膜狀尿道憩室內結石引起的尿道瘻管

許智凱、張廷瑞、陳世亮

台南市立醫院 泌尿科

Bulbous urethral diverticular stone with cutaneous fistula formation in a bed ridden patient

Chih-Kai Hsu, Ting-Jui Chang, Shih-Liang Chen

Divisions of Urology, Tainan Municipal Hospital, Tainan, Taiwan

 

Background: Urethral diverticulum was relative rare in men and might be related to urine stasis due to obstruction, infection, or congenital. We presented a case with multiple stones in bulbous urethral diverticulum, complicated with cutaneous fistula formation.

Case Report: A 47 years-old man has DM, post-traumatic ICH, and he was under bed-ridden status for 9 years. Spontaneous urinary voiding was observed, so he used diaper or condom catheter in these years. He suffered from recurrent UTI in recent month, and high fever up to 39℃ for 2 days. Besides, there’s an 1cm erosive wound at perineum with bloody discharge, and a gray colored stony hard material around 1cm in diameter was found in his diaper near the wound. He was brought to ER, CT scan was performed and showed a 4x4 cm diverticulum with lot of stones at the bulbous urethra. After infection got controlled, cystoscopy was performed. Whereas pin-hole long segment stricture was noted at the penile urethra, that only 4.5Fr ureteroscopy can pass through. The diagnosis of urethral diverticulum with fistula was confirmed under endoscopy, but the stones were hard to retrieval technically. To prevent further infection and under consideration of the poor health condition, permanent suprapubic cystostomy was performed for the patient.

Discussion: Urethral diverticulum is a saccular dilatation extending from the urethral lumen. It may have a narrow or a wide neck. Complications are often related to inadequate drainage, as a nidus for urinary stasis, recurrent UTIs, stone formation, urinary leakage, incontinence or a palpable penoscrotal mass. Around 67% to 90% urethral diverticulums are acquired, and the rests may be congenital. Acquired ones often result from stricture, infection, trauma, or catheter related. Treatments for urethral diverticulum included antibiotic with manual compression, resection with reconstruction, and urinary diversion. In the literature reviewed, urethral diverticulum with stones and ruptured to perineum that created a urethral-cutaneous fistula is possible but rare.