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Renal Disease Due to Schistosomiasis of the Lower Urinary Tract

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Renal Disease Due to Schistosomiasis of the Lower Urinary Tract View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Kidney International, Vol. 16 (1979), pp. 15-22 Renal disease due to schistosomiasis of the lower urinary tract A.B.O.O. OYEDTRAN Department of Preventive and Social Medicine, University of Ibadan, Ibadan, Nigeria Vesical schistosomiasis was known to ancient This paper reviews the literature concerning renal Egyptians, and there are numerous references to its impairment and damage due to S. haematobium in- most prominent clinical manifestation, hematuria, fections, with emphasis on radiologic, biochemical, in various medical papyri [1]. The adult causative and renographic studies of renal function in affected worm, Schistosoma haematobiu,n, was first identi- persons. fied in 1851, and it was not until many years later that the clinical features and life-cycles of S.japoni- Radiologic studies cum and S. mansoni were described. Despite this, it Techniques which have been used to study the is ironic that, presently, far more is known about radiographic manifestations of vesical schistoso- infections due to the latter two species than those miasis include plain X-ray of the abdomen and pel- due to S. haematobium. Indeed, there is still some vis, intravenous and retrograde urography, mictu- debate regarding the amount of morbidity and mor- rating cystography with or without fluoroscopy, tality attributable to vesical schistosomiasis in en- cystourethrography, and vesiculography. The find- demic areas, whereas it is generally accepted that ings have been reported by many authors [7, 13-24] infections with S. mansoni and S.japonicum are re- and have revealed a very high prevalence (up to sponsible for very significant disease, disability, 50%) of radiographic abnormalities in infected chil- and deaths in affected populations [2]. dren and adults, including those who are asympto- Reports concerning the amount of renal impair- matic except for hematuria. They have further ment and damage due to S. haematobium infections shown that, although the prostate, urethra, seminal have varied not only from country to country but vesicles, and other organs are commonly involved, also from place to place in the same country. This is most of the lesions are in the urinary bladder, ure- partly because various workers have used differing ter, and kidney. criteria for assessing the amount of damage caused Bladder. The most common early manifestations by vesical schistosomiasis. Moreover, some of the in the bladder are nodular filling defects, which may criteria which have been used could not have yield- be single but are usually multiple. They are particu- ed reliable estimates of the size and nature of the larly common in children, respond well to specific problem under investigation. For example, clinical chemotherapy [7, 20, 25-28], and may be spontane- manifestations including blood pressure studies ously reversible [26]. Late lesions include calcifica- have been used, but it is now widely recognized that tion and fibrotic reduction of bladder capacity. these are of limited value in assessing the impact of "Bilharzial bladder outlet obstruction" has been the disease on the renal function of affected per- described [29, 30], as well as carcinoma of the blad- sons. It is not uncommon for patients to present der, but the relationship between the latter and S. very late with chronic disease and clinical manifes- haematobium infection is the subject of con- tations of uremia [3]. The majority of infected per- troversy [31]. sons, however, even those with demonstrable ad- Ureter. Radiographic abnormalities of the ureter, vanced disease, show no specific clinical manifesta- tions, and are often apparently in good health [4-7]. Furthermore, reports on a possible association be- Received for publication July 11, 1978 tween vesical schistosomiasis and hypertension 0085-2538179/0016-0015 $01.60 have been conflicting [7—121. © 1979 by the International Society of Nephrology 15 16 Oyediran especially its lower third, are very common in vesi- schistosomiasis may have hydronephrosis [37], and cal schistosomiasis and are often associated with these lesions may be seen in up to 10% of infected bladder lesions. The most common finding in the children, even in areas of low to moderate endemic- lower ureter is stasis with or without dilatation in ity [7, 8, 38]. the lowest segment, and it is usually combined with Hydronephrosis causes renal damage due to symmetric fusiform narrowing at the ureterovesical back-pressure effects or secondary bacterial infec- junction. This lesion may be due to fibrosis in the tion. It is now known, however, that, particularly in ureteral wall with resultant atony or dyskinesia [13, children, hydronephrosis may be reversible follow- 17, 32,33].It may also be caused by a nodule at the ing specific chemotherapy [23, 25, 26, 391. Further- ureterovesical junction or by inflammatory reaction more, there have been conflicting reports con- to the presence of schistosome ova in the ureters cerning the relationship between vesical schistoso- without fibrosis. Such cases respond well to chemo- miasis and bacterial infections of the kidneys and therapy [23]. urinary tract [7, 10-12, 39—54]. Standardized studies Ureters, which are irregularly narrowed over a are required to resolve this conflict, and such stud- short distance, show marginal filling defects or a ies should include observations on the possible role beaded appearance; these changes have been attrib- of surgical instrumentation of the urinary tract in uted to fibrosis, ureteritis cystica, ureteritis glandu- affected patients. laris, and other chronic changes. The abnormalities In some cases, a normal ureter may be seen in may also be produced by ureteral nodules or edema association with calicectasis affecting the upper cal- from acute primary involvement of the ureter. It has yces alone or the whole of the collecting system. been reported that trigonal fibrosis may cause a Such lesions are thought to be due to an aberrant characteristic cow-horn" deformity of the ureters vessel or congenital ureteropelvic obstruction, re- [24]. This lesion may be identical with the "snake- spectively [23]. head ureter" described by earlier workers [211. In Radiographically non-functioning" kidney has such cases, ureteral catheterization is difficult, and been described in up to 8% of infected persons and therefore a stricture may be simulated. However, is reported to be associated with a poor prognosis true strictures of the ureter do occur in vesical [55]. There may be radiologic evidence of pyelone- schistosomiasis, although some workers consider phritis and, rarely, stones and calcification of the them rare [241. renal capsule may be seen [21, 56]. Various forms of ureteral calcification, including It has been reported that the frequencies of bilat- stones, have been reported to be common. In ad- eral obstructive uropathy, hydronephrosis, hydro- vanced cases, stasis and dilatation, often with tor- ureter, "non-functioning" kidney, calcified blad- tuousity, are common in the upper ureters, and may der, ureterolithiasis, and bladder retention increase involve the whole length of the ureter. These cases linearly with age, whereas urographic filling defects may result from mechanical obstruction by nodules and egg excretion decrease linearly with increasing and fibrosis. They also may be due to hypotonia and age [50]. atonia of the ureters, leading to functional derange- ment. Biochemical studies Pyelonephritis following obstructive uropathy is It is clear from the foregoing that patients with S. well understood, but it is being increasingly recog- haematobium infections have a high prevalence of nized that pyelonephritis may occur in patients structural abnormalities of the kidney and urinary without demonstrable obstruction. The role that tract demonstrable radiologically. It has been right- vesicoureteral reflux may play in such cases has ly observed, however, that it is not what a kidney been emphasized [34, 35]. Vesicoureteral reflux oc- looks like but how it works that counts" [57]. Re- curs in patients with S. haematobium infection, but cent refinements of urographic examination, includ- reports concerning its incidence in infected patients ing the use of modern contrast media, enable good have been conflicting [10, 21, 23, 36]. contrast density to be visualized even when renal Kidney. The most common radiographic lesion in function has been minimal. Thus, older criteria re- the kidney is hydronephrosis which is usually asso- lating urographic opacity to renal function are no ciated with and secondary to lesions lower down longer valid [58, 59]. There has, therefore, been the urinary tract. In such patients, there may be, in doubt regarding the clinical significance and ulti- addition, delayed calyceal filling. In some endemic mate prognosis of structural lesions observed in areas, up to 17% of unselected patients with vesical pyelograms of patients with vesical schistosomiasis Renal function in schistosomiasis 17 [21. This doubt is further underlined by the fact that has its limitations, such as its inability to indicate an many of the affected patients have been apparently exact anatomic or pathologic diagnosis, and its sus- well, and the observation that some of the lesions, ceptibility to dehydration and other extraneous fac- including hydronephrosis, are reversible following tors. It is, however, safe, sensitive, simple, and specific chemotherapy. quick, and allows
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