Acute Urinary Retention in a 47-month-old Girl Caused by the Giant Fecaloma
A 47-month-old female\nVoiding difficulty and urinary incontinence\nThe patient was born fullterm with a birth weight of 2.4 kg. At the age of 2 weeks, she was diagnosed with Hirschsprung disease and underwent the Duhamel operation. At that time, a ganglion cell was noted at the proximal sigmoid. After the operation, she was able to evacuate the bowels well until 6 months of age and she stopped visiting the outpatient clinic. She has a history of constipation of over 1 year. Constipation had been managed with oral lactulose and enema using glycerin at a nearby hospital over 1 year when she complained abdominal pain, agitation and holding her stools with 3- or 4-day interval. After enema, sausage-shaped stools were frequently observed. Her mother could not remember the exact characters of stool. There was no abnormal and unusual feeding history or urinary pattern before admission.\nThe patient was transferred to our hospital due to acute urinary obstruction. One week ago, diffuse lower abdominal pain developed which was managed at a local clinic with medicine for constipation. However, abdominal pain persisted. One day before admission, abdominal distension and voiding difficulty developed.\nOn initial evaluation the patient had a blood pressure of 110/70 mmHg, a pulse rate of 96 beats/min, a respiratory rate of 24 breaths/min, a body temperature of 36.5℃ with a body weight of 14.5 kg (the 50-75 percentile) and a height 99.9 cm (>the 97 percentile). She was irritable because she could not pass urine despite the feeling of micturition. Her abdomen was distended, and focal tenderness was present at the lower quadrant. Auscultation revealed lower than normal bowel sounds. The location of the anal orifice on the perineal area and anal tone were both physiologic. No abnormal dimple or skin lesion on her sacral area was observed and her neurologic examination was physiologic and normal. Fecal materials were palpable on digital rectal examination.\nAbundant fecal materials were observed on abdominal X-ray (), and ultrasonography (USG) of the abdomen revealed a distended bladder with a thin bladder wall and both hydronephrosis of grade III (). Hematological examinations and blood chemistries were as follows: a hemoglobin level of 13.0 g/dL, a total white cell count of 5.9×109/L, a platelet count of 357×109/L and granulocyte and lymphocyte levels of 41.5% and 46.1%, respectively; A serum calcium level of 9.7 mg/dL (8.6-10.2), a magnesium level of 1.2 mg/dL (1.5-2.3), a sodium level of 144.1 mmol/L (135-145), a potassium level of 3.6 mmol/L (3.3-5.1) and a chloride level of 104.6 mmol/L (98-110). Her blood urea nitrogen, creatinine, hepatic transaminase and C-reactive protein levels were normal. Urinalysis collected via a catheter was normal. Thyroid function test was not checked. Sigmoidoscopy could not be performed to her because of a large amount of feces in her distal colon despite repeated glycerin enema and digital evacuation.\nAfter urinary catheterization, 720 mL of urine was drained and abdominal pain and distension was improved. However, urinary obstruction persisted and urinary catheterization was kept continuously. On day 3 after admission, voiding difficulty persisted despite loose stool passage after repeated glycerine enema. For ruled out the abdominal mass, whole-abdominal computed tomography (CT) was performed and showed a large fecaloma in the sigmoid colon and a displaced bladder (). The coronal image of the CT showed that the distal part of the colon was markedly dilated and contained heterogeneous materials consisting of impacted feces. The markedly dilated distal colon was suspected as Duhamel pouch. The bladder neck was displaced into the upper abdomen because of the large fecaloma-filled pouch. After repeated glycerin enemas and digital evacuations, spontaneous urination was noted on day 5. USG revealed a normal sized bladder and improved both hydronephrosis. However, she could not evacuate bowels sufficiently by herself. We could palpate a membranous tissue in her rectum at the time of digital evacuation. On day 7, a colon study revealed a giant Duhamel pouch filled with fecal materials without a definitive the membranous tissue in her rectum (). We decided to perform an operation because she had a giant Duhamel pouch, an unidentified membranous tissue and to perform a full-thickness rectal biopsy. Two weeks later, operation was done after sufficient evacuation of the feces in her rectum. A septum was noted in Duhamel pouch, which ran transverse direction in her rectum on the operative findings. Post-Duhamel septum revision was performed. Histopathologic findings of the full-thickness rectal biopsies showed a ganglion cell in the rectum. Since the operation, she has been visiting our outpatient clinic regularly. She has been free of defecation and urination difficulties without the need for medicine.