Ir J Med Sci (2010) 179:443–445 DOI 10.1007/s11845-008-0232-1
CASE REPORT
Urethral erosion of a bone screw after internal urethrotomy: a rare complication after pelvic trauma R. Onur Æ E. Yilmaz Æ M. R. Onur Æ I. Orhan
Received: 18 February 2007 / Accepted: 16 September 2008 / Published online: 11 October 2008 Ó Royal Academy of Medicine in Ireland 2008
Abstract Background Although screw breakage or loosening are rarely encountered, they were reported to occur after instability of the internal fixation. Methods A man with a history of traumatic pelvic fracture 6 months ago presented to our clinic with inability to void. An anterior urethral meatotomy was made and a calcified but intact screw was removed from the urethra. Conclusions Screw migration with urological manifestations are extremely rare and usually include bladder migration with a subsequent voiding of the screw. We present a case in which internal urethrotomy for posterior urethral stricture caused erosion of a bone screw into the urethra which was subsequently removed by anterior meatotomy.
Introduction Some pubic rami fractures and symphysis pubis dislocations may require internal fixation of the anterior pelvic ring [1]. Screw breakage or loosening after these interventions is rarely encountered, but may occur due instability of the internal fixation [2]. Screw migration with urological manifestations is also extremely rare and bladder migration with subsequent voiding of the screw were reported in several cases [2, 3]. We present a case in which erosion of a bone screw into the urethra occurred after internal urethrotomy and was subsequently removed by anterior meatotomy.
Case report Keywords Trauma Urethra Erosion Screw Internal urethrotomy
R. Onur I. Orhan Department of Urology, Faculty of Medicine, Firat University, Elazig, Turkey E. Yilmaz Department of Orthopaedics, Faculty of Medicine, Firat University, Elazig, Turkey M. R. Onur Kovancılar Government Hospital, Elazig, Turkey M. R. Onur (&) Cumhuriyet Mahallesi, Arbay Sitesi, 21/7 23750, Bahc¸elievler, Elazig, Turkey e-mail:
[email protected]
A 28-year-old male patient presented to our clinic with inability to void and dysuria for the last 8 h. He felt a firm, stone-like particle in his anterior urethra. Physical examination revealed globe vesicale and tip of a screw 0.5 cm inside the external urethral meatus. A pelvic X-ray also showed a 18 mm diameter screw inside the penile shadow and the internally fixed bilateral pubic rami (Fig. 1). An anterior urethral meatotomy was made and a calcified but intact screw was removed from the urethra (Fig. 2). Subsequent ultrasonography revealed no foreign body within urinary tract. Patient had a history of traumatic pelvic injury and presented to our department 6 months ago. He had a bladder perforation and underwent bladder repair with simultaneous open reduction and internal fixation of bilateral pubic rami fracture with a hole plate using 3.5 mm screws. Peroperative X-ray showed proper internal fixation of the fractured pubic rami (Fig. 3). His bladder repair was
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Fig. 1 Pelvic X-ray showing migrated bone screw inside the penile shadow and the internally fixed bilateral ischium pubic rami
Fig. 3 Peroperative X-ray showed proper internal fixation of the fractured ischium pubis
Fig. 2 A 3.5 mm calcified screw removed from the urethra
uneventful, an 18 Fr Foley catheter was placed into the bladder and patient was followed at the orthopedic clinic for his bone surgery. Patient was discharged with an indwelling catheter to be removed later, but contrary the medical advice the patient had his catheter removed in a different medical center earlier than planned. Subsequently, the patient failed to attend for urological followup. History after the operation revealed that he had lower urinary tract symptoms (LUTS) and urinary tract infections and was treated at a primary care center with multiple doses of antibiotics. Patient persistently suffered from LUTS and diffuculty in voiding during this time. One week
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Fig. 4 Migrated screw to the midline
prior to his presentation to our hospital, he admitted to another center with LUTS and diffuculty in voiding. During evaluation his pelvic radiography revealed a migrated screw which was located between two ischium pubis arms (Fig. 4). Patient underwent cystoscopy and internal urethrotomy for urethral stricture at the same center. A dilatation of prostatic urethra and removal of a calcified
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stone in the urethra which was removed and an internal urethrotomy was performed. Bladder findings was normal except for a mild increase in trabeculation.
Discussion Disruption of the pelvic ring was reported to be associated with a 7–25% incidence of lower urinary tract injuries [2]. In the present case, we had a patient with bladder injury and bilateral pubic rami fracture managed simultaneously by repairing the bladder and internal fixation with hole plates using multiple screws. Urethral or bladder injury was not considered contraindications for early internal fixation and single, curved four- or six-hole pelvic plate with 3.5 mm screws were advocated [1]. Although internal fixation with multiple screws are commonly used without any complications, loosening and migration of screws may be encountered. Recently, spontaneous urinary voiding of a metallic implant after operative fixation of the pubic symphysis were reported in two different studies [3, 4]. Similarly, Heetveld et al. presented a screw spontaneously voided 9 years after treatment of sympysiolysis and dislocation of sacroilaic joint. They hypothesized that instability of the internal fixation materials bridging caused loosening of the screws. The unstable plate fixation of the symphysis pubis was reported to be the cause of screw migration into the bladder with subsequent expulsion via voiding [2]. Screw loosening and subsequent migration into the bladder was the hypotheses occurred due to long asymptomatic interval of 7 years. In their self critics, authors suggested a six-hole plate with four longer screws in a paired V-shaped formation would have been choice for their patient. The authors suggested early cystographic or cystoscopic evaluations after pelvic fixation in patients with recurrent urinary tract infection [2]. In contrast to the previous reports, the patient in our case was not asymptomatic in the post-operative period. He had had early removal of his catheter and multiple culture positive urinary tract infections predisposing him to urethral stricture. Although a paired V-shaped form of plate and long screws were used for fixation, one of the short screws was loosened and migrated 3–4 cm to the midline
and located at the junction of pubis arms (Fig. 4). We hypothesize that migrated screw was in junction with the anterior wall of urethra where the stricture was present. Subsequent direct visualization of urethra showed a dense stricture and an incision at 12 o’clock direction was assumed leading to thinning of anterior wall of urethra. The surgeon also reported a diverticulum-like widening of the part behind the stricture and a calcification which was later assumed to be calcification at the tip of the screw by us. Thus we think that internal urethrotomy led to erosion of the screw into the urethra with subsequent expulsion. Postoperative pelvic ultrasonography revealed no intravesical pathology and no perivesical fluid collection supporting the erosion of the screw into the urethra. To our knowledge, we report the first case of screw migration from the bone and erosion into the urethra after internal urethrotomy performed for urethral stricture. Concomitant presence of pelvic fractures and urogenital tract injuries is not rare. Bladder injuries and/or posterior urethral trauma, and development of urethral strictures in the presence of internal fixation of pelvic ring due to pelvic fractures need further attention for the loosening of screw and subsequent migration into the bladder or urethral erosion. We suggest evaluation by a pelvis graphy before any transurethral intervention in patients who underwent internal fixation of anterior pelvic ring and a carefully performed internal urethrotomy procedure, if necessary.
References 1. Matta JM (1996) Indications for anterior fixation of pelvic fractures. Clin Orthop Relat Res 329:88–96 2. Heetveld MJ, Poolman RW, Heldeweg EA, Ultee JM (2003) Spontaneous expulsion of a screw during urination: an unusual complication 9 years after internal fixation of pubic symphysis diastasis. Urology 61:645 3. Poolman RW, Heetveld MJ, Heldeweg EA, Ultee JM (2004) Spontaneous urinary voiding of a metallic implant after operative fixation of the pubic symphysis. J Bone Joint Surg Am 86:645–646 4. Fridman M, Glass AM, Noronha JA, Carvalhal EF, Martini RK (2003) Spontaneous urinary voiding of a metallic implant after operative fixation of the pubic symphysis: a case report. J Bone Joint Surg Am 85:1129–1132
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