Clin. RadioL (1972) 23, 492-494

T H E P R E V A L E N C E OF P E L V I C P H L E B O L I T H S IN R E L A T I O N TO A G E , S E X A N D U R I N A R Y T R A C T I N F E C T I O N S

MALCOLM GREEN and M. LEA THOMAS

From the Department of Radiology, St. Thomas" Hospital London, S.E.1

The pelvic radiographs of 214 patients were reviewed and the prevalence of phleboliths statistically analysed. The overall prevalence was 39.2 ~ .

There was a highly significant increase in the number of patients having phleboliths with increasing age. No difference was found in the prevalence between the two sexes.

No significant difference was found in the prevalence of phleboliths in patients with urinary tract infection compared with the control group of patients.

INTRODUCTION Phleboliths were recognised by pathologists long

before x-rays allowed their widespread occurrence to be appreciated. Pelvic phleboliths were first recognised radiologically by Orten (1908) and he also laid down the diagnostic criteria. Clark (1909) radiographed the pelvis at post mortem before and after removal of the vesico-prostatic plexus thus proving conclusively that the opacities shown on pelvic radiographs were in fact the phleboliths of the early pathologists.

It is generally believed that phleboliths represent calcified thrombi in peri-vesical venous plexuses (Culligan, 1926; Nichols, 1946; Pena and Reig, 1951; Muir, 1958; Johnstone and Keats, 1960, Dovey, 1966).

Several factors have been implicated in the aetiology. Thus Hall Edwards (1913) stated that they were rare under the age of 40 and other observers (Butzler, 1934; Greenberg, 1949; Stein- bach, 1960; Dovey, 1966) have noted an increased incidence in older people. The difference in frequency between the sexes has been variously given as commoner in men (Culligan, 1928; Dillon and Cody, 1928), in women (Butzler, 1934) and as equal (Dovey, 1966). There have been many reports suggesting that pelvic phleboliths may be associated with the genito-urinary infections (Hall Edwards, 1913; Culligan, 1926; Dillon and Cody, 1928; Butzler, 1934; Nichols, 1946, Steinbach, 1960).

Dovey (1966) analysed the distribution of pelvic phleboliths in 400 patients according to age and sex but did not apply statistical methods to his results. He also compared the distribution of pelvic phleboliths in 250 patients undergoing excretion urography with 150 patients who were being

radiographed for other reasons. His intravenous pyelograms were performed for a variety of medical conditions so that no firm conclusions could be drawn as to the frequency of phleboliths in patients with genito-urinary infections. He assumed, how- ever, that more patients in the group having intravenous pyelograms would have had urinary infections but he did not specifically compare patients with or without urinary infections.

In this paper we statistically analyse the prevalence and size of phleboliths in pelvic radio- graphs according to age and sex. We also compare their incidence in patients who had known urinary tract infection with a control group.

MATERIAL Two hundred and fourteen radiographs were

examined in a retrospective study covering the years 1962-1963.

The control group consisted of 170 patients who had pelvic radiographs taken in the Casualty Department to exclude bone injury. None of the control group had evidence of urinary tract infec- tion.

The urinary tract infection group (UTI Group) consisted of 44 patients with proven urinary tract infections of at least 2 years duration, who had had pelvic x-rays as part of an intravenous pyelogram.

METHODS Phleboliths were identified as sharply defined,

rounded or oval opacities, sometimes laminated or with a translucent centre.

The pelvic radiographs were mixed randomly and assessed by counting the number of phleboliths and measuring their diameter to the nearest

492

P E L V I C P H L E B O L I T H S I N R E L A T I O N TO AGE~ SEX A N D U R I N A R Y T R A C T I N F E C T I O N S 493

millimetre. These assessments were made by 3 observers working independently.

RESULTS

The mean age of the 214 patients whose radio- graphs were examined was 44.1 years (range 2-94 years). There were 112 males (mean age 38.7, range 3-94) and 102 females (mean age, 54, range 2-86 years).

The overall prevalence of phleboliths was 84 (39.2%).

Age Prevalence.--There was a statistically signifi- cant increase (correlation coefficient (r)=0.956, p < 0.01) in the number of patients with phleboliths with increasing age (Table).

TABLE 1

PREVALENCE OF PHLEBOLITHS BY AGE GROUPS

Age in Number of % with years patients phleboliths

0-19 38 5 20-39 59 27 40-59 68 56 60-79 37 52 80-- 12 75

ALL 214 39'2

The mean diameter (2-53_+ 1-44 ram.) of the phleboliths did not increase with age (r=0.693, p>0.10).

The mean number (4-74-+ 4.23) of phleboliths in patients having phleboliths increased slightly with age (r=0.896, p<0.05).

Sex Prevalence.--There was no statistically significant difference between the incidence in the two sexes (X2= 1.66, p > 0-8).

There was also no significant difference in the mean diameter of phleboliths between the sexes (unpaired test: p > 0.6).

Prevalence in Control and Urinary Tract Infection Groups..In the control group there were 102 men (mean age 37 years) and 68 females (mean age 51.3 years).

In the U.T.I. group there were 10 men (mean age 44 years) and 34 women (mean age 51 years).

There was no statistically significant difference between the prevalence of phleboliths in the 2 groups (X2~2.68, p > 0.2).

but one possible source o f inaccuracy is that occasionally renal tract calculi may be indistinguish- able. This was excluded by the intravenous pyelo- gram in patients with urinary tract infections.

It would be unethical because of radiation to x-ray the pelves of symptomless patients to provide a control group, and instead we used pelvis radio- graphs taken for suspected trauma. I t must be admitted that some of these patients may have had symptomless urinary tract infection. However, a survey of an unselected population in urban and rural Wales showed an incidence of 5.8 % symptom- less bacteriuria in 1111 women and 0-5% in men (Kass, 1962). A group of working women from Charlottsville, U.S.A. had a similar incidence of 4-3 % (Kunin and McCormack, 1968). An incidence of bacteriuria of this order in our survey would predict that 1 man and 3 or 4 women with symptom- less bacteriuria might have been included in our control group. These numbers would not affect the conclusions drawn.

The overall frequency of phleboliths in our series is similar to that of other workers (Culligan, 1926; Dillon and Cody, 1928; Butzler, 1934; Kohler, 1935; Dovey, 1966). The small differences are probably accounted for by the different age distribution in each series.

Our statistically analysed series confirms the suggestion (Butzler, 1934 and Dovey, 1966) that there is a tendency for more people to have phlebo- liths as they grow older. However, we found no evidence that phleboliths are larger in older people although they were slightly more numerous. There was a prevalence of 19 % in patients under 40 years old and hence we cannot subscribe to the conclusion of Hall Edwards (1913) that phleboliths are rare below this age.

The incidence and sizes were similar in the 2 sexes. This confirms Dovey's conclusion (1966) by a statistical analysis.

In our series there was no significant difference in the prevalence of phleboliths in patients with urinary tract infections compared with control patients. This is in agreement with Dovey's sugges- tion (1966). It seems probable that the early workers who remarked on the high incidence of phleboliths in patients with genito-urinary infection believing this to be causative, were unaware of the high incidence of phleboliths in the population at large.

DISCUSSION

Phleboliths are radiographically characteristic

Acknowledgements. We should like to thank Dr. J. Burton and Dr. R. Linton for their assistance in reading the radiographs.

494 C L I N I C A L RADIOLOGY

REFERENCES

BUTZLER, O. (1934). Zur differentialdiagnose der phle- bolithen and ureterokonkremente im rotgenbild des kleinen beckens. Fortschritte auf dem Gebiete der Roent- genstrahten und der Nuklear Medzin, 49, 253-262.

CLARK, G. O. (1909). Peri-ureteral pelvic phleboliths. Annals of Surgery, 50, 913-921.

CULLIGAN, J. M. (1926). Phleboliths. Journal of Urology, 15, 175-188.

DILLON, J. R. • CODY, B. A. (1928). Pbleboliths. California and Western Medicine, 28, 800-802.

DOVEY, P. (1966). Pelvic phleboliths. Clinical Radiology, 17, 121-125.

GREENBERG, G. (1949). Post-operative complications and sequelae with special reference to embolism following prostatectomy and historical review. Urologic and Cutaneous Review, 53, 726-741.

HALL EDWARDS, J. (1913). The significance of phleboliths. British Medical Journal, 2, 1531-t533.

JOHNSTONE, A. S. & KEATES, P. G. 0960). PuNished in Textbook of X-ray Diagnosis, edited by Shanks, S. C. and Kerley, P., 3rd edition, VoL 3, page 760, H. K. Lewis & Co. Ltd., London.

KASS, E. H. (1962). Pyelonephritis and Bacteriuria. Annals of Internal Medicine, 56, 46-53.

KOHLER, A. (1935). In Roentgenology, translated by Turn- bull, A., 2nd edition, Ballier Tindall and Cox, London.

KONIN, C. M. & McCORMACK, R. C. (1968). An epidemio- logical study of bacteriuria and blood pressure among nuns and working women. The New England Journal of Medicine, 278, 635-642.

MmR'S TEXTBOOK OF PATHOLOGY (1958). Edited by D. F. Cappell ,7th edition, Edward Arnold, London.

NICHOLS, B. H. (1946). Genito-urinary lesions in male and female in Clinical Radiology, edited by G. U. Pillmore, Vol. 1, page 701, Davis, Philadelphia.

ORTEN, G. H. (1908). Some fallacies in the x-ray diagnosis of renal and ureteral calculi. British Medical Journal, 2, 716-719.

PENA, A. DE LA & REIG, J. (1951). Einiges uber phlebolithen, Medizinische Welt, 20, 55-56.

STEINBACH, H. L. (1960). Identification of pelvic masses by phlebolith displacement. American Journal of Roent- genology, 83, 1063-1066.

BOOK REVIEWS

Principles of Chest X-ray Diagnosis by GEORGE SIMON. Pp. 282. Published by Butterworths, London. £8.

First appearing in 1956 this is the third - and best - edition of a book that will surely become a classic. Dr. Simon's approach to his subject is essentially visual and didactic. Unlike most other books on chest radiology the division of the subject matter into chapters is based not on patho- logical, clinical or anatomical grounds, but on the abnormal appearances of the X-ray film; surely a logical approach for a radiologist. The shadows, or translucencies, are grouped and categorised, and from their appearance deductions are made as to the possible morbid anatomy underlying them; only then is the clinical information adnaitted and combined in an attempt to suggest a diagnosis. Thus there are chapters among others - on 'homogenous shadows,' 'linear shadows', 'hypertransradiancies' and ' the pulmonary vessels in lung disease'. There are also chapters on broncho- graphy and tomography. A particular virtue of the book is that the first five pages are devoted to a definition of the author's descriptive terms, followed by a description of the normal. I t is a great treat nowadays to read a book written by one man, but it follows that the author 's particular interests are reflected in the text, and the chapters on bronchitis, emphysema and linear shadows appear to be more successful than the sections dealing with the heart. Discussing consolidation, no mention is made of the effects of gravity on its distribution. Rather more space is devoted to segmental consolidation than would seem necessary after it is pointed out that the use of this term is facile, intersegmental barriers capable of limiting the extent of consolidation being non-existent. Nor is it pointed out that when consolidation is really confined to a segment, under- lying bronchial occlusions should be suspected. All in all however, in spite of a few minor ciriticisms, this is undoubtedly the best book available for the training of radiologists.

J. W. PIERCE

The Roentgenographie Diagnosis of Renal Mass Lesions by ERICH K. LANG. Warren H. Green Inc., St. Louis, Missouri, U.S.A. (Price not given).

In this monograph the author points out that in the last decade there has been a dramatic change in our attitude to the diagnosis of a space occupying lesion in the kidney. He has related the change in statistical occurrence of cyst and tumour to the increase in the use of excretion urography. In the past, demonstration of a space occupying lesion suggested the presence of a carcinoma and thus surgical exploration was the method of choice. However, the inci- dence rate of cyst presenting as space occupying lesions of the kidneys exceeds by far that of malignant turnouts. There is also an appreciable surgical mortality and morbidity and this rises with the age of the patient. Furthermore, it is not always easy to detect a carcinoma at operation so that a kidney containing a benign lesion might be removed.

A rational approach to the differential diagnosis of renal masses is described and a critical evaluation of the role of excretion urography, nephrotomography, renal arterio- graphy, cyst puncture and retroperitoneal gas studies is presented. Particular emphasis is placed on the importance of selective pre-injection of epinephrine hydrochloride into the renal artery in order to differentiate between normal and abnormal renal vessels. Renal tumours, renal cysts and combined tumours and cysts are described and the problems of interpretation are presented in a lucid manner.

This book is a delight to read, the illustrations are profuse and are of first class quality, clearly showing the lesions described. The problems of a space occupying lesion of a kidney are seen frequently in both specialist and general radiological departments. This book can be recommended for inclusion in every departmental library and should assist those specialising in this branch of radiology.

K. T. EVANS