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  IN THIS Article
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  References

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Year : 1987  |  Volume : 33  |  Issue : 4  |  Page : 213-5

An Indian Munchausen with urologic symptoms (a case report).







How to cite this article:
Basu A A, Tandon S P, Goswami A K, Sharma S K, Bapna B C. An Indian Munchausen with urologic symptoms (a case report). J Postgrad Med 1987;33:213


How to cite this URL:
Basu A A, Tandon S P, Goswami A K, Sharma S K, Bapna B C. An Indian Munchausen with urologic symptoms (a case report). J Postgrad Med [serial online] 1987 [cited 2019 Nov 18];33:213. Available from: http://www.jpgmonline.com/text.asp?1987/33/4/213/5258




  ::   Introduction Top

Munchausen syndrome refers to those patients who like the famous Baron von Munchausen have travelled widely and their stories like those attributed to him are both dramatic and untruthful.[2] We report a patient who exhibited the classical features of Munchausen syndrome viz. (i) documented history of multiple hospitalizations, (ii) convincing evidence that the pattern of hospitalization involved the voluntary production of physical signs of illness and (iii) acts of malingering excluded.[11] To the best of our knowledge this is the fourth such case in the Indian literature[1],[7],[8] and the first one with urologic manifestations.

  ::   Case report Top

A 27 year old unmarried lady presented with history of passing urine per rectum in addition to normal voiding for 6 months. There was no history of passing urine or stools per vaginum. She had not delivered a child; nor was there a history of injury to the perineum. She had undergone two negative laparotomies before for pain in abdomen.[5]
On command, patient demonstrated passing urine per rectum. A plain film of the pelvis, showed radio-opaque shadows [Fig. 1]. Dilute contrast cystogram did not show a rectovesical fistula and the radio-opaque shadows in the pelvis were found to be in the rectum [Fig. 2]. On cystoscopy, no fistula was seen, nor was there a calculus in the bladder. The patient was reinvestigated after 2 months as her complaints persisted. Cystoscopy was again negative. Her bladder was filled with dilute methylene blue and the patient asked to wait 'outside' the minor operating theatre and demonstrate in case she left like voiding per rectum. The patient came back after some time and voided the entire dilute methylene blue per rectum. A repeat cystogram failed to demonstrate a fistulous communication between bladder and rectum.
Dilute Povidone-iodine solution was next used to fill the bladder and patient asked to wait 'under observation'. In spite of waiting for more than 2 hours, the patient did not pass the povidone-iodine solution per rectum. The patient was consoled that she did not suffer from any organic disease but she preferred to go to another hospital for treatment.
On detailed psychiatric evaluation, it was found that she had four previous hospitalizations with the clinical presentation of abdominal pain during two of which she had undergone laparotomies. The second laparotomy was one year prior to the complaint described here.[5] She has since been presenting repeatedly to the hospital with vague complaints but all her investigations revealed no organic cause or any motive. Since no motive could be established a diagnosis of Munchausen syndrome was made as against 'malingering' where a motive is usually present.

  ::   Discussion Top

Malingering is a patient's willful, deliberate and fraudulent imitation of exaggeration of illness with conscious intent to deceive others for a specific purpose. Unlike malingering, in Munchausen syndrome, the sole objective is to assume the role of a patient without an acute emotional crisis or a recognizable motive, and indeed, without a need for treatment, many of these patients make hospitalization itself a primary objective and often a way of life.[11] In our patient, there was no recognizable motive behind imitating illness. Secondly, she was willing to undergo invasive investigations and surgery, which a malingerer will not.
There are three common modes of clinical presentation viz. (i) severe abdominal pain mimicking an acute abdominal emergency (ii) blood loss from various orifices and (iii) neurologic symptoms of various types. Other manifestations like repeated ingestion of foreign bodies, simulation of cardiac problems, pulmonary edema, eye injury, and limb swelling have also been reported.[7] The basic psychiatric abnormality of these patients have been well described.[11] Urologic symptoms have been reported on a few occasions.[3],[4],[6],[9] Our patient had different symptoms and is the first to be reported in the Indian literature. Fear of genital inadequacy has been mentioned as an etiologic factor in cases of factitious illness of the genito-urinary tract.[10]
Instillation of voided urine into the rectum and voiding regain was a unique feature of this case. As to how exactly she did so is not known. The radio-opaque shadows in the pelvis were small, oval and smooth in outline. Cystoscopy and lateral view of cystogram proved these to be in the rectum. These were the stones she had placed in the rectum.
This patient initially presented with symptoms of the abdominal type of Munchausen syndrome and had undergone two laparotomies. She presented a year later with urologic complaints, to the same hospital where she had undergone the second laparotomy. On careful investigation all her symptoms were found to be self-inflicted or fabricated. When she was told that she did not suffer any organic disease, she decided to go to another hospital for treatment, as would be expected of a patient with Munchausen syndrome.

  ::   References Top

1.Agarwal, B. L.: An Indian Munchausen. J. Assoc. Phys. India, 20: 467-469, 1972.   Back to cited text no. 1    
2.Asher, R.: Munchausen syndrome. Lancet, 1: 339-341, 1951.  Back to cited text no. 2    
3.Atkinson, R. L. and Earll, J. M.: Munchausen syndrome with renal stones. J Amer. Med. Assoc., 230: 89, 1974.  Back to cited text no. 3    
4.Nickel, J. C.: Blunt renal trauma; another ploy in Munchausen syndrome, Can. Med. Assoc. J., 130: 348-349, 1984.  Back to cited text no. 4    
5.Palnitkar, D. V., Mina, M., Sabharwal, V., Bhave, S. and Kaushik, S. P.: Fictitious gastric calculi. Ind. J. Gastro-enterol., 5: 220. 1986.  Back to cited text no. 5    
6.Reich, P., Lazarus, J. M., Kelly, M. J. and Rogers, M. P.: Fictitious feculent urine in an adolescent boy. J. Amer. Med. Assoc.. 238: 420-421, 1977.  Back to cited text no. 6    
7.Sakhuja, V., Murthy, R. S., Dhir, S. P., Anand, I. S, and Deodbar. S . P.: Munchausen syndrome-case report and review of literature. J. Assoc. Phys. India, 30: 383-386. 1982.  Back to cited text no. 7    
8.Sehgal, A. K. and Mangla, J. C.: Munchausen syndrome. (a case report). J. Assoc. Phys. India, 12: 309-313, 1964.  Back to cited text no. 8    
9.Sharon, E. and Diamond, H. S.: Fictitious uric acid urolithiasis as a feature of the Munchausen syndrome. Mt. Sinai J . Med. (N.Y.), 41: 696-698, 1974.  Back to cited text no. 9    
10.Spiro, H. R.: Chronic factitious illness: Murchausen syndrome. Arch. Gen. Psychiat., 18: 569-579, 1968.  Back to cited text no. 10    
11.Sussmann, N. and Hyler, S. E.: Factitious disorders. In: "Comprehensive Textbook of Psychiatry." Editors: H. I. Kaplan and B. J. Sadock, 4th edition, Williams and Wilkins, Baltimore, 1985, pp. 1242-1247.  Back to cited text no. 11    

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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
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