A 53-year-old man presented to the emergency department with major complaints of progressive weakness and confusion. He had a medical history of prostate cancer and a radiation prostatectomy complicated by post-prostatectomy incontinence that resulted in the insertion of an artificial urethral sphincter (AUUS).
The patient had to be hospitalized six months after the insertion of the USA for urinary retention and acute renal failure which resolved with intravenous fluids. The device was deactivated upon discharge and remained deactivated until the week before presentation to the emergency room. Home nurses said the device was working fine when reactivated, but the patient was having difficulty figuring out how to use it.
An initial physical examination showed a lethargic man who was alert and pointed only to his name. He had abdominal tenderness in the suprapubic region, but had no tenderness, rebound, stiffness, or costo-vertebral angle guard. Lung sounds were normal, but he was noted to have tachypnea. The remainder of his physical examination was unremarkable.
His initial vital signs indicated a temperature of 99.5 ° F, blood pressure of 142/96 mm Hg, heart rate of 85 beats per minute, respiratory rate of 31 breaths per minute, and oxygen saturation of 95% in Ambiant air. . Laboratory studies were significant for bicarbonate of 13 mEq / dL, anion gap of 22 mEq / dL, blood urea nitrogen of 112 mg / dL, creatinine of 13.38 mg / dL and white blood cell count of 12.99 x 109 / L. A bedside bladder ultrasound was performed and showed urinary retention> 500 ml. A CT scan of the abdomen and pelvis was performed (shown).
What is the diagnosis of this patient? Find a discussion on the next page.
Diagnosis: Infected artificial urethral sphincter
Urinary incontinence has been shown to affect up to 60% of patients after undergoing radical prostatectomy. (Jurol. 2002; 167[2 Pt 1]: 591.) The artificial urethral sphincter (AUUS) is the current gold standard after patients have failed conservative approaches to incontinence control. (Turkish Jurol. 2014; 40: 1; https://bit.ly/3qnU7kcThe device consists of a control pump placed in the scrotum, a reservoir of subcutaneous fluid, inflation and deflation mechanisms, and an inflatable occlusive cuff that surrounds the bulbous urethra. (Figure.) (Jurol. 2002; 167[2 Pt 2]: 1125.)
The device is in the activated state at rest and allows the cuff to remain inflated to obstruct the urethra and maintain continence. Deactivation occurs when the control pump is squeezed, then engages the cuff deflation mechanism and induces urination. Reactivation of the cuff occurs automatically 45 to 90 seconds after pressing the pump to prevent further flow of urine. (Turkish Jurol. 2014; 40: 1; https://bit.ly/3qnU7kc.)
USA is widely recognized as an effective method of controlling incontinence, but has associated risks and adverse events. Previous literature has well documented complications of AUS, such as persistent incontinence, device dysfunction, erosion, and infection. (Int Braz J Urol. 2018; 44: 114; https://bit.ly/3D7WB9W; Urology. 2008; 71: 85.)
The reported reoperation rate for the artificial urinary sphincter is 17 to 35 percent, with approximately 50 percent of cases caused by mechanical complications (loss of fluid from the system, obstruction from debris, airlock, blood or crystallized material, and tube twisting [rare because kink-resistant tubing is now used]) and the remaining 50% by non-mechanical complications (infection [Staphylococcus epidermidis and aureus most commonly], tissue atrophy [leads to recurrent stress incontinence due to loss of cuff compression], and erosion of the cuff by the urethra). The success rate for secondary artificial urinary sphincter operations is high and patient satisfaction is excellent, despite the reoperation rates.
The acute onset of metabolic encephalopathy in the patient and repeated episodes of urinary retention and acute renal failure highlight relevant clinical features in suspected SUA infection. Urology has disabled the device in the emergency room. A Foley catheter gave 500 ml of amber urine with little blood. The urinalysis was positive for a urinary tract infection. He was given intravenous fluids and started taking ceftriaxone and vancomycin based on an examination of previous urine cultures.
The patient was admitted to manage his acute renal failure and urinary tract infection. Blood and urine cultures collected after admission were positive for methicillin resistance Staphylococcus aureus (MRSA). Meropenem was added due to its increasing white blood cell count and persistent fever. The patient’s bacteremia resolved four days later. His kidney function returned to baseline after hydration, and his mental state improved with the resolution of his acute kidney injury.
Urogenital infections are common complaints in ED patients, and it is important to recognize the underlying pathologies of these infections to provide the most appropriate treatments. It is important that EPs take into account antibiotic management and the increasing incidence of SARM-related AUS infections when selecting initial empirical antibiotics. Early identification and treatment of infected artificial urethral sphincters is essential to prevent this devastating complication and could potentially reduce future morbidity and mortality.
The patient was to be followed up with his urologist for the device to be removed, as USA was the suspected source of infection for the bacteremia. The device was then removed and showed full thickness erosion but no purulence. Culture and Gram stain of the device were performed with no growth or organism shown on any sample. No further intervention was performed and he was ordered to return in six months to assess the reimplantation of the USA.
Our case presented a notable expansion of data and currently limited detail on clinical events preceding the discovery of an artificial urethral sphincter infected with MRSA. An earlier study described not only a lack of literature, but also a void in understanding the microbiology of AUS infections. This study challenged the earlier belief that Staphylococcus epidermidis being the most common organism found in urologic prosthetic infections. Their results showed an increase in MRSA and MRSA, with MRSA being the organism most often responsible for AUS infections. (Jurol. 2008; 180: 2475.) The positive culture results in our case further support the evidence of an increasing incidence of artificial urethral sphincters infected with MRSA.
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Clockwise from top left:Dr Watkinsis an emergency physician in Akron, OH, and senior professor at the Akron General Emergency Medicine Residency. Dr Makowskiis a resident in emergency medicine at the Cleveland Clinic Akron General. Follow him on twitter@BrianMakowski. Dr Simonis an emergency physician and research director at the Cleveland Clinic Akron General and associate professor of emergency medicine at Northeast Ohio Medical University. She is also the medical director of the Cleveland Clinic Bath.