Background: Phimosis is a rare cause of obstructive uropathy and renal failure. This report presents a case of a 22-year-old man with phimosis, resulting in such complications. Case report: The patient with incidentally revealed elevated serum creatinine level was subjected to ultrasonography, voiding cystourethrography and static fluid MR urography (sMRU), combined with conventional T1- and T2-weighted images. The urinary tract dilatation and the bladder diverticula were diagnosed with the use of imaging modalities. Two months after circumcision the degree of hydroureteronephrosis as well as creatinine level decreased. Conclusions: The obstructive uropathy involving the upper urinary tract and resulting in renal failure may develop on the basis of chronic phimosis. Completing of standard imaging techniques with MR urography significantly improved the possibility of the urinary tract evaluation in the presented case

Rutkowska, Beata

Studniarek, Michał

Zielonko, Joanna

Polish Journal of Radiology

Jagiellonian Univeristy Repository

99C A S E  R E P O R TChronic phimosis as a cause of obstructive uropathy in an adult patientJoanna Zielonko, Beata Rutkowska, Michał StudniarekDepartment of Radiology, Medical University of Gdansk, PolandAuthor’s address: Joanna Zielonko, Department of Radiology, Medical University of Gdansk, St. Debinki 7, Poland, e-mail: joanziel@wp.pl Summary	 Background:  Phimosis	 is	a	rare	cause	of	obstructive	uropathy	and	renal	 failure.	This	report	presents	a	case	of	a	22-year-old	man	with	phimosis,	resulting	in	such	complications. Case report:  The	 patient	 with	 incidentally	 revealed	 elevated	 serum	 creatinine	 level	 was	 subjected	 to	ultrasonography,	voiding	cystourethrography	and	static	fluid	MR	urography	(sMRU),	combined	with	conventional	T1-	and	T2-weighted	images.	The	urinary	tract	dilatation	and	the	bladder	diverticula	were	diagnosed	with	the	use	of	 imaging	modalities.	Two	months	after	circumcision	the	degree	of	hydroureteronephrosis	as	well	as	creatinine	level	decreased.				 Conclusions:  The	 obstructive	 uropathy	 involving	 the	 upper	 urinary	 tract	 and	 resulting	 in	 renal	 failure	may	develop	on	the	basis	of	chronic	phimosis.	 	 Completing	 of	 standard	 imaging	 techniques	 with	 MR	 urography	 significantly	 improved	 the	possibility	of	the	urinary	tract	evaluation	in	the	presented	case. Key words:  phimosis • obstructive uropathy • magnetic resonance urography PDF file: http://www.polradiol.com/fulltxt.php?ICID=478121Otrzymano: 2007.02.15 Zaakceptowano:2007.03.26Sygnatura:Pol J Radiol, 2007; 72(2): 99-103BackgroundThere	are	several	causes	of	obstructive	uropathy.	The	sub-vesical	 obstacles	 resulting	 in	urinary	 obstruction	 include:	sclerosis	of	the	bladder	neck,	prostatic	diseases,	valvula	of	the	posterior	urethra,	urethral	diverticula,	stricture	of	 the	external	urethral	meatus	(commonly	associated	with	hypo-spadiasis)	and	rarely	-	phimosis.Phimosis,	i.e.	inability	to	retract	the	foreskin,	is	the	abnor-mality	 affecting	 1-10%	 of	 boys.	 It	 should	 be	 differentia-ted	 from	the	adhesion	between	 the	 foreskin	and	 the	glans	which	is	found	in	neonates	and	infants	and	associated	with	maturation	of	the	glans.	The	term	“physiological	phimosis”	is	used	for	this	condition	[1].	In	about	90%	of	boys	under	3	years	of	age	the	foreskin	 is	rectractable,	while	 in	17-year-old	adolescents	the	percentage	is	99%	[2].As	 there	 are	 only	 a	 few	 literature	 data	 concerning	 chronic	phimosis	resulting	 in	obstructive	uropathy	and	renal	failure,	a	case	of	a	patient	with	such	abnormalities	has	been	reported.Case reportA	22-year-old	male	with	 pulmonary	 tuberculosis	 (confir-med	by	both	bacteriological	and	radiological	examinations)	was	admitted	 to	 the	Department	of	Pulmonology	 for	anti-tuberculosis	 therapy.	Accessory	 laboratory	 tests	 revealed	elevated	 serum	 creatinine	 concentration	 to	 505	 μmol/L	(6,53	mg/dL).Ultrasonography	displayed	bilateral	 hydronephrosis,	more	intensified	 in	 the	 left	 kidney,	 the	 parenchyma	 of	 which	was	significantly	narrowed.	Both	ureters	visible	within	the	subpelvic	and	perivesical	segments	were	markedly	dilated.	The	bladder	wall	was	very	thickened	and	irregular.	Behind	the	bladder	there	were	noticed	two	fluid	spaces	showing	no	clear	 connection	with	 it	 (fig.	 1).	After	 twofold	micturition	urine	retention	was	about	400	mL.Secondary	MR	examination	 of	 the	urinary	 tract	was	per-formed	 using	 0,5	 T	 scanner	 (Gyroscan	 T5NT,	 Philips,	Eindhoven,	 The	 Netherlands).	 Conventional	 T1-	 and	100Pol J Radiol, 2007; 72(2): 99-103Case ReportT2-	weighted	 images	as	well	as	static	 fluid	MR	urography	(sMRU)	were	 obtained.	 Slice	 thickness	was:	 5	mm	 (axial	T1-	 and	 T2-weighted	 images),	 3	 mm	 (sagittal	 T1-	 and	T2-weighted	 images)	 and	 2	mm	 (source	 images	 of	 sMRU	planned	 in	 sagittal	 plane).	 Bilateral	 hydronephrosis	 and	tortuous,	 widened	 on	 all	 the	 course	 ureters	 were	 seen.	Numerous	tiny	diverticula	of	the	bladder	wall	and	two	big-ger	ones	within	its	posterior	wall	were	noticed	(fig.	2).Urinary	tract	tuberculosis	was	excluded	in	a	series	of	bac-teriological	 urine	 cultures.	 Bladder	 diverticula	 and	 urine	retention	suggested	suspicion	of	subvesical	obstacle	 in	the	Figure 1.	 	Initial	ultrasonography	prior	to	operation.	A.	Sonogram	of	the	right	kidney	shows	hydronephrosis	(observed	also	on	the	left	side).	B.	Fluid	space	is	noted	behind	the	bladder.Figure 2.	 	Preoperative	MR	examination.	A.	Sagittal	T2-weighted	turbo	spin-echo	image	(2500/100)	reveals	two	diverticula	at	the	posterior	wall	of	the	bladder.	Several	small	diverticula	are	visible	near	the	bladder	vertex.	B.	An	sMR	urogram	(MIP;	2500/700)	shows	severe	bilateral	ureterohydronephrosis.	C.	Coronal	T2-weighted	turbo	spin-echo	image	(2500/100)	visualizes	bilateral	hydronephrosis	with	reduction	of	renal	parenchyma	on	the	left	side.A BCA B101Pol J Radiol, 2007; 72(2): 99-103 Chronic phimosis as a cause of obstructive...urine	 output.	On	 the	 basis	 of	 exact	 physical	 examination	phimosis	was	 diagnosed.	Directly	 after	 circumcision	 per-formed	 in	 the	 Department	 of	 Urology,	 creatinine	 level	decreased	to	398	μmol/L	(5,21	mg/dL).A	 few	 days	 after	 circumcision	 another	MR	 examination	was	 carried	 out.	 The	 bladder	wall	was	 thickened,	 folded	with	 small	 diverticula.	Within	 the	 stratified	 muscular	layer	of	the	anterior	bladder	wall	urine	accumulation	was	observed.	The	bigger	of	the	two	diverticula	at	the	posterior	wall	 diminished	 slightly.	 Hydronephrosis	 decreased,		however	there	were	still	visible	dilated	subvesical	ureteral	segments	(fig.	3).Taking	 advantage	 of	 catheterization	 of	 the	patient	 after	circumcision,	 the	 cystourethrography	 was	 performed	Figure 4.	 	Voiding	cystourethrography	carried	out	10	days	after	operation.	A.	Multiple	diverticula	of	the	bladder	and	no	abnormalities	of	the	urethra	are	noted.	B.	Post-voiding	residue	is	visible	within	diverticula.Figure 3.	 	MRI	performed	3	days	after	circumcision.	A.	On	sagittal	T2-weighted	turbo	spin-echo	image	(2500/100)	urine	accumulation	within	thick	anterior	wall	of	the	bladder	is	observed.	Diverticula	at	the	posterior	wall	are	filled	with	the	urine	to	a	larger	extent	in	comparison	with	the	preoperative	MR	examination.	B.	An	sMR	urogram	(MIP;	2500/700)	reveals	a	decrease	of	ureterohydronephrosis.A BA B102Pol J Radiol, 2007; 72(2): 99-103Case Reportto	 exclude	 additional	 urethral	 abnormalities	 and	 vesi-coureteral	 reflux.	 The	 examination	 revealed	 normal	picture	 of	 the	 urethra	 as	well	 as	 intensified	 trabecula-tion	of	the	bladder	wall,	several	bladder	diverticula	and	no	 vesicoureteral	 reflux	 after	 removal	 of	 the	 catheter	(fig.	4).In	the	follow-up	ultrasonography	(4	weeks	after	operation)	the	 pelvicaliceal	 systems	were	 still	widened	but	 in	 a	 less	degree	than	before.	Thickening	of	the	bladder	wall	as	well	as	 its	 diverticula	 persisted.	 Post-voiding	 urine	 retention	diminished	to	200	mL.After	 successful	 treatment	 of	 pulmonary	 tuberculosis	(radiologically	 confirmed	 by	 regression	 of	 infiltrative	changes)	 the	patient	 discontinued	hospitalization	 and	was	transferred	 to	 the	 Outpatient	 Clinic	 of	 Pulmonology	 and	Nephrology.Two	 months	 after	 surgery	 creatinine	 level	 decreased	 to	256	μmol/L	(3,35	mg/dL).	In	ultrasonography	hydronephro-sis	 further	 diminished	 (fig.	 5).	Narrowing	 of	 the	 cortical	layer	 in	 the	 left	 kidney	 persisted,	 the	 distal	 parts	 of	 the	ureters	were	 still	 dilated.	The	 sonographic	 picture	 of	 the	urinary	bladder	remained	unchanged.DiscussionPhimosis	 develops	 on	 the	 basis	 of	 recurrent	 balanopos-thitis	 caused	 by	 Staphylococcus	 aureus,	 Proteus	 vul-garis	 and	 -	 rarely	 -	 by	 viruses	 [3].	 Lichen	 sclerosus	 et	atrophicus	 is	 a	 disease	 often	 leading	 to	 phimosis	 [4].	Chronic	 candidiasis,	Bowen’s	 disease,	 condylomata	 acu-minata	 are	 dermatological	 entities	 less	 frequently	 caus-ing	 phimosis.	 Cicatrization	 of	 the	 preputial	 orifice	 due	to	 forceful	 retraction	 of	 the	 foreskin	 as	 well	 as	 self-mutilation	 of	 the	 urethra	 are	 the	 additional	 propitious	factors.The	onset	of	phimosis	in	an	adult	patient	may	be	a	sign	of	diabetes	[5].Worth	mentioning	is	the	theory	by	Volmar	et	al.	according	to	which	phimosis	occurring	in	foetal	development	plays	a	role	in	pathogenesis	of	the	prune	belly	syndrome	defined	as	deficiency	of	 the	anterior	abdominal	wall,	 several	urinary	tract	abnormalities	and	undescended	testes	[6].Phimosis	is	treated	conservatively	(topical	steroids)	or	oper-atively	[7,	8,	9,	10].Accumulation	of	 smegma	under	 the	prepuce	 in	 the	course	of	 phimosis	 results	 in	 chronic	 balanoposthitis	which	may	cause	penile	cancer	[11].The	described	case	of	22-year-old	man	proves	that	phimo-sis	can	lead	to	changes	of	the	bladder	being	a	consequence	of	 an	 increase	 in	 the	 intravesical	 pressure	 (hypertrophy	of	 the	bladder	wall,	 diverticula)	 and	 to	 the	upper	urinary	tract	dilatation	as	well.	Sometimes	morphological	lesions	in	the	 obstructive	uropathy	 are	 completed	by	vesicoureteral	reflux.	 Long-lasting	 abnormalities	 cause	 the	 reduction	 of	renal	parenchyma	and	 renal	 failure.	There	are	only	a	 few	literature	data	describing	those	complications	[12,	13].The	 presented	 diagnostic	 algorithm	 concerning	 the	 uri-nary	tract	imaging	is	especially	recommended	in	patients	with	high	creatinine	level.	Static	fluid	MRU	using	urine	as	natural	contrast	material	 is	 found	 to	be	a	valuable	com-plement	to	ultrasonography	in	those	patients	[14,	15,	16].	In	 conditions	 of	 intense	 urine	 retention	 sMRU	 visuali-zes	 the	urinary	 tract	without	 diuretic	 injection	 and	 oral	hydration	[17].	In	the	presented	case	thin	slices	of	T1-	and	T2-weighted	 images	 and	 source	 images	 of	 sMRU	 (acqui-red	 in	 sagittal	 plane)	 enabled	 to	 assess	 the	 abnormali-ties	 of	 the	 bladder,	 especially	 those	within	 its	 posterior	wall.	 For	 evaluation	 of	 the	 urethra	 and	 vesicoureteral	reflux	voiding	cystourethrography	still	remains	a	method	of	choice.ConclusionsThe	 presented	 case	 proves	 that	 obstructive	 uropathy	involving	 the	 upper	 urinary	 tract	 and	 resulting	 in	 renal	failure	may	develop	in	adult	patients	with	phimosis.MR	 urography	 performed	 as	 a	 complement	 to	 standard	methods	 (ultrasonography,	 voiding	 cystourethrography)	improves	 the	possibility	of	 the	urinary	 tract	evaluation	 in	patients	with	such	complications.Figure 5.	 	The	follow-up	ultrasonography	performed	8	weeks	after	surgery.	The	regression	of	hydronephrosis	is	observed	on	the	sonogram	of	the	right	kidney.	 1.	Shankar	KR,	Rickwood	AM.	The	incidence	of	phimosis	in	boys.	BJU	International	1999;	84:	101–102.	 2.	Huntley	JS,	Bourne	MC,	Munro	FD,	Wilson-Storey	D.	Troubles	with	the	foreskin:	one	hundred	consecutive	referrals	to	paediatric	surgeons.	J	R	Soc	Med	2003;	96:	449–451.	 3.	Escala	JM,	Tickwood	AM.	Balanitis.	Br	J	Urol	1989;	63:	196–197.	 4.	Meuli	M,	Briner	J,	Hanimann	B,	Sacher	P.	Lichen	Scleroticus	et	Atrophicus	causing	phimosis	in	boys:	A	prospective	study	with	5-years	follow-up	after	complete	circumcision.	J	Urol	1994;	152:	987–989.	 5.	Chopra	R,	Fisher	R,	Fencl	R.	Phimosis	and	diabetes	mellitus.	J	Urol	1982;	127:	1101–1102.References:103Pol J Radiol, 2007; 72(2): 99-103 Chronic phimosis as a cause of obstructive...	 6.	Volmar	KE,	Nguyen	TC,	Holcroft	CJ,	Blakemore	KJ,	Hutchins	GM.	Phimosis	as	a	cause	of	prune	belly	syndrome:	comparison	to	a	more	common	pattern	of	proximal	penile	urethra	obstruction.	Virchows	Arch.	2003;	442:	169–172.	 7.	Orsola	A,	Caffaratii	J,	Garat	JM.	Conservative	treatment	of	phimosis	in	chidren	using	a	topical	steroid.	Urology	2000;	56:	307–310.	 8.	Ashfield	JE,	Nickel	KR,	Siemens	DR,	MacNeily	AE,	Nickel	JC.	Treatment	of	phimosis	with	topical	steroids	in	194	children.	J	Urol	2003;	169:	1106–1108.	 9.	Rickwood	A.,	Hemalatha	V.,	Batcup	G.	Phimosis	in	boys.	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Chronic phimosis as a cause of obstructive uropathy in an adult patient

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Chronic phimosis as a cause of obstructive uropathy in an adult patient

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