Case Report Urethrogluteal Fistula Developing Secondary to the Use of Clean Intermittent Self-Catheterization: First Case Report in the Literature

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1 Case Reorts in Urology, Article ID , 4 ages htt://dx.doi.org/ /2014/ Case Reort Urethrogluteal Fistula Develoing Secondary to the Use of Clean Intermittent Self-Catheterization: First Case Reort in the Literature Aliseydi Bozkurt, 1 Mehmet Karabakan, 1 Mehmet Soyturk, 2 Erkan Hirik, 1 and BarJG Nuhoglu 1 1 Urology Deartment, Erzincan University, Mengücek Gazi Training and Research Hosital, Basbaglar Mahallesi, 1430 Sokak, Erzincan, Turkey 2 Radiology Deartment, Erzincan University, Mengücek Gazi Training and Research Hosital, Erzincan, Turkey Corresondence should be addressed to Mehmet Karabakan; mkarabakan@yandex.com Received 18 August 2014; Revised 24 Setember 2014; Acceted 25 Setember 2014; Published 2 October 2014 Academic Editor: Aul Goel Coyright 2014 Aliseydi Bozkurt et al. This is an oen access article distributed under the Creative Commons Attribution License, which ermits unrestricted use, distribution, and reroduction in any medium, rovided the original work is roerly cited. Clean intermittent self-catheterization is the standard method for bladder evacuation in these atients today. The atient was diagnosed with urethrogluteal fistula and gluteal-erineal abscess by radiological evaluation. Gluteal drainage decreased after cystostomy. In our aer, a case of urethrogluteal fistula and elvic urinoma that develoed as a result of the use of clean intermittent self-catheterization (CISC), which is rarely found in the literature, is resented. 1. Introduction Clean intermittent self-catheterization (CISC) is the referred method for bladder emtying in atients with sinal cord injury. It was first roosed by Guttmann in the form of sterile catheterization in 1966 and it was alied in the form of nonsterile catheterization by Laides et al. in 1972 [1]. In several studies, it was reorted to have reventive or theraeutic effects in the case of diseases such as hydronehrosis, vesicoureteral reflux, urinary tract infections, and urinary incontinence [2]. Although it has obvious advantages comared to continuous catheterization, a number of comlications including urethral stricture and formation of urethral false assage may develo due to recurrent urethral catheterizations. In our case, diagnosis and treatment of urethrogluteal fistula and a very large elvic urinoma that develoed as a result of the use of CISC for emtying neurogenic bladder are discussed. 2. Case Reort A 36-year-old male atient was admitted to our clinic with comlaints of ain, swelling, and redness that develoed in suraubic, scrotal, and gluteal areas and of difficulty in imlementing the CISC, dysuria, and fever for the last one week. He has been aralegic due to a sinal cord injury which took lace 17 years ago by a firearm. He has been imlementing CISC with single-use hydrohilic coated catheters for the last 5 years. He is an obese, diabetic (tye 2, controlled) atient oor in self-care and with normal mental functions. There was no history of urethral stricture or catheterization difficulties on his medical background. A ainful, red, swollen lesion looking like an abscess which starts from suraubic area, covers the entire scrotum and extends to left thigh and gluteal region was observed. In left gluteal region, a cutaneous fistula orifice with urulent discharge was observed. Biochemical and heamatologic analyses were normal.

2 2 Case Reorts in Urology (a) (b) b (c) Figure 1: ((a) + (b)) Fluid collection with dense eriheral contrast utake in sections with contrast extending from dee elvic muscle grous to the erineum and left gluteal region. ((c) + (d)) : rostate, b: bladder. This collection extends to erineum, left scrotum, and left gluteal region and is connected to the skin from the gluteal region. (d) During suerficial diagnostic ultrasonograhy (USG), a 21 5 cm collection of fluid extending from left gluteal region to the erineum was observed. Pelvic magnetic resonance imaging (MRI) revealed a large collection of fluid of about cm with dense content and dense eriheral contrast utake extending from left gluteal region to the elvic floor (Figure 1). In cystourethrograhy of the atient, the contrast agent was seen moving from rostatic urethra toward the gluteal region (Figure 2). Gluteal abscess drainage in the resence of USG was erformed on the atient and ercutaneous suraubic cystostomy catheter was inserted. During his ostcystostomy follow-us, a reduction in gluteal drainage was observed. After urinary tract infection of the atient was brought under control, cystoscoy was erformed to confirm our diagnosis. In cystoscoy, a wide and deformed fistula tract extending to trigon base in the osterior urethra was seen. After cystoscoy, the atient was diagnosed with urethrogluteal fistula. In order to enable sontaneous closure of fistula tract, follow-u of the atient with suraubic cystostomy catheter was recommended. At the third month followu visit, the drainage from fistula was minimal. Therefore, it was decided to continue the follow-u with suraubic cystostomy. 3. Discussion As a result of recurrent catheterization, a local urethral trauma occurs in male atients who imlement CISC, which increases with long-term use of CISC [3, 4].

3 Case Reorts in Urology 3 (a) (b) Figure 2: In cystourethrograhy, fistula tract and urinoma filled from a defect in the urethra were observed; f: fistula tract. Incidence of formation of urethral false assage during the use of CISC was reorted to be 3 9%, while that of urethral stricture was reorted to be 1 9% in the literature [2]. Abscess formation as a comlication of intermittent catheterization has only been described twice reviously [5, 6]. In our atient, we encountered a comlication induced by CISC, which was rarely reorted in the literature reviously. A fistula extending from the osterior urethra to the gluteal region was detected in our atient. Imaging methods, including cystourethrograhy, cystourethroscoy, fistulograhy, and magnetic resonance imaging (MRI) can be used to diagnose fistula tract and detect ossible factors that may cause it [7]. In our case, wide abscess foci extending from osterior urethra to gluteal muscle grous were observed in MRI. A large fistula tract extending between the urethra and the gluteal region was revealed by cystourethrograhy. Wide urethral defect was seen in the osterior urethra during cystourethroscoy erformed on the atient. Michielsen and Wyndaele [8] detected a false assage that develoed as a result of traumatic catheterization of external shincter area in one of their atients and thought that this was caused by shincter sasticity. Similarly, large fistula tract arising from immediate roximal of external shincter was thoughttobeduetoshinctersasticityinouratient. Detailed information on recovery of fistulas extending fromurethratowardmusclegrousisnotavailableinthe literature. During the first treatment, it is aimed to revent urinary sesis using aroriate antibiotics [8]. Some of the fistulas can be treated with simle rocedures such as urethral catheterization and follow-u [6, 7]. We diagnosed our atient with fistula and erformed his followu by suraubic catheterization. Suraubic gluteal abscess foci was seen to recover during catheterization; however, comleteclosureofthefistulatractcouldnotbeachieved. In comlicated cases, rimary reair techniques for fistula as well as graft methods can be utilized [9]. Koleilat et al. [10] achieved comlete recovery by urethral catheterization and follow-uin7of9atientswithurethralfalseassage,while theyimlementedurinarydiversioninoneoftheatients whodidnotrecover.inourcase,itislannedtocarry out a rimary urethral reair if comlete recovery cannot be achieved by follow-u with suraubic catheterization. Urinary diversion is also among the otions if urethral defect does not close. 4. Conclusion The CISC-induced urethral fistulas can, albeit occasionally, be seen. Treating atients with a temorary urethral stent and antibiotics seem to be a good treatment otion. In the case of fistulas which do not recover desite this, rimary reair, the use of graft, and urinary diversion may be considered. Conflict of Interests The authors declare that there is no conflict of interests regarding the ublication of this aer. References [1] J.Laides,A.C.Diokno,S.J.Silber,andB.S.Lowe, Clean,intermittent self-catheterization in the treatment of urinary tract disease., Urology,vol.107,no.3, ,1972. [2] P. Di Benedetto, Clean intermittent self-catheterization in neuro-urology, EuroeanJournalofPhysicalandRehabilitation Medicine,vol.47,no.4, ,2011. [3] J.Laides,A.C.Diokno,F.R.Gould,andB.S.Lowe, Further observations on self catheterization, Urology,vol.116, no. 2, , 1976.

4 4 Case Reorts in Urology [4] J. Labat, B. Perrouin-Verbe, J. M. Lanoiselée, J. E. Mathé, and J. M. Buzelin, L utosondage intermittent rore dans la réeducation des blessés médullaires et de la queue de cheval. I et II, Annales de Réadatation et de Médecine Physique, vol. 28, , , [5] S. Iida, H. Iuchi, Y. Sasaki et al., A case of erineal abscess duetourethralfistulainaatientwithsinalcordinjury, Acta Urologica Jaonica,vol.49,no.9, ,2003. [6] J. Pannek, K. Göcking, and U. Bersch, Perineal abscess formation as a comlication of intermittent self-catheterization, Sinal Cord,vol.46,no.7, ,2008. [7] M. Yucel, S. Kabay, L. Sahin et al., Posttraumatic ventral urethral fistula: a case reort, Cases Journal,vol.2,no.9,article 8644, [8] D. P. Michielsen and J. J. Wyndaele, Management of false assages in atients ractising clean intermittent self catheterisation, Sinal Cord,vol.37,no.3, ,1999. [9] T.M.Grandhi,O.Shelley,A.K.Ray,andJ.R.McGregor, Dorsal urethral fistula: case reort and review of literature, Urology, vol. 63, , [10] N. Koleilat, A. A. Sidi, and R. Gonzalez, Urethral false assage as a comlication of intermittent catheterization, Urology,vol.142,no.5, ,1989.

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