Ureteric obstruction due to pelvic actinomycosis

Since 1973 several reports of pelvic actinomycosis arising in association with modern types of IUDs have appeared. Various presentations occur such as vaginal discharge tubo-ovarian abscess or "frozen pelvis." Ureteric obstruction is uncommon and its management unclear. A case is presented of ureteric obstruction due to pelvic actinomycosis associated with an IUD. A 34 year old woman presented with a 6 month history of alternating constipation and diarrhea weight loss amenorrhea and laterally a vaginal discharge. A Lippes loop had been inserted 2 years earlier. On examination she was anemic cachectic pyrexial and had a frozen pelvis. There was a stricture of the midrectum but the mucosa was intact. The strings of the IUD could be felt and the cervix appeared normal. There was skin redness and induration over the right ischiorectal fossa. Intravenous urogram showed bilateral hydronephrosis with hydroureter. Examination under anesthesia confirmed the midrectal stricture. Biopsies showed mild inflammatory changes only. The IUD was removed and curettings revealed an acute endometritis. At laparotomy apparently normal small bowel loops were adherent to a friable mass in the pelvis which displaced the bladder forwards. The colon and uterus appeared normal but bilateral pyosalpinges were present and were resected. Neither ovary could be identified. Despite the tubal infection pelvic malignancy was suspected and a sigmoid colostomy fashioned in view of impending rectal obstruction. Histology of the mass showed a large amount of fibrous tissue infiltrated by acute and chronic inflammatory cells and containing micro-abscesses. In 2 places only colonies of actinomycetes surrounded by polymorphs were observed. No sulphur granules were identified. No growth was obtained on aerobic and anaerobic culture of the tissue and the pyosalpinges. Treatment with penicillin V 500 mg q.d.s. produced an allergic reaction and was changed to tetracycline 250 mg q.d.s. which was continued for 2 months at home. 4 months later the rectal stricture had resolved and the colostomy was closed. 9 months after the initial presentation a urogram showed complete resolution of the left hydronephrosis. There was slight residual right hydronephrosis but no evidence of ureteric obstruction.