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A Tympanitic Abdomen

In the March JRSM, Mr Richard Krysztopik presented a diagnostic dilemma. Here he records the outcome. The names of those who offered the correct diagnosis, and the prizewinner drawn from a hat, will be announced in the next issue 
 
The patient, a man aged 61 with type 2 diabetes, had been referred with hesitancy of micturition, poor stream, haematuria and dysuria. Pneumaturia was not reported. On examination his abdomen was distended and tympanitic; the prostate was mildly enlarged and smooth. The urine contained 1% glucose and Gram-negative bacteria were seen on microscopy. Antibiotics were prescribed. 
 
Abdominal radiography revealed a massive gas-filled structure, seemingly arising from the pelvis, and a diagnosis of caecal volvulus was suggested. Colonoscopically, the distal colon appeared normal. On barium enema, contrast flowed freely as far as the ascending colon but none reached the caecum (Figure 1). 
 
 
 
Figure 1 
 
Abdominal radiograph 
 
 
 
Caecostomy was undertaken through a right gridiron incision. On entry into the peritoneal cavity a large smooth viscus was encountered, into which a balloon catheter was inserted and secured with a purse-string suture. Gas was released and the viscus deflated; subsequently pus and then urine drained from it. When contrast solution was instilled down the tube, radiographs disclosed an irregular cavity in the pelvis anterior to the rectum. Intravenous urography showed bilateral pelvicalyceal dilatation, with a high-capacity bladder filling easily and corresponding topographically to the gas-filled structure seen on the original radiographs. On cystoscopy the bladder was oedematous and there was moderate enlargement of the median and lateral lobes of the prostate. 
 
The prostate was resected transurethrally and histological examination of the material showed benign prostatic hypertrophy with foci of chronic infection, and chronic cystitis with prominent lymphoid follicles in the lamina propria. On culture the urine grew Escherichia coli. The abdominal tube was removed and the patient recovered without incident.