The case of the month

May 2006 case of the month

A 56 years old man, is referred to an andrology clinic by a urologist for painful ejaculation associated with hemospermia. He suffers from prostatodynia, perineal pain, painful micturitions and ejaculations from more than one year. All the cultures (Urine, sperm) and bacteriological exams performed were negative.
The diagnosis of an abacterial chronic prostatitis has been retained, the cause being probably a foley catheter maintained 3 weeks into the bladder two years ago following a complex hip fracture. The patient tried all the drugs options proposed in this option with no efficacy.
The digital rectal examination found something hard and thin just in the mid-part of the prostate which palpation was very painful.

A CT scan of the pelvis with voiding cystography was performed.

Question 1:
What is your diagnosis?

Chronic pelvic pain syndrome from psychogenic origin
Intrapelvic pin migration after periacetabular reconstruction
chronic prostatitis due to chlamydia metallica

Correct answer: B
The unthreaded pin inserted 2 years ago for a hip arthroplasty migrated slowly and penetrated into the prostate.
Few cases of pin migration have been reported either immediately found on postoperative radiography or several months later causing hematuria. The urinary bladder, the ureter or iliac vessels are the reported injured organs. To our knowledge, this is the first case of sexual symptoms due to pin migration.

Question 2:
What kind of management do you propose to the patient?

Refer to his orthopaedic surgeon for pin removal
Urethrocystoscopy for pin direct removal
Perineal approach for pin extraction
Transperitoneal laparoscopic approach

Correct answer: B
A cystoscopy was performed in order to explore the prostatic urethra. The pin was found just lateral to the colliculus seminalis and extracted very softly using a bladder stone forceps.
The symptoms immediately resolved and the patient had no complications.

Pin pelvic migration usually necessitates an open surgical approach to remove the pin. In this case, the presence of the pin into the urethra allowed a very simple removal technique despite the size of the pin.

References

Kircher J, Durr HR, Jansson V. Intrapelvic pin migration after periacetabular reconstruction and arthroplasty of the hip in metastatic pelvic disease--a case report. Acta Orthop 2005, 76:941-3.
Sayegh FE, Tsintzas D, Kapetanos GA. Intrapelvic migration of a guide pin during fixation of a hip fracture: who and what is to blame? Acta Orthop Belg 2005, 71:239-41.
Kleinman SZ, Russin LA. Migration of left hip pin with involvement of left ureter. Urology 1980, 16:396-7.