Br. J. Surg. Vol. 69 (1982) 156 Printed in Great Britain

Ureteric obstruction due to pelvic acti nomycosis

AND J. BANCEWICZ A case is presented of ureteric obstruction due to pelvic actinomycosis Department of Surgery, Clinical Sciences Building.

M68HD. associated with an intra-uterine contraceptive device. Resolution of ureteric obstruction occurred with antibiotic therapy alone. Hope Hospital. Eccles Old Road, Salford

A number of reports of pelvic actinomycosis arising in association with modern types of intra-uterine contraceptive devices (IUCDs) have appeared since 1973 (1,2). Various presentations occur, such as vaginal discharge, tubo-ovarian abscess or ‘frozen pelvis’. Ureteric obstruction is uncommon and its management unclear.

Case report A 34-year-old woman presented with a 6-month history of alternating constipation and diarrhoea, weight loss, amenorrhea and, latterly, a vaginal discharge. An IUCD (Lippes loop) had been inserted 2 years before. On examination, she was anaemic, cachectic, pyrexial and had a ‘frozen pelvis’. There was a stricture of the mid-rectum but the mucosa was intact. The strings of the IUCD could be felt and the cervix appeared normal. There was skin redness and induration over the right ischiorectal fossa.

Abnormal investigation results included haemoglobin 7.2 g/dl, white cells 16.9 x 109/1 (78 per cent neutrophils), ESR 40mm/h. albumin 31 g/l and alkaline phosphatase 306 i.u./l. Blood urea and creatinine were normal. High vaginal swab showed pus cells but grew commensal flora only.

Intravenous urogram showed bilateral hydronephrosis with hydro- ureter (Fig. 1). CT scan showed a mass in the pelvis, displacing the bladder anteriorly and a mass in the right ischiorectal fossa. Both were thought to be neoplastic.

Examination under anaesthesia confirmed the mid-rectal stricture; biopsies showed mild inflammatory changes only. The IUCD was removed and curettings revealed an acute endometritis.

At laparotomy, apparently normal small bowel loops were adherent to a friable mass in the pelvis, which displaced the bladder forwards. The colon and uterus appeared normal but bilateral pyosalpinges were present and were resected. Neither ovary could be identified. Despite the tuba1 infection, pelvic malignancy was suspected and a sigmoid colostomy fashioned in view of impending rectal obstruction. Histology of the mass showed a large amount of fibrous tissue infiltrated by acute and chronic inflammatory cells and containing micro-abscesses. In two places only, colonies of actinomycetes surrounded by polymorphs were seen. No sulphur granules were identified. No growth was obtained on aerobic and anaerobic culture of the tissue and the pyosalpinges.

Treatment with penicillin V 500mg q.d.s. produced an allergic reaction and was changed to tetracycline 250mg q.d.s. which was continued for 2 months at home. Four months later, the rectal stricture had resolved and the colostomy was closed. Nine months after initial presentation, a further urogram showed complete resolution of the left hydronephrosis (Fig. 2). There was slight residual right hydronephrosis but no evidence of ureteric obstruction.

Discussion In recent years, primary pelvic actinomycosis has been recognized as related to the use of IUCDs (1,2). Preoperative diagnosis is extremely difficult (3), and may not be made even at laparotomy. Debulking procedures of ‘a widespread pelvic tumour’ have been performed mistakenly (4).

Although the infecting organism produces a dense fibrotic response, ureteric obstruction is rare. When it does occur, ureterolysis has been used (4,5). In the case reported here, any attempt to identify the ureters would have been hazardous whereas resolution of ureteric obstruction occurred with antibiotic therapy alone.

~ i ~ . 1. I~~~~~~~~~~ urogram showing bilateral h,,,dronephrosis with

References 1.

2.

Henderson S. R.: Pelvic actinomycosis associated with an intra- uterine device. Obster. Gynerol. 1973; 41: 726-32. Hager W. D., Douglas B., Majmudar B. et al.: Pelvic colonisation with actinomyces in women using intrauterine contraceptive devices. Am. J . Obstet. Gvnecol. 1979; 135: 680-4. McCormick J. F. and Scorgie A. D. F.: Unilateral tubo-ovarian actinomycosis in the presence of an intrauterine device. Am. J . Clin. Pathol. 1977; 68: 622-6.

3.

Fig. 2. hydronephrosis.

4.

A further urogram 9 months later showing slight residual right

Willscher M. K., Mozden P. J. and Olsson C. A,: Retroperitoneal fibrosis with ureteral obstruction secondary to Artinomyces israelii. Urology 1978; 12: 569-71. Jennings M. and Isaacson P.: Bilateral ureteric obstruction in a patient with ileocaecal Crohn‘s disease complicated by actino- mycosis. Br. J . Urol. 1977; 49: 410.

5.

Paper accepted 9 July 1981