Surgical treatment of endocarditis. Prog Cardiovasc Dis 1997;40:239-64. Painful ejaculation after inguinal hernia repair. J D Butler BSc FRCS M J Hershman MS ...
JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
occlusion of the distal popliteal artery. During surgical exploration of the wound the ankle joint and metatarsal heads were seen to be necrotic and on the forty-fifth day of her illness a below-knee amputation was performed. She was discharged after eight weeks of intravenous antibiotics and made a good recovery. COMMENT
Before penicillin, S. pneumoniae was a common cause of infective endocarditis, responsible for more cases than Staphylococcus aureus. The disease is now rare (less than 2% of endocarditis)1. The triad of endocarditis, pneumonia and meningitis is well recognized2. In a study of 325 episodes of pneumococcal bacteraemia at a hospital over a five-year period there were 7 cases of endocarditis3. Among 9 cases with both pneumonia and meningitis, 4 also had endocarditis. Peripheral embolism, the presumed cause of our patient's leg lesion, is said to be an uncommon feature of pneumococcal endocarditis4. However, femoral artery embolism has been reported5, as have other metastatic complications including stroke and septic arthritis. Pneumococcal endocarditis often occurs on normal valves. Alcoholism has been cited as an important risk factor (our patient and her family denied that she was a heavy drinker). The disease has a predilection for the aortic valve and often causes myocardial abscesses and conduction defects. The incidence of acute heart failure is high, as is the mortality (50%)1.
Painful ejaculation after inguinal hernia repair J D Butler BSc FRCS A Leach MB FFARCS
M J Hershman MS FRCS
J R Soc Med 1998;91:432-433
CUNICAL SECTION, 16 OCTOBER 1997
We have found only one reported case of painful ejaculation as a complication of inguinal hernia repairl. Here we describe two cases arising after Halsted repairs. CASE HISTORIES Case one A man aged 63 described discomfort in his right groin that had started three months after a Halsted inguinal hernia
432
Royal Liverpool University Hospital NHS Trust, Prescot Street, Liverpool, L7 8XP, UK
Correspondence to: Mr M J Hershman, MASTER Unit
Volume 91
August 1 998
The principles of antibiotic therapy in infective endocarditis are that it should be intravenous, of long duration, and in bactericidal doses. For many organisms synergistic combinations are employed but for penicillinsensitive S. pneumoniae benzylpenicillin alone has been most often used in reported cases. Valve replacement is commonly requiredl. As in other forms of infective endocarditis the most important indication for surgical intervention is the development of heart failure6. Our patient had an additional indication-intracardiac extension of her infective process (an aortic root abscess). A single peripheral embolic event would not alone be regarded by most authors as reason for operation. REFERENCES 1 Wolff M, Regnier B, Witchitz S, Gibert C, Amoudry C, Vachon F. Pneumococcal endocarditis. Eur Heart J 1984: 5(suppl 6):77-80 2 Austrian R, Gold J. Pneumococcal bacteremia with especial reference to bacteremic pneumococcal pneumonia. Ann Intern Med 1964;60: 759-76 3 Gransden WR, Eykyn SJ, Phillips I. Pneumococcal bacteraemia: 325 episodes diagnosed at St. Thomas's Hospital. BMJ 1985;290: 505-8 4 Strauss AL, Hamburger M. Pneumococcal endocarditis in the penicillin era. Arch Intern Med 1966;118:190-8 5 Bruyn GAW, Thompson J, Van der Meer JWM. Pneumococcal endocarditis in adult patients. A report of five cases and review of the literature. Oj Med 1990;74:33-40 6 Moon MR, Stinson EB, Miller DC. Surgical treatment of endocarditis. Prog Cardiovasc Dis 1997;40:239-64
repair. It was continuous but worse on walking or coughing, resembling the discomfort he had had before the operation. In addition, however, the patient described severe pain around the area of the herniorrhaphy scar, only on ejaculation. This pain was localized, with no radiation into the scrotum. It was 'like a red hot poker' and was sufficient to stop him having sexual intercourse. He was otherwise fit and well. On examination there was decreased sensation to light touch in the area of the ilioinguinal nerve. All other findings were normal. Initially he was seen in a pain clinic and he was referred for surgical exploration when treatment with amitriptyline and lumbar sympathetic nerve blocks had failed. At exploration the spermatic cord was found anterior to the external oblique aponeurosis and was noted to be twisted and stuck to surrounding scar tissue. There was obvious tension on the vas together with 'omega'-shaped kinking medially. These structures were dissected out and freed such that the vas was tension-free at the end of the operation. The inguinal canal was opened and the cut ilioinguinal nerve was identified and traced back to its origin where it was cut cleanly away from the scar tissue. A darn
JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
Volume 91
August 1 998
Case two A 53-year-old man had a left inguinal hernia repair (Halsted) and four months later reported pain around the site of the scar. A sharp, burning pain localized to the scar with no radiation to the scrotum occurred only on ejaculation. The patient was otherwise fit and well. He had been sterilized fourteen years previously without experiencing any ejaculatory pains postoperatively. On examination there was decreased sensation to light touch and pin prick beneath the herniorrhaphy scar. As in case one the patient was initially seen in the pain clinic and then referred for exploration when treatment with amitriptyline had failed. At exploration the vas, which was superficial to the external oblique aponeurosis, was found tethered and twisted at the superficial ring. The vas was untethered and the cut ilioinguinal nerve was traced backwards and cut cleanly away from the scar. The patient became pain free and remains so 4 years post-exploration.
tubercle (possibly by a suture), while neuropathic pain (usually in the area of the genitofemoral or ilioinguinal nerve) may result from operative nerve damage or scar tissue development. What could be the mechanism of painful ejaculation after hernia repair? In the single previous report, dysfunction of the periurethral structures was postulated, but that patient's symptoms were mild and surgical exploration revealed kinking and scarring affecting both vasa deferentia. Resultant engorgement within the vas, with the rhythmic contractions of ejaculation, might lead to the pain. In the senior author's (MJH) opinion, scarring around the vas is especially common with Halsted inguinal hernia repair, which leaves the cord structures superficial to the external oblique aponeurosis. Neuroma formation at the scar site is a recognized cause of wound pain and our excision of the ends of the ilioinguinal nerves may have contributed to the relief of symptoms in these patients. We recommend that patients with painful ejaculation after inguinal hernia repair should be considered for exploration, to detect and treat scarring, tethering or kinking of the vas.
COMMENT
REFERENCES
Although painful ejaculation after inguinal hernia repair is evidently rare, painful ejaculation itself is not uncommon, most cases being secondary to urological conditions such as prostatic cysts2, prostatitis3 and seminal vesicle calculi4. In children, groin surgery often injures the vas deferens and may be a cause of painful ejaculation later in life. Pain around a herniorrhaphy scar is commonly reported, the pain being variably described as somatic or neuropathic. Somatic pain has been attributed to trauma to the pubic
1 Cunningham J, Walley JT, Mitchell P, Nixon JA, Preshaw RM, Hagen NA. Cooperative Hernia Study-pain in the postrepair patient. Ann Surg
repair was made to the posterior wall and the canal was closed again behind the cord. The patient became pain-free and 3 years later he remains so, with a normal sex life.
Heart failure with fludrocortisone in Addison's disease A Bhattacharyya MD MRCP
D J Tymms MD FRCP
J R Soc Med 1998;91:433-434
Autoimmune destruction of adrenal cortex causes Addison's disease and demands lifelong replacement of glucocorticoids and mineralocorticoids. We report a patient with a normal Department of Medicine (Division of Diabetes and Endocrinology), Royal Albert Edward Infirmary, Wigan WN1 2NN, UK
Correspondence to: Dr D J Tymms
1996;224:598-602 2 Dik P, Lock TM, Schrier BP, Zeijlemaker BY, Boon TA. Transurethral marsupialisation of a medial prostatic cyst in patients with prostatitislike symptoms. J Urol 1996;155: 1301-4 3 Mene MP, Ginsberg PC, Finkelstein LH, et al. Transurethral microwave hyperthermia in the treatment of chronic non-bacterial prostatitis. J Am Osteopath Assoc 1997;1:25-30 4 Corriere JN. Painful ejaculation due to seminal vesicle calculi. J Urol 1997;157:626
heart who developed heart failure on replacement fludrocortisone. CASE HISTORY On admission to hospital a 47-year-old woman gave a sixmonth history of intermittent abdominal pain, vomiting and diarrhoea. She was clinically dehydrated and pigmented and
her blood pressure was 110/70mmHg. Examination findings were otherwise normal, as was the chest X-ray. Serum sodium was 122 mmol / L, potassium 5.8 mmol/ L, urea 11.2 nmol / L and creatinine normal. Addison's disease was confirmed by the absence of a cortisol response to tetracosactrin 250 i'g (serum cortisol 19, 16, and 13 nmol/ L at 0, 30 and 60 min) and a baseline corticotropin of 112 ng/L (normal 5-50). Anti-adrenal antibodies were present. Replacement therapy with hydrocortisone (30mg
433
