foreign body and vesical calculus with diverticulectomy; the stone measured 8cm×8cm×8cm (Figure 2). She did well after the procedure and was voiding with good urinary stream. She was subsequently discharged and was advised to take flavoxate HCl 100 mg tablets 3 times a day for symptomatic relief of LUTS.

Antispasmodic medications such as flavoxate are widely used, especially in women, to treat bladder symptoms

of burning micturition, dysuria and overactive bladder.³Laborde EE, McVary KT. Rev Urol. 2009 Fall;11(Suppl 1): S19-S25.   Flavoxate is a smooth muscle relaxant and has been widely used to treat urgency and urge incontinence. In an unblinded, uncontrolled clinical trial in urology departments involving 361 patients with urgency/incontinence of various types, patients were given flavoxate 200 mg three times daily, orally, for 2 weeks (33 patients received a daily dosage of 1200 mg).⁴Gu FL, Reng ZY, Shang GZ, et al. J Int Med Res. 1987;15(5):312-8.   Results from 336 evaluable patients indicated that 67% (228) were completely cured of urgency/ incontinence symptoms, and 20% (66) improved. Also, flavoxate was found to be effective in 77.4% of patients refractory to previous anti-cholinergic treatment. The 1200 mg dose produced a complete cure in 82% of patients and improvement in the remaining 18%, with no side-effects. Thus, flavoxate was concluded an effective and well tolerated treatment for urgency/incontinence of various causes.

A repeat ultrasound at three months after surgery was essentially normal, and she expressed enhanced quality of life with diminished LUTS.

Discussion

A bladder calculus represents one of the oldest problems in surgery.⁵Yalcin V, Demiskesen O, Ach B, et al. Urology International 1998:61; 240-242.   Also, secondary vesical stones usually complicate vesical obstruction with LUTS. Foreign body in the bladder may act as a nidus for stone formation of stone⁶Weston B. Br J Urol 1957;29:146.  , and is not that common world wide. Nevertheless, the types of foreign bodies have been classified as inserted, migratory and iatrogenic.⁷Hiller N, Zagal I, Solomom I. The danger of eroticism. Urologia 1999;66:2.   Common foreign bodies in the bladder include missing intrauterine contraceptive device (IUCD), or an object left unintentionally after a surgical procedure for example gauze, sutures or drains.⁸Osea J M, Breseta E , Server G et al. Br J Urol 1991; 68:510-512.  ^,9Kanne N, Iwasa A, Seneh H, et al. Br J Urol 1994; 73: 587- 588.   Sporadically, a foreign body may be inserted per urethra as seen in the present case.

Foreign bodies in the urinary bladder represent a urological challenge that requires prompt management; the suspected history and presenting symptoms are crucial.¹⁰Kochakarn W, Pummanagura W. Asian J Surg. 2008;31(3):130-3.   Misdirected attempts to relieve voiding problems by individuals might also act as antecedent to foreign bodies in the female urinary bladder, with the major route for ingress of foreign bodies being via the urethra. Recurrent or chronic unexplained LUTS after catheterization or some surgical and endoscopic procedures should raise a suspicion of presence of a foreign body in the urinary bladder.

Shaikh et al^{11Shaikh AR, Shaikh NA, Abbasi A, et al. RMJ. 2010; 35(2): 194-197.}   conducted a descriptive study to determine the cause and clinical presentation for foreign bodies from urinary bladder. Patients were divided into 2 groups on account of having known or unknown foreign bodies in urinary bladder. While in group-I the diagnosis of presence of foreign body was confirmed with the help of investigations, in group-II the foreign bodies were discovered incidentally either during cystoscopy or in the core of vesical calculus while doing intra-corporeal cystolithotripsy procedure. All the patients presented with variable LUTS such as dysuria, frequency, suprapubic pain and hematuria (Table 1). A total of 34 cases having foreign body in urinary bladder were treated. Group-I comprised of 6 (17.64%) patients, while group-II consisted of 28(82.3%) cases.

While on one hand the known foreign bodies included bullet (01, 2.94%), piece of metallic urethral dilator (01, 2.94%) and piece of Foleys catheter (04, 11.76%), the unknown foreign bodies were broken piece of Foleys catheter’s balloon (13. 38.2%), suture material (10, 29.4%), IUCD (02, 5.88%), gauze piece (02, 5.88%) and thermometer (01, 2.94%). All foreign bodies were removed by endoscopic approach except 2 (5.88%), which required open surgery.

Interestingly, the patient in the above case had no psychiatric illness. While, most bladder stones contain struvite or uric acid, analysis of the stone in the above patient revealed triple phosphate. Treatment by operative retrieval had satisfactory outcome, and postoperatively she had diminished LUTS with flavoxate. She now voided freely, and with good urinary stream. Thus, a foreign body in bladder should be suspected in a female patient with chronic LUTS even in the absence of trauma/intervention. The case, thus, shows that development of vesical calculus commonly complicates these bladder foreign bodies with usual presentation of LUTS.

LUTS in women

Lower urinary tract symptoms (LUTS) in women are highly prevalent with a profound influence on well-being and quality of life.¹²Wennberg AL, Molander U, Fall M, et al. BJU Int. 2009;104(7):954-9.   Its prevalence and severity tend to increase

with age and can have a negative impact on quality of life. Compared with men, LUTS in women are a dynamic rather than a necessarily progressive disorder. LUTS can be divided into storage and voiding symptoms; a Bristol Female LUTS (BFLUTS) questionnaire can be used to assess the symptoms.¹³Stefan H, Clifford D, et al. European urology 2007;52(6):1744-1750.  

Based on BFLUTS, the patients can be categorized into no/minimal LUTS (score, 0-2), moderate LUTS (score, 3-5), and severe LUTS (score, 6-11). The boundaries mimic the International Prostate Symptom Score (IPSS) grading system (no/minimal LUTS, 0-7; moderate LUTS, 8-20; severe LUTS, 21-35). While the categorization applied for storage and voiding symptoms, adding the storage and voiding scores yields LUTS overall, resulting in the following boundaries: no LUTS, score 0-4, moderate LUTS, 3-10, severe LUTS, 6-13. The overlapping is attributable to varying combinations of the storage and voiding scores.

LUTS in women is not only a gerontology problem, and affects more often women in active and child-bearing age. Slavov and Dimitrov¹⁴Slavov Ch, Dimitrov R. Khirurgiia (Sofiia). 2004;60(4-5):35-8.   examined and monitored 74 women with LUTS, ranging in age from 26 to 76 years old (average age of 48.6 years) to determine the symptomatic index, and found 51 (68.9%) women with predominantly irritative symptoms, and 23 (31.1%) with predominantly obstructive symptoms. The urodynamic studies revealed: obstruction of the lower urinary tract-7 (9.4%); obstruction with detrusor hyperactivity-15 (20.3%); detrusor hyperactivity-33 (44.6%); sensory urge-syndrome-6 (8.1%); disturbed contractility of the urinary bladder-4 (5.4%); with no significant deviations-9 (12.2%).

Prevalence, incidence and remission of LUTS in women

The definition of LUTS is commonly used to describe several symptoms with a variety of causes. Evidence is continuously growing on the prevalence of LUTS in women, and they constitute dynamic conditions; women experience more or fewer symptoms, and eventually a cessation of symptoms. In a longitudinal cohort study, Møller et al¹⁵Møller LA, Lose G, Jørgensen T. BMJ 2000;320:1429-32.   aimed to determine the incidence and rates of remission of LUTS at 1 year in women aged 40-60 years, and to assess factors associated with remission. The prevalence, incidence, and rates of remission of LUTS in 2284 women were 28.5%, 10.0%, and 27.8% respectively. Thus, LUTS are encountered frequently in women. A distinction between permanent and fluctuating cases may have important clinical implications.

Reluctance to seek treatment in women with LUTS

Andrades et al¹⁶Andrades M, Paul R, Ambreen A, et al. J Coll Physicians Surg Pak. 2004;14(3):132-5.   conducted a cross-sectional analytical study in order to determine the distribution of LUTS in adult women and the frequency with which the women consulted a health care provider for their symptoms, and found that even though the distribution of LUTS among females was high, the patients did not consider it important enough to consult a health care provider. This underscores the need to create awareness among females regarding LUTS, and the need to consult a health care provider for their problems.

References

1. Sozen S, Kupeli B, Ogunzulgen A I, et al. Gazi Medical Journal 2000;11:179-181.
2. Nasir SS, Singh B, Qazi WS. JK Practitioner 2004;11:268-269.
3. Laborde EE, McVary KT. Rev Urol. 2009 Fall;11(Suppl 1): S19-S25.
4. Gu FL, Reng ZY, Shang GZ, et al. J Int Med Res. 1987;15(5):312-8.
5. Yalcin V, Demiskesen O, Ach B, et al. Urology International 1998:61; 240-242.
6. Weston B. Br J Urol 1957;29:146.
7. Hiller N, Zagal I, Solomom I. The danger of eroticism. Urologia 1999;66:2.
8. Osea J M, Breseta E , Server G et al. Br J Urol 1991; 68:510-512.
9. Kanne N, Iwasa A, Seneh H, et al. Br J Urol 1994; 73: 587- 588.
10. Kochakarn W, Pummanagura W. Asian J Surg. 2008;31(3):130-3.
11. Shaikh AR, Shaikh NA, Abbasi A, et al. RMJ. 2010; 35(2): 194-197.
12. Wennberg AL, Molander U, Fall M, et al. BJU Int. 2009;104(7):954-9.
13. Stefan H, Clifford D, et al. European urology 2007;52(6):1744-1750.
14. Slavov Ch, Dimitrov R. Khirurgiia (Sofiia). 2004;60(4-5):35-8.
15. Møller LA, Lose G, Jørgensen T. BMJ 2000;320:1429-32.
16. Andrades M, Paul R, Ambreen A, et al. J Coll Physicians Surg Pak. 2004;14(3):132-5.