Infarct of the right basal ganglia in a male spinal cord injury patient: adverse effect of autonomic dysreflexia.

Autonomic dysreflexia is a clinical emergency that occurs in individuals with spinal cord injury at level T-6 and above. We present a 58-year-old male patient with paraplegia who developed a severe, recurrent, throbbing headache during the night, which was relieved by emptying the urinary bladder by intermittent catheterisation. As this person continued to get episodes of severe headache for more than 6 months, computed tomography (CT) of the brain was performed. CT revealed an infarct measuring 1.2 cm in the right basal ganglia. In order to control involuntary detrusor contractions, the patient was prescribed propiverine hydrochloride 15 mg four times a day. The alpha-adrenoceptor blocking drug doxazosin was used to reduce the severity of autonomic dysreflexia. Following 4 weeks of treatment with propiverine and doxazosin, the headache subsided completely. We learned from this case that bladder spasms in individuals with spinal cord injury can lead to severe, recurrent episodes of autonomic dysreflexia that, in turn, can predispose to vascular complications in the brain. Therefore, it is important to take appropriate steps to control bladder spasms and thereby prevent recurrent episodes of autonomic dysreflexia. Intermittent catheterisations along with an alpha-adrenoceptor blocking drug (doxazosin) and an antimuscarinic drug (propiverine hydrochloride) helped this individual to control autonomic dysreflexia, triggered by bladder spasms during the night.

Barriers to implementing intermittent catheterisation in spinal cord injury patients in Northwest Regional Spinal Injuries Centre, Southport, U.K.

Intermittent catheterisation is the preferred method of managing the neurogenic bladder in patients with spinal cord injury. However, spinal cord physicians experienced problems when trying to implement an intermittent catheterisation regime in some spinal cord injury patients in the northwest of England. We present illustrative cases to describe practical difficulties encountered by patients while trying to adopt an intermittent catheterisation regime. Barriers to intermittent catheterisation are (1) caregivers or nurses are not available to carry out five or six catheterisations a day; (2) lack of time to perform intermittent catheterisations; (3) unavailability of suitable toilet facilities in public places, including restaurants and offices; (4) redundant prepuce in a male patient, which prevents ready access to urethral meatus; (5) urethral false passage; (6) urethral sphincter spasm requiring the use of flexible-tip catheters and á-adrenoceptor-blocking drugs; (7) reluctance to perform intermittent catheterisation in patients >60 years by some health professionals; and (8) difficulty in accessing the urethral meatus for catheterisation while the patient is sitting up, especially in female patients. These cases demonstrate the urgent need for provision of trained caregivers who can perform intermittent catheterisation, and improvement in public facilities that are suitable for performing catheterisation in spinal cord injury patients. Further, vigilance should be exercised during each catheterisation in order to prevent complications, such as urethral trauma and consequent false passages. Health professionals should make additional efforts to implement intermittent catheterisation in female spinal cord injury patients and in those >60 years.

Ureteral obstruction by the vas deferens after urostomy.

A male patient with spina bifida and paraplegia, born in 1968, underwent urostomy in 1973. In 1999, he developed urine infections. Intravenous urography showed bilateral hydronephrosis and hydroureter. This patient continued to get recurrent urine infections. In 2009, computed tomography of the abdomen revealed dilatation of the ureters, but the ureters reverted to normal calibre as they passed forward through the anterior abdominal wall. The vas deferens on either side was crossing and kinking the ureter. Magnetic resonance imaging of the abdomen confirmed that the level of obstruction in both ureters was at the site where the vas deferens crossed the ureter and kinked it. While performing urostomy, the ureters below the crossover by the vas deferens were detached from the bladder and attached to the skin for urinary diversion, thus causing the vas deferens to hook the lower end of the ureters. As the patient gained height and weight, thereby increasing abdominal girth, kinking of the ureters by the vas deferens was accentuated. In hindsight, bilateral midline cutaneous urostomy using the ureters below the crossover by the vas deferens represents a poor surgical technique for urinary diversion.

Recurrent autonomic dysreflexia due to chronic aortic dissection in an adult male with cervical spinal cord injury.

Autonomic dysreflexia is a hypertensive clinical emergency for persons with spinal cord injury at T-6 level or above. Recurrent autonomic dysreflexia is uncommon in spinal cord injury patients and is usually caused by noxious stimuli that cannot be removed promptly, e.g., somatic pain, abdominal distension. A 61-year-old man, who sustained tetraplegia at C-5 (ASIA-A) 38 years ago, was admitted with chest infection. Computerised tomography (CT) of the chest showed the ascending aorta to measure 4 cm in anteroposterior diameter; descending thoracic aorta measured 3.5 cm. No dissection was seen. Normal appearances of abdominal aorta were seen. He was treated with noninvasive ventilation, antibiotics, and diuretics. Nineteen days later, when there was sudden deterioration in his clinical condition, CT of the pulmonary angiogram was performed to rule out pulmonary embolism. This showed no pulmonary embolus, but the upper abdominal aorta showed some dissection with thrombosis of the false lumen. Blood pressure was controlled with perindopril 2 mg, once a day, doxazosin 4 mg, twice a day, and furosemide 20 mg, twice a day. Since this patient did not show clinical features of mesenteric or lower limb ischaemia, the vascular surgeon did not recommend subdiaphragmatic aortic replacement. This patient subsequently developed recurrent episodes of autonomic dysreflexia. Each acute episode of dysreflexia was controlled by nifedipine given sublingually in doses varying from 5 to 20 mg. No inciting cause for autonomic dysreflexia could be found other than chronic aortic dissection. This patient's medication was then changed to doxazosin 8 mg, twice a day, and sustained-release nifedipine 10 mg, twice a day, which helped to prevent recurrent autonomic dysreflexia. Chronic aortic dissection is a very rare cause for recurrent autonomic dysreflexia in ageing spinal cord injury patients. When the inciting cause for dysreflexia is not amenable for treatment, recurrent dysreflexic episodes can be prevented by pharmacotherapy with an alpha-adrenergic blocking agent (doxazosin) and sustained-release nifedipine.

Seminoma of testis masquerading as orchitis in an adult with paraplegia: proposed measures to avoid delay in diagnosing testicular tumours in spinal cord injury patients.

Orchitis is common in adult male spinal cord injury (SCI) patients and, therefore, both health professionals and SCI patients themselves tend to attribute testicular swelling to orchitis, with a consequent potential delay in the diagnosis of testicular tumours. A 37-year-old man with paraplegia developed swelling of the right testis. With a presumptive diagnosis of acute bacterial orchitis, he was prescribed ciprofloxacin while awaiting an ultrasound scan. Ultrasound examination of the testis 4 weeks later showed a moderate hydrocele, enlargement and altered echogenicity of both the epididymis and testis, and features of mass-like lesions within the substance of the testis. As these changes might merely have represented a partly treated infection, a follow-up scan was carried out 2 weeks later, which revealed a lobulated mass of mixed echogenicity within the testis and a focal area of increased echogenicity indicative of calcification. A radical orchidectomy performed 19 days later revealed a seminoma. To prevent delay in the diagnosis of testicular tumours in SCI patients, we propose the following measures: (1) patients who develop swelling of the testis should consult a physician as soon as possible for clinical examination; blind antibiotic therapy should be avoided if possible; (2) if clinical examination reveals a hard swelling of the testis and the typical features of acute urinary infection are absent, an ultrasound scan of the scrotum should be performed as soon as possible; (3) in patients with equivocal ultrasound findings, ultrasound-guided, fine-needle aspiration cytology may allow an early diagnosis of testicular malignancy; (4) education of SCI patients and their caregivers is needed to implement these recommendations.

Generalised muscle weakness after bladder wall injection of Abobotulinum Toxin A: experience of a woman with tetraplegia who required increased caregiver support: importance of doctor-patient communication: duty of candour for spinal cord physician and responsibilities of a patient.

INTRODUCTION: Generalised muscle weakness can occur after bladder wall injection of Abobotulinum toxin and the patient may require additional caregiver support. CASE PRESENTATION: A woman with C-8 AIS A tetraplegia received bladder wall injection of Abobotulinum toxin A 1000 units for detrusor over-activity. After 2.5 weeks, she developed weakness of arms; could not lift herself for pressure relief; could not transfer using sliding board; she regained the original muscle strength in 6 weeks. After 13 months, Abobotulinum toxin A 1000 units were injected into detrusor. Ten days after the second Abobotulinum toxin A injection, she developed generalised muscle weakness. She had not regained full function in her arms and hands 8 months later.Prior to bladder wall injection of Abobotulinum toxin A, this patient was not aware that she could develop muscle weakness albeit very rarely. Therefore, the patient made no association of the muscle weakness, which occurred after the first injection, to Abobotulinum toxin A. For this reason, she did not inform the clinicians that she developed weakness of upper limbs following Abobotulinum toxin A injection. As she was not informed of this side effect before the second bladder wall injection of Abobotulinum toxin A, she consented to undergo the repeat procedure and developed generalised muscle weakness. DISCUSSION: Patients should inform doctors the adverse effects of medical therapy so that future treatment is amended to ensure patient safety. Professional duty of candour states that doctors should discuss risks which occur often, those that are serious even if very unlikely, and those that are important to the patient.

Persistent urine leakage around a suprapubic catheter: the experience of a person with chronic tetraplegia.

INTRODUCTION: Persistent urine leakage after suprapubic cystostomy in tetraplegic subjects occurs due to shrinkage of the urinary bladder and bladder spasms. The patient's social life is adversely affected as clothes become wet, smelly, and require frequent changing, thus increasing the workload of carers. CASE PRESENTATION: A 48-year-old male sustained C-4 complete (AIS:A) tetraplegia while swimming in 2007. Suprapubic cystostomy was performed in 2009. From 2012, this patient had urine leakage around the suprapubic catheter, which became progressively more frequent. Propiverine, then oxybutynin tablets instead of propiverine, oxybutynin transdermal patches, and mirabegron in addition to oxybutynin were tried. An indwelling urethral catheter was used in addition to the suprapubic catheter to alleviate urine leakage when the bladder was undergoing spasms. This patient continued to have leakage around the suprapubic catheter. Leakage of urine was occasionally accompanied by autonomic dysreflexia. Leakage of urine caused huge amounts of extra work for carers, and family. Furthermore, leakage of urine had a significant impact on quality of life, and going out with friends and family. Bladder wall injection of Botox was performed in 2015 and in 2016, which reduced urine leakage. DISCUSSION: Bladder wall injection of Botox to treat persistent urine leakage around the suprapubic catheter in spinal cord injury patients with suprapubic cystostomy has not been mentioned in NICE guidelines or publications indexed in PubMed. While recommending suprapubic cystostomy to subjects with tetraplegia, leakage of urine around the suprapubic catheter, which may occur sometime after suprapubic cystostomy, should be included in the conversation so that patients and carers become aware of this potential complication.

Bilateral renal milk of calcium masquerading as nephrolithiasis in patients with spinal cord injury.

Milk of calcium is a viscous colloidal suspension of calcium carbonate, calcium phosphate, or calcium oxalate, or a mixture of these compounds. The calcific material gravitates to the dependent portion of a cystic cavity. Crescent- or hemisphere-shaped calcium density with a sharp horizontal upper border at the milk of calcium-clear fluid interface confirms the diagnosis. Bilateral milk of calcium in the renal pelvis or in dilated calyces is very rare and has not been reported in patients with spinal cord injury. A 63-year-old male patient with T-10 paraplegia presented with recurrent urinary tract infections. X-ray of the kidneys, taken with the vertical beam while the patient lay supine, revealed a poorly defined opacity overlying the lower pole of the right kidney. Findings on ultrasonography of the kidneys were interpreted as a large, staghorn-type calculus in the dilated lower pole calyx of the right kidney. Because x-ray of the kidneys showed a poorly defined opacity overlying the lower pole of the right kidney, milk of calcium was suspected, and computed tomography (CT) of the kidneys was performed. Calcific debris with horizontal layering in the lower pole calyces of both kidneys was seen; this confirmed the diagnosis of milk of calcium. A 62-year-old female patient with C-7 tetraplegia underwent ileal conduit urinary diversion. Subsequently, she developed calculi in the right kidney, which were treated with shock wave lithotripsy. Follow-up x-ray revealed faintly opaque shadows with indistinct margins in the region of both kidneys. Intravenous urography showed cortical thinning at the upper poles and blunting of the calyces, suggestive of chronic pyelonephritis. The right renal pelvis was bulky, and bilateral renal calculi were diagnosed during ultrasonography; however, the presence of faintly radio-opaque shadows with indistinct margins raised suspicions of renal milk of calcium. A CT scan of the kidneys, which was performed in the supine and subsequently in the prone position, revealed gravity-dependent layering of calcific material in the pelves of both kidneys and in the midpole calyces of the right kidney, thus confirming the diagnosis of milk of calcium. In conclusion, CT scan of the kidneys confirmed the diagnosis of bilateral renal milk of calcium, a very rare entity in patients with spinal cord injury. Awareness of typical and unique features of milk of calcium during imaging enables physicians to recognize renal milk of calcium and to differentiate it from nephrolithiasis, thereby avoiding unwarranted interventions such as shock wave lithotripsy or endoscopic procedures.

Midodrine: insidious development of urologic adverse effects in patients with spinal cord injury: a report of 2 cases.

Midodrine, a prodrug, is converted after oral administration into its active drug, desglymidodrine, which acts as an alpha(1)-adrenoceptor stimulant. Midodrine is prescribed for the treatment of neurogenic orthostatic hypotension in patients with spinal cord injury. By virtue of its alpha(1)-adrenergic effects, midodrine causes an increase in the tone of the vesical sphincter, which may silently lead to progressive retention of urine, particularly in patients with spinal cord injury who void urine spontaneously. Further, midodrine may aggravate detrusor-sphincter dyssynergia, which can lead to hydroureteronephrosis. A 68-year-old man with C-4 tetraplegia was voiding urine satisfactorily through reflex detrusor contractions. He was prescribed midodrine (5 mg at 8:00 AM, 5 mg at 1:00 PM, and 2.5 mg at 10:00 PM) for postural hypotension. During the next 7 wk, this patient experienced severe leg spasms while passing urine, and the flow of urine became very slow. Intravenous urography showed bilateral hydroureteronephrosis, although an earlier study had revealed normal kidneys. Midodrine therapy was stopped, and intermittent catheterization 4 times a day, along with oral oxybutynin, was started. After midodrine was discontinued, the leg spasms during passage of urine and slowing of the urine stream coincident with the spasms disappeared completely. The patient was able to pursue activities of daily living without taking midodrine. A 40-year-old man with C-7 tetraplegia was passing urine spontaneously with no problem. For postural hypotension, he was prescribed midodrine (5 mg in the morning and 2.5 mg at lunchtime), fludrocortisone (100 microg daily), and ephedrine (15 mg by mouth, taken 10 min before getting up in the morning). Three months later, the patient presented with sweating. During the day, he would pass only small amounts of urine, but from evening onward, he would void large volumes of urine, and the sweating would diminish. Intravenous urography showed vesical diverticula; a postmicturition film revealed moderate residual urine. This patient was able to stop taking the second dose of midodrine, but he required midodrine and ephedrine in the morning to enable him to get up without feeling dizzy. After the noon midodrine dose was stopped, the patient's sweating diminished by late afternoon. During the morning hours, however, he continued to sweat and had difficulty passing urine. Intermittent catheterization was not possible in the community setting, and the patient remains under close follow-up. These cases illustrate that patients with cervical spinal cord injury who void spontaneously may develop insidious urologic adverse effects after taking midodrine for postural hypotension. When patients with spinal cord injury develop urologic adverse effects while taking midodrine, the drug should be stopped, and other pharmacologic agents (eg, fludrocortisone) and nonpharmacologic methods should be prescribed for management of orthostatic hypotension. If a patient continues to require midodrine to control postural hypotension, intermittent catheterization combined with antimuscarinic therapy (eg, oxybutynin) should be recommended instead of spontaneous voiding.

Bluish discolouration of urine drainage tube and bag in a female patient with spina bifida, paraplegia, and suprapubic cystostomy.

We present a female patient with spina bifida, paraplegia, suprapubic cystostomy, and chronic constipation, who became anxious when she noticed a bluish discolouration of her urine drainage system. Urine microbiology revealed growth of Providencia stuartii and Staphylococcus aureus. There were no systemic features of infection and, therefore, antibiotics were not prescribed for asymptomatic bacteriuria. This patient was advised to change the urine bag every day, and was prescribed senna to facilitate bowel evacuation. She was reassured that bluish discolouration of the urine drainage tube and bag was a transient, benign phenomenon and not indicative of any underlying pathology. Over the next 7 days, the bluish discolouration gradually faded away. Clinical characteristics of patients who are likely to develop this phenomenon and the underlying biochemical mechanism for bluish discolouration of the urine drainage system are discussed in brief.

Unusual complication of suprapubic cystostomy in a male patient with tetraplegia: traction on Foley catheter leading to extrusion of Foley balloon from urinary bladder and suprapubic urinary fistula--importance of securely anchoring suprapubic catheter with adhesive tape or BioDerm tube holder.

Suprapubic cystostomy is recommended to patients with neuropathic bladder to prevent complications of long-term urethral catheter drainage. We present a 50-year-old male patient with tetraplegia who had long-term urethral catheter drainage. Following flexible cystoscopy, he developed a urine leak from the right side of the scrotum. Suprapubic cystostomy was performed. After suprapubic cystostomy, the urinary fistula healed completely. A follow-up cystourethrogram confirmed an intact urethra with no leak of contrast. Six weeks later, this patient presented with a hole below the suprapubic cystostomy through which a small amount of urine was leaking. A keyhole dressing had been applied around the suprapubic catheter and the catheter was hanging loosely, thus permitting traction on the catheter, especially when the urine bag was full. Computerised tomography of the pelvis showed extrusion of the Foley balloon from the urinary bladder, but the tip of the catheter was still located within the bladder. The extruded catheter was removed and a Foley catheter was inserted, ensuring that the balloon was inflated within the urinary bladder. The suprapubic catheter was secured firmly to the anterior abdominal wall with a BioDerm Tube Holder, thus preventing any traction on the catheter or Foley balloon. The urine leak through the hole below the suprapubic cystostomy stopped and the sinus healed. This case illustrates the need to anchor the suprapubic catheter securely to the anterior abdominal wall with adhesive tape or BioDerm Tube Holder to prevent traction and consequent displacement of the catheter or Foley balloon.

Possible role of large fluid intake in delaying formation of encrustations and, thereby, prolonging working life of Memokath stent for nearly 14 years in a spinal cord injury patient.

The Memokath stent has been used in spinal cord injury patients as a reversible alternative to external urethral sphincterotomy, but the stent has a finite lifetime of <2 years before failure in the majority of patients. We report an unusual case of a spinal cord injury patient in whom memokath stent was functioning for almost 14 years. The long life span of the Memokath in this patient was probably due to this person's habit of drinking around 5 l of fluids a day. Large fluid intake resulted in high urine output and, consequently, deceased the risk of urine infections and delayed formation of encrustations around the stent. Although this case represents an unusual length of time for a Memokath stent to have been in place and functioning, caution should be exercised against the long-term use of Memokath stents. Memokath stents do not get absorbed into the mucosa unlike urolume stents and, therefore, are prone to stone formation. Further, Memokath stents have not yet been approved in the U.S. either for bladder outlet obstruction or detrusor-sphincter dyssynergia. This case is also a reminder to health professionals that if a tetraplegic patient, in whom a Memokath stent has been deployed for treatment of detrusor-sphincter dyssynergia, presents with autonomic dysreflexia, encrustations blocking the lumen of the stent or calculus formation around the stent should be considered as possible reasons for autonomic dysreflexia.

Fatal collapse due to autonomic dysreflexia during manual self-evacuation of bowel in a tetraplegic patient living alone: lessons to learn.

BACKGROUND: To identify areas for improvement, the National Health Service in England mandates the review of case reports of patients who have died, which should be translated into improved care for other patients. CASE REPORT: A 49-year-old Caucasian man sustained C-7 tetraplegia in a motorcycle accident in 1992. In 2009, he developed seizures and collapsed in the lavatory on a number of occasions during manual self-evacuation of his bowel. A 24-hour electrocardiogram recording at that time showed sinus rhythm with a maximum heart rate of 97 and a minimum of 39 beats per minute; there were no significant arrhythmias that could have contributed to his episodes of collapse. In 2015, the patient again collapsed while performing manual evacuation of his bowel; on this occasion, he did not suffer a seizure. He was found unresponsive in the bathroom by his daughter, who contacted the emergency services. He recovered consciousness on arrival at the Accident and Emergency Department. A noncontrast computed tomography scan of his head revealed no acute intracranial pathology. In 2016, he suffered a fatal collapse in the lavatory, again while performing manual bowel evacuation. At autopsy, no other significant disease was found that might have caused death, and given the clinical history, the cause of death was recorded as autonomic dysreflexia. CONCLUSION: There were delays in 1) recognizing that his episodes of collapse in the lavatory were due to autonomic dysreflexia induced by manual bowel evacuation; 2) recommending the prior application of topical 2% lidocaine jelly to prevent or limit autonomic dysreflexia occurring during manual bowel evacuation; and 3) considering alternative bowel management such as stimulant laxatives, transanal irrigation, or colostomy, which could have prevented the occurrence of autonomic dysreflexia caused by manual evacuation.

Antibiotic therapy for patients with spinal cord injury undergoing urologic procedures.

This prospective study was performed to determine whether gentamicin can be prescribed routinely to patients with spinal cord injury undergoing urologic procedures, or whether antibiotic therapy must be selected on the basis of recent urine microbiologic test results. Between January 2004 and June 2005, procedures were performed on 38 patients, all of whom were prescribed antibiotics on the basis of a microbiology report. Sixteen patients who underwent urologic surgery during 2003 and received gentamicin empirically served as a control group. The patients' clinical course was monitored for postprocedure sepsis. Only 12 patients received gentamicin as the sole antibiotic; 10 patients required an additional antimicrobial for urine samples that grew more than 1 organism and contained bacteria resistant to gentamicin; 26 patients needed antibiotics other than gentamicin for gentamicin-resistant uropathogens. Three patients with organisms sensitive to gentamicin as well as another antibiotic received an agent considered less nephrotoxic than gentamicin. After the procedure, sepsis occurred in only 1 patient, a man with chronic lymphocytic leukemia and small cell carcinoma of the urinary bladder. Three control group patients developed a fever in excess of 39 degrees C. One of these patients did not require a change of antibiotic, another patient recovered after 3 changes of antibiotic, and the third patient recovered from septicemia after receiving ventilatory support. Antibiotics should be prescribed on the basis of recent urine microbiologic test results, and empiric therapy with gentamicin should be avoided in patients with spinal cord injury who are scheduled to undergo urologic procedures.

Fatality due to septicemia and hemorrhage in a patient with spinal cord injury and ischemic heart disease with the need for long-term catheter drainage.

Percutaneous suprapubic cystostomy is generally considered to be a safe procedure provided the bladder is distended adequately, as palpable bladder is the landmark for insertion of a trocar. This report describes fatality due to septicemia and hemorrhage following suprapubic catheter insertion in a tetraplegic male patient with long-term indwelling urethral catheter drainage and urine infection with Escherichia coli, Pseudomonas species, and Enterococcus faecalis. Before the surgical procedure was begun, the urinary bladder was distended by repeated injection of 50 mL of sterile, 0.9% sodium chloride through the urethral catheter with a catheter-tip syringe until the bladder became palpable in the suprapubic region; by this time, the bladder had been filled forcibly with 500 mL of saline. Percutaneous cystostomy was performed with the use of an Add-a-Cath trocar and cannula (Femcare Limited, Nottingham, Nottinghamshire, UK). Immediately after a 16 French Foley catheter had been inserted, the drainage fluid appeared heavily stained with blood. The patient developed septicemia, and a blood culture report, received posthumously, showed growth of E. coli. Despite resuscitative measures, the patient expired 13 hours after suprapubic catheter insertion. Postmortem examination revealed bilateral hydronephrosis with fluid and clotted blood in the renal pelves and ureters; the urinary bladder showed a thick wall and hemorrhagic mucosa. This fatal incident raises the question of whether forcible distention of the urinary bladder for percutaneous cystostomy is safe in patients with spinal cord injury who have a small-capacity bladder, infected urine, and ischemic heart disease. In such patients, it may be prudent to avoid forcible distention of the urinary bladder and instead perform ultrasound-guided or fluoroscopically guided suprapubic cystostomy.

Pitfalls in radiologic and histopathologic diagnosis of urologic disease--report of 4 cases.

Cases are presented to illustrate pitfalls in radiologic and histopathologic diagnosis in urology. In a 73-year-old woman, ultrasound revealed calcification in an irregular mass arising from the left wall of the bladder. Bladder biopsy reported the mass as papillary transitional cell carcinoma. Histologically, the specimen showed marked hyperplasia of the urothelium with formation of Brunn's nests and no evidence of dysplasia or malignancy. A review of medical images showed that the mass was a calcified uterine fibroid. In a 36-year-old man, a calcified opacity in the pelvis was reported as a ureteric calculus, and the patient underwent ureteroscopy. No stone was found. A review of an intravenous urogram showed that the radio-opaque shadow appeared outside the left ureter. A 41-year-old man with tetraplegia developed hydronephrosis as the result of a calculus in the renal pelvis. Ureteric stenting was performed, followed by shock wave lithotripsy. A follow-up x-ray of the abdomen showed a small radioopacity that projected over the line of the left ureter at the L-3 level-probably a ureteric calculus. A review of a computed tomography scan revealed that the calculus, noted on plain film at the level of L-3, had become extruded and was lying posterior to the ureter. A 59-year-old man underwent nephrectomy for a 5-cm solid lesion in the mid pole of the left kidney. Histology showed multiple synchronous renal cell carcinomas and angiomyolipomas. The patient underwent further investigation for von Hippel-Lindau disease and tuberous sclerosis. A review of tissue blocks from the nephrectomy specimen, however, showed no evidence of angiomyolipoma. What was interpreted as renal angiomyolipoma was actually simple distorted blood vessels in areas of renal scarring. To prevent mistakes in diagnosis and to detect medical errors without delay, the authors recommend that physicians set aside time to reflect upon their clinical practice, regularly participate in honest and informal case discussions, and seek a second opinion when in doubt.

A simple radiological technique for demonstration of incorrect positioning of a foley catheter with balloon inflated in the urethra of a male spinal cord injury patient.

In a male patient with cervical spinal cord injury, the urinary bladder may go into spasm when a urethral catheter is removed and a new Foley catheter is inserted. Before the balloon is inflated, the spastic bladder may push the Foley catheter out or the catheter may slip out of a small-capacity bladder. An inexperienced health professional may inflate the balloon of a Foley catheter in the urethra without realizing that the balloon segment of the catheter is lying in the urethra instead of the urinary bladder. When a Foley balloon is inflated in the urethra, a tetraplegic patient is likely to develop autonomic dysreflexia. This is a medical emergency and requires urgent treatment. Before the incorrectly placed Foley catheter is removed, it is important to document whether the balloon has been inflated in the urinary bladder or not. The clinician should first use the always available tools of observation and palpation at the bedside without delays of transportation. A misplaced balloon will often be evident by a long catheter sign, indicating excessive catheter remaining outside the patient. Radiological diagnosis is not frequently required and, when needed, should employ the technique most readily available, which might be a body and pelvic CT without intravenous contrast. An alternative radiological technique to demonstrate the position of the balloon of the Foley catheter is described. Three milliliters of nonionic X-ray contrast medium, Ioversol (OPTIRAY 300), is injected through the side channel of the Foley catheter, which is used for inflating the balloon. Then, with a catheter-tip syringe, 30 ml of sterile Ioversol is injected through the main lumen of the Foley catheter. Immediately thereafter, an X-ray of the pelvis (including perineum) is taken. By this technique, both the urinary bladder and balloon of the Foley catheter are visualized by the X-ray contrast medium. When a Foley catheter has been inserted correctly, the balloon of the Foley catheter should be located within the urinary bladder, but when the Foley catheter is misplaced with the balloon inflated in the urethra, a round opaque shadow of the Foley balloon is seen separately below the urinary bladder. This radiological study takes only a few minutes to perform, can be carried out bedside with a mobile X-ray machine, and does not require special expertise or preparations, unlike transrectal ultrasonography. When a Foley balloon is inflated in the urethra, abdominal ultrasonography will show an absence of the Foley balloon within the bladder. The technique described above aids in positive demonstration of a Foley balloon lying outside the urinary bladder. Such documentation proves valuable in planning future treatment, education of health professionals, and settlement of malpractice claims.

A comparative study of ultrasound examination of urinary tract performed on spinal cord injury patients with no urinary symptoms and spinal cord injury patients with symptoms related to urinary tract: do findings of ultrasound examination lead to changes in clinical management?

Findings of ultrasound examination of the urinary tract and changes in clinical management, which were instituted on the basis of ultrasound examination, were compared between two groups of spinal cord injury patients. Group 1 had no urinary symptoms when they underwent the scan, whereas group 2 was comprised of patients with symptoms pertaining to the urinary tract. Between 2000 and 2006, ultrasound examination of the urinary tract was performed in 87 spinal cord injury patients who had no urinary symptoms when they underwent the ultrasound scan. No abnormality was found in 63 patients. The ultrasound scan showed some abnormality of the urinary tract in 24 patients (simple cyst in the kidney: 4; reduced size of a kidney: 3; increased echogenicity of left kidney: 1; prominent extrarenal pelvis and mild calyceal dilatation: 1; slightly dilated renal pelvis and calyceal system: 1; pelvic kidney showing mild hydronephrosis: 1; foetal lobulation of kidney: 2; multicystic kidney with no interval change in the appearance since last examination: 1; 2-cm-diameter parapelvic cyst: 1; small renal calyceal calculus: 5; a little cortical scarring bilaterally: 1; focal renal scar: 2; generalised thinning of renal cortex: 3; increase in renal sinus fat: 3; trabeculated bladder: 2; small vesical diverticulum: 1; mild generalised bladder wall thickening: 1; small residual urine in postvoid scan; 2). No specific interventions were performed in these patients on the basis of ultrasound findings. In Group 2, ultrasound examination revealed serious abnormalities such as hydronephrosis, pyonephrosis, vesical calculi, vesical polyp in 20 of 21 patients, and all 20 patients required therapeutic intervention on the basis of ultrasound scan findings. In conclusion, routine ultrasound examination of the urinary tract in spinal cord injury patients who have no urinary symptoms may not be justifiable in terms of cost effectiveness; limited hospital resources should be directed to spinal cord injury patients with urinary symptoms so that ultrasound examination and therapeutic interventions based on ultrasound findings are carried out expeditiously.

Synostosis between pubic bones due to neurogenic, heterotopic ossification.

Neurogenic, heterotopic ossification is characterised by the formation of new, extraosseous (ectopic) bone in soft tissue in patients with neurological disorders. A 33-year-old female, who was born with spina bifida, paraplegia, and diastasis of symphysis pubis, had indwelling urethral catheter drainage and was using oxybutynin bladder instillations. She was prescribed diuretic for swelling of feet, which aggravated bypassing of catheter. Hence, suprapubic cystostomy was performed. Despite anticholinergic therapy, there was chronic urine leak around the suprapubic catheter and per urethra. Therefore, the urethra was mobilised and closed. After closure of the urethra, there was no urine leak from the urethra, but urine leak persisted around the suprapubic catheter. Cystogram confirmed the presence of a Foley balloon inside the bladder; there was no urinary fistula. The Foley balloon ruptured frequently, leading to extrusion of the Foley catheter. X-ray of abdomen showed heterotopic bone formation bridging the gap across diastasis of symphysis pubis. CT of pelvis revealed heterotopic bone lying in close proximity to the balloon of the Foley catheter; the sharp edge of heterotopic bone probably acted like a saw and led to frequent rupture of the balloon of the Foley catheter. Unique features of this case are: (1) temporal relationship of heterotopic bone formation to suprapubic cystostomy and chronic urine leak; (2) occurrence of heterotopic ossification in pubic region; (3) complications of heterotopic bone formation viz. frequent rupture of the balloon of the Foley catheter by the irregular margin of heterotopic bone and difficulty in insertion of suprapubic catheter because the heterotopic bone encroached on the suprapubic track; (4) synostosis between pubic bones as a result of heterotopic ossification.. Common aetiological factors for neurogenic, heterotopic ossification, such as forceful manipulation, trauma, or spasticity, were absent in this patient. Since heterotopic bone formation was observed in the pubic region after suprapubic cystostomy and chronic urine leak, it is possible that risk factors related to the urinary tract might have played a role in heterotopic bone formation, which resulted in synostosis between pubic bones.

Amikacin dosing and monitoring in spinal cord injury patients: variation in clinical practice between spinal injury units and differences in experts' recommendations.

The objective of this article was to determine the current practice on amikacin dosing and monitoring in spinal cord injury patients from spinal cord physicians and experts. Physicians from spinal units and clinical pharmacologists were asked to provide protocol for dosing and monitoring of amikacin therapy in spinal cord injury patients. In a spinal unit in Poland, amikacin is administered usually 0.5 g twice daily. A once-daily regimen of amikacin is never used and amikacin concentrations are not determined. In Belgium, Southport (U.K.), Spain, and the VA McGuire Medical Center (Richmond, Virginia), amikacin is given once daily. Whereas peak and trough concentrations are determined in Belgium, only trough concentration is measured in Southport. In both these spinal units, modification of the dose is not routinely done with a nomogram. In Spain and the VA McGuire Medical Center, monitoring of serum amikacin concentration is not done unless a patient has renal impairment. In contrast, the dose/interval of amikacin is adjusted according to pharmacokinetic parameters at the Edward Hines VA Hospital (Hines, Illinois), where amikacin is administered q24h or q48h, depending on creatinine clearance. Spinal cord physicians from Denmark, Germany, and the Kessler Institute for Rehabilitation (West Orange, New Jersey) state that they do not use amikacin in spinal injury patients. An expert from Canada does not recommend determining serum concentrations of amikacin, but emphasizes the value of monitoring ototoxicity and nephrotoxicity. Experts from New Zealand recommend amikacin in conventional twice- or thrice-daily dosing because of the theoretical increased risk of neuromuscular blockade and apnea with larger daily doses in spinal cord injury patients. On the contrary, experts from Greece, Israel, and the U.S. recommend once-daily dosing and determining amikacin pharmacokinetic parameters for each patient. As there is considerable variation in clinical practice across spinal units and experts differ on ideal dosing and monitoring of amikacin therapy in spinal cord injury patients, there is an urgent need to develop best-practice guidelines.