Complex Urogenital Infections in a Rural Community Urology Practice: A Northern Ontario Experience

1
Complex Urogenital Infections in a Rural
Community Urology PracticeA Northern Ontario
Experience

• J. THERIAULT ,O. ABARA , S. SOGBEIN, E. ABARA

2
Background

• Genitourinary infections are common
• Diagnosed early and treated properly, results are
  gratifying
• In areas where there is sparse health care
  resources and limited access, simple conditions
  can become complex
• Co-morbid factors, environmental, socio-economic,
  concurrent disease may compound these

3
Aim of Study

• Review some complex genitourinary infections to
  understand some of the factors, challenges to
  health care providers and possibly learn from the
  outcomes of treatment

4
Method

• Descriptive Retrospective Case Study in Rural
  Community Urology Practice of 2 Northern Ontario
  Urologists 1989 to 2009
• Information obtained from various MDs offices
  and clinical records
• Representative cases discussed for illustration

5
Results
6
CASE 1 -- 1991

• 38 year old lady
• Previous hysterectomy for carcinoma-in-situ
  cervix
• Multiple genital perineal warts
• Urinary Frequency
• Bladder condylomata
• Been treated in Ottawa and Montreal with several
  modalities (Intravesical agents included)

7
CASE 1

• Required multiple TUR of condylomata lesions
• Excision of warts/condylomata from the vagina,
  vaginal vault, urethra, introitus and perineum,
  peri-anal areas
• Conservative endoscopic treatment failed to
  control disease
• Required radical Cystectomy and Ileoconduit
  (1993)
• 16 years post-op alive, with disease in the
  vulva and perineum
• Normal renal function at the last evaluation

8
Pathology Report TUR Curettings

• Bladder subepithelial tissues, smooth muscle and
  mucosa
• Mucosa squamous epithelium with Acanthosis and
  marked parakeratosis
• Focally Koilocytic Atypia
• Extensive squamous metaplasia with condylomata
  effects

9
Condylomata invading the ureter
Normal urothelium in a ureter (HPS stain)
Condyloma in the ureter (HPS stain)
10
Bladder condylomata
Bladder condylomata magenta parakeratosis
papillomatosis acanthosis koilocystosis (HPS
stain)
Bladder condylomata- atypical parakeratosis
koilocytosis mild squamous cell dysplasia
11
CASE 2 -- 1990

• 54 year old lady transferred by air ambulance
• Type 2 Diabetic
• One week of fever, chills, vomiting and left
  flank pain
• Blood and urine cultures E. coli
• IVP suggested left kidney abscess with air in and
  around the kidney
• Broad-Spectrum IV antibiotics, supportive therapy
• Diagnostic Imaging studies Ultrasound, CT Scan,
  Renal scan
• Cysto and Bilateral Retrograde
• Diagnosis Emphysematous pyelonephitis and
  abscess xanthogranulomatous pyelonephritis
  near-non function of left kidney

12
CASE 2

• Management options discussed, informed consent
  obtained
• Left radical nephrectomy and drainage of abscess
  in left kidney
• Post-op day 7 discharged home
• Follow-up over 10 years
• Passed away a few years ago from natural causes

13
Pathology

• Specimen weighed 760 g
• Areas of fibrosis and pustular material
• Yellow lobulated masses replace normal renal
  architecture
• Urine cytology revealed characteristic foamy cells

14
Pathology Kidney
Parenchymal abscess Lipid-laden
macrophages/foamy histiocytes with small, dark
nuclei and clear cytoplasm, lymphocytes, giant
cells and plasma cells
Typical xanthoma cells. This may be present where
inflammation and obstruction coexist.
15
Pathology Urine cytology
Urine cytology demonstrates same foamy xanthoma
cells
Xanthoma cells demonstrated in urine
16
Pathology Xanthogranuloma pyelonephritis
Renal parenchymal abscess showing
xanthogranulomatous pyelonephritis (Hematoxylin
and eosin stain)
17
CASE 3 -- 1991

• 29 year old man
• 5 year history of intermittent gross hematuria
  and flank pain, NO FEVER
• Non-smoker Occasional alcohol
• Ultrasound IVP, CT Scan done showed area of
  calcification in the upper pole of left kidney
• Cysto Bladder biopsy dysplasia
• Working diagnosis Hematuria, Nephrocalcinosis
  and calcified cyst, upper pole left kidney

18
CASE 3

• Management options discussed, informed consent
  obtained
• Left upper pole partial nephrectomy
• Lesion solid and cystic areas calcification
• Milk of calcium calcified particles retrieved
• No blood transfusion
• Discharged 7th post-op day

19
Histology Report

• Left kidney chronic inflammed cyst with
  calcification
• Polymorphous debris within lumen of cyst
• Stroma surrounding the cyst wall had chronic
  inflammatory infiltrates lymphocytes,
  histiocytes, Langhans giant cells
• Renal tubules adjacent to cyst are distended with
  hyaline casts
• Review of bladder biopsy chronic cystitis and
  focal granulomatous inflammation and a few
  multifocal Langhans giant cells
• Diagnosis Genito-Urinary Tuberculosis

20
Medical Management

• Patient referred to public health/health unit
• Anti Tuberculosis treatment over a period of 18
  months
• Annual follow-up
• Last seen in Timmins on July 24, 1996
• Follow-up reports have been received

21
Gows Short Course Regimen for Treatment of
Tuberculosis
From Gow JG The management of genitourinary
tuberculosis. J Antimicrob Chemother 1981
7590-591
22
CASE 4

• 58 year old male
• Mineral prospector
• Acute urinary retention in the bush
• Relieved himself by inserting a plastic tube he
  found on the ground
• History of hypertension and diabetes well
  controlled
• Physical exam normal except hard enlarged
  prostate on DRE
• Treatment TURP (Transurethral resection of
  prostate)

23
CASE 4

• Post-TURP
• Became septic
• CXR Abnormal interstial pattern both lungs
• Cystic marks in the forehead aspirated thick
  yellow pus-cultured blastocytes

• Blastomyces Dermatitis
• Prostatic curetting (Histology) showed
  blastomycosis prostatitis (North American
  Blastomycosy)
• Patient was treated with Amphotericin B and
  gradually improved
• Discharged home voiding urine well

24
Microphoto of Blastomycoses
Acute prostatitis hematoxylin eosin saffron stain
Methenamine silver stain, fungi are black
25
Macrophoto of Blastomycoses
PAS stain, budding yeast are magenta
26
Comments

• Limitations of the Study
• Complex genitourinary infections are challenging
• They consume health care resources
• They abound in rural communities
• High index of suspicion lead to correct
  diagnosis and treatment
• Prompt, appropriate treatment can be life saving
• Future studies to look at preventive measures,
  cost control and post op surveillance. A
  Collaborative study is recommended.

27
Acknowledgments

• Office staff of Drs. Sogbein and Abara
• TDH, Notre Dame Hospital, Sensenbrenner Health
  records
• Dr. Alex Steele, Consultant Pathologist- North
  Bay General Hospital
• NOSM Faculty