Suprapubic Aspiration Associated with Hematoma

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PEDIATRICS Vol. 69 No. 4 April 1982 455

Suprapubic

Aspiration

Associated

with

Hematoma

Rose

Ellen

Morrell,

MDCM,

FRCP(C),

Gilbert

Duritz,

MD,

PhD,

and

Charles

Oltorf,

MD

From the Department of Pediatrics, Children ‘s Hospital Medical Center of Northern California, Oakland

ABSTRACT. A newborn female infant who experienced

an intramural bladder hematoma with upper tract

ob-struction secondary to a suprapubic aspiration is de-scribed. The literature is reviewed and the conservative management of this child is discussed. Pediatrics

69:455-457, 1982; suprapubic bladder aspiration, bladder he-matoma.

Suprapubic aspiration is a commonly used

tech-nique to obtain urine specimens from infants. It has the advantages of being simple, reliable, and

yield-ing urine specimens suitable for culture. This

method has few sequelae. Nelson and Peters’

re-ported a 90% success rate in obtaining urine speci-mens from newborn infants. The only complication

that they reported was transient hematuna in two

infants. Saccharow and Pryles2 performed

supra-pubic aspirations in 654 infants and children with a

success rate of 92%. Four of their patients had

transient hematuria; one patient developed a

blad-der hematoma which was visualized at cystoscopy,

but caused no morbidity. Mandell and Stevens3

described a newborn infant with a pelvic hematoma

anterior and adherent to the bladder which was

thought to be due to suprapubic aspiration.

Al-though the mass displaced the bladder, the upper

tracts appeared normal on intravenous pyelogram

(IVP). Several authors46 have described

hemor-rhage significant enough to cause a decrease in

hematocrit, following suprapubic tap. In two

pa-tients urine aspiration was repeatedly attempted.

Carlson and Pullon6 reported a bladder hematoma

Received for publication Jan 16, 1981; accepted May 7, 1981. Reprint requests to (REM.) Children’s Hospital Medical Center of Northern California, 51st and Grove Streets, Oakland, CA 94609.

American Academy of Pediatrics.

which was considered to be the source of the bleed-ing. Two cases of an anterior bladder wall abscess

have been reported in infants7; both patients were

treated successfully with no evidence of renal dys-function.

We have recently seen an infant who developed

a bladder mass and obstructive uropathy

subse-quent to percutaneous suprapubic aspiration of

urine. This is a complication which, to our knowl-edge, has not been previously reported.

CASE REPORT

The patient was a 1,300-gm female infant, the first of twins, born to a 22-year-old gravida 2, para 1 after 33

weeks of gestation; the pregnancy was complicated only

by spontaneous premature labor. An attempt was made

to delay labor using an alcohol infusion and steroids were

given prior to delivery, but the infant was born

sponta-neously 48 hours after rupture of the membranes. The

Apgar scores were 7 and 8 at one and five minutes,

respectively. The infant developed increasing respiratory distress, requiring intubation and ventilation within 30

minutes of birth. An umbilical arterial line was inserted but was removed shortly after placement because of poor

blood return. At 3 hours of age a second umbilical catheter was inserted with some difficulty but with good function. A single suprapubic tap was attempted 15 minutes later using a 23-gauge needle but was unsuccessful. Bleeding

occurred from the puncture site but this ceased when pressure was applied. At 5 hours of age, the central

hematocrit was 50% and the blood pressure was stable

(56/28 mm Hg). At 6 hours of age, the infant voided

“normal appearing” urine. Two hours later, duskiness

and discoloration of the lower extremities were noted, and a suprapubic mass was palpated. At this time, the

infant was given 44 ml of packed RBCs, and transfer to Children’s Hospital Medical Center of Northern Califor-ma was requested.

Upon admission to this facility, a firm mass in the midline of the lower abdomen was found. The upper edge

was palpable at the level of the umbilicus; the lower edge

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456 SUPRAPUBIC ASPIRATION

extended behind the symphysis pubis. No femoral pulse

was palpable on the left side. The blood pressure was 73/

36 mm Hg. Laboratory studies disclosed the following

values: BUN, 37 mg/100 ml; creatinine, 1.2 mg/100 ml;

uric acid, 14.9 mg/100 ml; sodium, 128 mEq/liter;

potas-sium, 6.0 mEq/liter; and calcium, 5.8 mg/100 ml. A Hy-paque aortogram was obtained to enable better evalua-tion of the mass and any arterial occlusion related to the presence of the umbilical artery line. The aortogram

showed a probable pelvic hematoma with occlusion of

the left femoral artery and compression and displacement of the right iliac and right femoral arteries. The umbilical line was removed and pulses became palpable in both the femoral arteries.

Following admission the hematocrit decreased from 54% to 42% and the infant was given a second transfusion

of packed RBCs. The total urine output during the first 24 hours following admission was 6.5 ml. A No. 5 French urinary catheter was inserted easily into the bladder, and

2.5 ml of blood-tinged urine was obtained. Shortly

there-after, an IVP failed to visualize either kidney.

By the end of the first day of hospitalization, the BUN level had increased to 40 mg/100 ml, and the creatinine

level had increased to 1.8 mg/100 ml. On the second hospital day, the BUN level peaked at 46 mg/100 ml.

Urine output began to increase on the second day of

hospitalization, and the urinary catheter was removed.

Urinalysis was now normal, and renal function, as re-flected by decreasing BUN and creatinine levels, was improving.

On the 22nd day oflife, the infant developed hematuria.

No hematologic abnormalities were present and there

had been no further instrumentation of the bladder. An IvP, obtained on the 28th day of life, revealed deviation

of the bladder to the left, and right hydronephrosis and

right hydroureter secondary to obstruction by the bladder

mass (Figure). At this time, the infant had normal urine

output but intermittent hematuria persisted. At the time

of discharge from the hospital the BUN level was 8 mg/ 100 ml and the creatinine level was 0.5 mg/100 ml.

At follow-up at 4 months of age, the baby weighed

4.097 kg and was 50.8-cm long. She had been well since

discharge except for several urinary tract infections and had been treated with suppressive antibiotic therapy.

Results of laboratory tests were all normal; of specific

note, her urine was entirely clear of blood. An IVP with voiding films showed normal bladder contours and emp-tying of the upper tracts.

DISCUSSION

The obstructive uropathy in this patient resolved with conservative management. No attempt was

made to remove the hematoma when it was first

diagnosed lest further bleeding be provoked by the

surgery.

A 23-gauge needle was used in this infant. In

previous reports of complications in which the needle gauge has been specified,6’7 a needle as large

as or larger than 23-gauge was used. In their series of 654 patients, Saccharow and Pryles2 routinely

Figure. Deviation of bladder to left; right

hydrone-phrosis and hydroureter secondary to obstruction by

bladder mass.

used a 21-gauge needle and had no major

compli-cations. On the other hand, urine may be

success-fully aspirated using a 25-gauge needle.

Visser and Hall9 have questioned whether urine

cultures were necessary in infants less than 3 days of age inasmuch as the yield of positive urine cul-tures without simultaneous positive blood cultures was low. Their series was small, and therefore, the

risk-benefit ratio of this procedure in newborns suspected of sepsis remains to be determined.

CONCLUSION

It is our impression that suprapubic aspiration of

urine, although generally safe, may produce signif-icant complications and therefore, should not be attempted unless the bladder can be palpated, transilluminated,’#{176} or delineated by ultrasound. A case of obstructive uropathy resulting from this procedure is described in order to alert physicians to the possibility of this unusual complication and

to demonstrate that it may be successfully managed

with conservative treatment.

REFERENCES

1. NeLson JD, Peters PC: Suprapubic aspiration of urine in premature and term infants. Pediatrics 36:132, 1965 2. Saccharow L, Pryles CV: Further experience with the use of

percutaneous suprapubic aspiration of the urinary bladder.

Pediatrics 43:1018, 1969

3. Mandell j, Stevens P: Supravesical hematoma following

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ARTICLES

457

suprapubic urine aspiration. J Urol 119:286, 1978 bladder aspiration. Arch Dis Child 50:80, 1975

4. Lanier B, Daeschner CW: Serious complication of suprapu- 8. Aronson AS, Gustafson B, Svenningsen NW: Combined su-bic aspiration of the urinary bladder. J Pediatr 79:711, 1971 prapubic aspiration and clean-voided urine examination in

5. Rockoff AS: Hemorrhage after suprapubic bladder aspira- infants and children. Acta Paediatr Scand 62:396, 1973 tion. J Pediatr 89:327, 1976 9. Visser yE, Hall RT: Urine culture in the evaluation of 6. Carlson KP, Pullon DHH: Bladder hemorrhage following suspected neonatal sepsis. J Pediatr 94:635, 1979

transcutaneous bladder aspiration. Pediatrics 60:765, 1977 10. Kuhns LR: Bladder transillumination to facilitate bladder

7. Polnay L, Fraser A, Lewis JM: Complication of suprapubic puncture. J Pediatr 91:850, 1977

THE BURROW INK TEST FOR SCABIES

In France, the diagnosis of scabies rests upon finding le sillon (a well defined, zigzagged burrow) on an afflicted patient with the aid of a simple fountain pen. This so called

Burrow Ink Test (BIT) consists of gently rubbing the scabietic papule with the underside of a fountain pen, covering it with ink. The excess ink is then wiped off with an alcohol-saturated gauze. If a burrow is present the ink will track down it and outline the limits of

the canal. ...

In the United States, the diagnosis of scabies is made by the direct demonstration of

the mite, the egg or the scybala (fecal pellets) in the skin. ...

Although the importance of le sillon . .. was emphasized in 1835 by Simon Fran#{231}ois

Renucci, the BIT has been passed along from generation to generation of French

dermatologists by word of mouth without . . . a definitive study. . . . We attempted to complete the work of Dr. Renucci by comparing the BIT with the superficial shave biopsy to establish its diagnostic validity. ...

Results. All . . . 25 BIT-positive lesions provided material for superficial shave biopsy

in which the mites, eggs, fecal pellets or any combination of the three were found. ... Stated another way, if a lesion was BIT positive, it was also positive with the superficial shave biopsy.

By contrast, 1 1 of 30 BIT-negative lesions provided material for a positive superficial

shave biopsy.

Discussion. The history of scabies seems to have evolved in a “two steps forward, one

and one-half steps backward” fashion. . . . In 1657, Hauptman observed the mite under

the microscope. . .. Thirty years later . . . Bonomo and Cestoni extracted the mite from under the skin, observed it under the microscope and described it as a “small turtle

Unfortunately, others could not repeat this work. .. . Lugol (of .. . solution fame) ... offered 300 crowns . . .to anyone who could demonstrate the mite.

In 1834, . . . Renucci, a Corsican chief resident of dermatology . . .announced he would

give a live demonstration that the scabies mite . . .could be extracted from patients. On

August 20 and 25, 1834 Renucci successfully and consistently extracted mite after mite from several patients in front of a host of onlookers. Lugol awarded Renucci the 300

crowns.

Why was it Renucci succeeded when so many failed? Renucci revealed his secret to

the medical community: one must not search for the mite in pustular or vesicular lesions, rather one must . . . find the . . . burrow (le sillon) from which the mite can be

extracted. ... Some anonymous person(s) between 1888 and 1928 developed the BIT to facilitate finding the . . .burrow.

. . .The scabietic burrow is seen less frequently today than in previous years. . . .In our

small study . .. at least one burrow could be found with the BIT in every patient in

whom scabies was the leading diagnosis. . . . Occasionally a prolonged search was

re-quired. . . . We strongly recommend that dermatologists who are not accustomed to

characterizing a true BIT perform both the BIT and the superficial shave biopsy on the same lesion . . . until confidence is obtained in recognizing a positive BIT. ...

Edgar K. Marcuse, MD, MPH

Abstracted from Woodley D, Sauret JH. The burrow ink test and the scabies mite. J Am Acad

Dermatol 4:715-722, 1981.

(Note: Woodley suggests using an inexpensive cartridge ink pen.)

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1982;69;455

Pediatrics

Rose Ellen Morrell, Gilbert Duritz and Charles Oltorf