Pseudomonas aeruginosa as an Etiologic Agent of Nephrolithiasis in Deep Water Divers

Abstract

Background: A number of occupations and professions may be associated with unique hazards relevant to urologic care. Case Presentation: We relate the presentation, care, and the occupational hazard of urinary tract infection (UTI), presenting as cystitis and pyelonephritis, with stone formation in a scuba diver. The patient voiced concern that his diving suit malfunction was related to his UTI and stone disease. We review the risk of UTI in the diving environment. We also report the development of infection-related stone in this case. Our evaluation included consultation with an expert in diving and associated equipment. Conclusion: Careful installation of P-valves in dry suits, proper maintenance, and monitoring for leakage improved post-dive hygiene, and proper maintenance of P-valve tubing and diving equipment may decrease the incidence of these complications described. Urologists treating UTI and stone disease should be aware of this occupation-related hazard.

Keywords: P-valve; diving; infection; urinary stone.

FIG. 1.

Preoperative axial (A) and coronal (B) arterial phase CT images at the level of the kidneys showing partial staghorn calculus in the right collecting system (red arrows). There is heterogeneous enhancement of the right kidney (white arrows) radiographically consistent with pyelonephritis and abnormal proximal right ureteral enhancement (white arrowhead) radiographically consistent with ureteritis.

FIG. 2.

Photograph of the infected staghorn calculus. On gross examination, calculus took the form of tan-yellow, bosselated stone with loosely adherent blood clots. Crystallographic analysis (Louis C. Herring and Company) revealed calculus composition of 67% magnesium-ammonium-phosphate-hexahydrate (struvite) and 30% calcium phosphate in carbonate form, calculus culture grew Pseudomonas aeruginosa.

FIG. 3.

P-valves can be unbalanced (A) or balanced (B). Balanced P-valves equalize the pressure between the valve system and the outside water pressure, avoiding reflux of water at high pressure. In addition, it prevents “genital squeeze” that can occur with an unbalanced system's tubing. An unbalanced P-valve also protects from water entering into the suit; however, it may allow some retroflux of ambient water into the P-valve tubing system at extreme depths. P-valves can be installed in the upper thigh of a dry suit (C).