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Journal of Postgraduate Medicine, Vol. 56, No. 3, July-September, 2010, pp. 222-223 Case Snippet Ascaris lumbricoides: A stranger in the urinary bladder causing urinary retention Singh D, Vasudeva P, Dalela D, Sankhwar SN Department of Urology, C.S.M. Medical University (Upgraded King George’s Medical College), Lucknow – 226 003, Uttar Pradesh, India Correspondence Address: Dr. Dharamveer Singh, Department of Urology, C.S.M. Medical University (Upgraded King George’s Medical College), Lucknow – 226 003, Uttar Pradesh, India, drdharamveersingh@yahoo.co.in Code Number: jp10065 PMID: 20739775 DOI: 10.4103/0022-3859.68641 Ascaris lumbricoides (Roundworm) infection is primarily limited to the gastrointestinal tract, specifically the area of the hepatopancreatic ducts. Signs and symptoms are coincident with parasite's lifecycle, as it migrates from the lung to the intestine. We report a unique and extremely rare case of Ascaris lumbricoides presenting as acute urinary retention in an adult female. A 35-year-old-female presented with acute urinary retention following tingling-sensation in the urethra and bladder. She was catheterized with 16F Foley catheter and clear urine was drained. She had no past urinary complaints, but had received mebendazole 500 mg once two days ago for vague abdominal pain. While emptying the urobag, the nurse noticed a worm, which was subsequently confirmed to be Ascaris lumbricoides [Figure - 1]. Stool examination was positive for Ascaris lumbricoides ova. She also passed two worms per anus over the next 24 h. Thorough evaluation including history, clinical and radiological examination excluded the possibility of an enterovesicular fistula and any other cause for urinary retention. Complete blood counts (CBC), urinalysis, chest X-ray, computed tomography (CT) scan abdomen, intravenous pyelography (IVP) and cystourethroscopy with retrograde pyelography (RGP) were unremarkable. Subsequent trial without catheter was successful. She received albendazole 400 mg once after three weeks. Patient is asymptomatic during 28-month follow-up. Adult roundworms live in the small-intestinal lumen for 12-18 months and usually cause no symptoms. Each mature female Ascaris produces up to 240,000 eggs/day which pass with the feces. Ascarid eggs are remarkably resistant to environmental stresses, become infective only after several weeks of maturation in soil and can remain infective for years. For this reason, self-inoculation and inoculation through sexual practice is not the usual route of infection. [1] Outside the gastrointestinal tract, only a few case reports of adult roundworms have been reported. [1] Cousin et al., reported an adult roundworm within the uterine-cervix and transanal migration of the worm into the vagina was given as the explanation. [2] Two case reports describe renal-ascariasis. In the first case, adult roundworms gained entrance through the urethra as there was no enterovesicular fistula. [3] In the second case, one fistula was colo-ureteral and the other fistula communicated through the renal-capsule to the skin. [4] Recently, a case report of urinary bladder stone formed over a dead Ascaris lumbricoides has also been reported. [5] Adult roundworms can be stimulated to migrate by stressful conditions such as fever, illness, anesthesia and anthelmintic drugs. [1] Urogenital tract infection could be explained by enterovesicular fistula, [4] or transanal migration of the worm. [2],[3] The exact mechanism of urinary infection in our case is not clear. The most likely explanation in our case is that the worm was potentially forced to migrate and exit per anus by deworming therapy, and subsequently moved transperineally to ascend into the urethra and bladder. Ascariasis should always be treated to prevent potentially serious complications such as bowel obstruction, biliary ascariasis, and rarely, extraintestinal complications. Albendazole/mebendazole binds to the worm's microtubular-protein 'b-tubulin' and inhibits its polymerization by blocking glucose uptake in the parasite. The immobilizing and lethal action of mebendazole on worms is rather slow; takes two to three days to develop. Urinary retention both in children and adults as a presenting symptom of Ascaris lumbricoides infection has previously been reported but only as a few case reports. [6],[7] To our knowledge, urinary retention in an adult attributed to Ascaris lumbricoides infection is extremely rare. References
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