Transcript Urinary Retention as a Complication of Non-gravid

Urinary Retention as a Complication of Non-gravid Uterine Fibroid: two case
reports in University Malaya Medical Centre (UMMC)
Shazni Izana Shahruddin MD(UNIMAS), Khong Su Yen MBChB (UK) MRCOG (London) FRANZCOG
Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya
Introduction
Discussion
Urinary retention is defined as the inability to void voluntarily when the
volume of urine in the bladder exceeds its normal capacity (4).
Uterine fibroid, although rarely causes acute urinary retention in the gravid
uterus, mostly present with persistent urinary retention (5-10). However,
the occurrence of urinary retention is not well studied and reported in
cases of non-gravid uterus.
Uterine fibroid is remarkably common. A random sampling of women aged
35 to 45 who were screened by self-report, medical record review and
sonography found that by the age of 35, the incidence of uterine fibroid
was 60% among African-American women; the incidence increased to
over 80% by age 50. Caucasian women have an incidence of 40% by age
35 and almost 70% by age 50 (1). Fibroids were also the primary
indication for surgery in 199,000 hysterectomies and 30,000
myomectomies in the United State in 1997 (2).
Uterine fibroid is an uncommon cause of urinary retention affecting only 7
in 100,000 young women per year (3). However, the resulting obstructive
uropathy can lead to serious sequelae such as hydronephrosis and renal
impairment.
Most reports of urinary retention involve incarcerated or retroverted gravid
uterus (5,6,11-13). In these cases, the problem with urinary retention is
usually transient, occurring at the start of pregnancy (12) but resolves
spontaneously as the uterus enlarges with increasing gestation and
becomes an abdominal organ. However, in our two non pregnant patients
with uterine fibroids, the severity of urinary retention worsened as the
fibroids enlarged. The pressure resulting from an enlarging uterine fibroid
likely aggravated the bladder outlet obstruction thus worsening the urinary
retention (7).
Objectives
Methods
Posterior uterine fibroid
Results
POSSIBLE MECHANISMS OF URINARY RETENTION
1.Progesterone causing fibroid enlargement
Interestingly, voiding dysfunction worsened in both Patient A and B during
menses. This may be because progesterone plays an important role in
uterine fibroid pathophysiology. As fibroids have increased concentrations
of progesterone receptors A and B compared with normal myometrium
(14,15), they may increase in size during the secretory phase when
progesterone production peaks. In addition, lowered uterine artery
impedance at the time of menstruation may cause increases in intrauterine
pressure and uterine volume from menstrual flow (4).
TEMPLATE DESIGN © 2008
www.PosterPresentations.com
During daytime, overdistension of the bladder is prevented due to frequent
micturition caused by irritability of the compressed bladder on a standing
position (4,7). This could also be habitual.
Eadematous bladder
due to overdistension
In a supine position such as during sleep, the large posterior uterine fibroid
displaces the cervix anteriorly and superiorly, and thus compresses on the
lower part of the bladder. This results in bladder outlet obstruction and can
lead to urinary retention. Valsalva manoeuvre can further increase the
pressure to the lower part of the bladder and worsen bladder impaction from
the uterine fibroid (7,13).
Yang and Huang (7) suggested a few preventive measures to avoid urinary
retention:
1) Restriction of liquid before going to bed
2) Urination before going to bed and preventive urination during the
night
3) Crede’s manoeuvre, consisting of leaning forward in a sitting
position at the beginning of urination
4) Moving from a supine to prone position before getting up
5) Avoidance of valsalva manoeuvre
Therefore, a careful pelvic examination (12) is important to identify patients
with posterior fibroid as preventive measures listed above may reduce voiding
dysfunction.
To improve our understanding of the mechanism involved when a nongravid uterine fibroid causes urinary retention.
Case reports of two non-pregnant patients who presented with urinary
retention secondary to uterine fibroid in University Malaya Medical Centre
(UMMC) and discussion based on current literatures.
2. Compression of fibroid causing bladder outlet obstruction
Generally, in a non-gravid uterus, complete resolution of urinary retention is
possible with surgical removal of the uterine fibroid. However in complex
cases which include younger age women for fertility conservation, this may be
a challenge.
Medical and other alternative treatments such as with gonadotrophin-releasing
hormone agonist (16), uterine artery embolization (17) and high-intensity
focused ultrasound (18) have been reported to reduce the size of uterine
fibroid. However, efficacy and treatment success depend on the number and
size of fibroids as well as renal status.
Conclusion
Although urinary retention secondary to uterine fibroid is uncommon, we
should maintain a high index of suspicion when a woman, especially in the
reproductive age group, presents with voiding dysfunction. A careful
assessment should be undertaken and if a non gravid uterine fibroid is
present, specific advice and special maneouvres can be undertaken to
prevent urinary retention.
References
(1) Day Bird D, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and
white women: ultrasound evidence. Am J Obstet Gynecol 2003; 188:100-7
(2) Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol 2002;99:229-34
(3) Choong S, Emberton M. Acute urinary retention. BJU Int 2000;85:186-201
(4) Barnacle S, Muir T. Intermittent urinary retention secondary to a uterine leiomyoma. Int urogynecol J 2007;18:339-341
(5) Schwartz Z, Dgani R, Katz Z, lancet M. Urinary retention caused by impaction of a leiomyoma in pregnancy. Acta Obstet
Gynecol Scand 1986;65:525-526
(6) Nitti A, Feusner AH, Muller PD. Incarceration of a gravid fibroid uterus. Ann Emerg Med 1997;30(6);821-624
(7) Yang JM, Huang WC. Sonographic findings of acute urinary retention secondary to an impacted pelvic mass. J Ultrasound
med 2002;21(10);1165-1169
(8) Kondo A, Toshikazu O, Takita T, Hayashi H, Kihira M, Itoh F. urinary retention caused by impaction of enlarged uterus.
Urol Int 1992;37:87-90
(9) Varras M, Polyzos D, Alexopoulus C, Pappa P, Akrvis C.Torsion of a non-gravid leiomyomatous uterus in a patient with
myotonic dystrophy complaining of acute urinary retention: anesthetic management for total abdominal hysterectomy. Clin Exp
Obstet Gynecol 2003;30(2-3):147-150
(10) Novi JM, Dolan TS, Cespedes RD. Acute urinary retention caused by a uterine leiomyomas: case report. J Reprod med
2004;49(2):131-132
(11) Yang JM, Huang WC. Sonographic findings in acute urinary retention secondary to retroverted gravid uterus:
pathophysiology and preventive measures. Ultrasound Obstet Gynecol 2004;23:490-495
(12) Love JN, Howell JM. Urinary retention resulting from incarceration of a retroverted, gravid uterus. J Emerg Med
2000;19(4):351-354
(13) Chauleur C, Velliez L, Seffert P. Acute urine retention in early pregnancy resulting from fibroid incarceration: proposition for
management. J Fert Stert 2008;90(4):1198.e7-1198.210
(14) Englund K, Blanck A, Gustavsson I, Lundkvist U, Sjoblom P, Norgren A, et al. Sex steroids receotors in human
myometrium and fibroid: changes during the menstrual cycle and gonadotrophin-releasing hormone treatment. J Clin Endocrinol
Metab 1998;83:4092-4096
(15) Nisolle M, Gillerot S, Casanas-Roux F, Squifflet J, Berliere M, Donnez J. Immunohistochemical study of the proliferation
index, oestrogen receptors and progesterone receptor A and B in leiomyomata and normal myometrium during the menstrual
cycle and under gonadotrophin-releasing hormone agonist therapy. Hum Reprod 1999;14:2844-2850
(16) Parker WH. Etiology, symptomtology, and diagnosis of uterine myomas. J Fert Stert 2007;87(4):725-736
(17) Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids; clinical results in 400 women with imaging
follow up. Int J Obstet Gynaecol 2002;109(11):1262-1272
(18) Morita Y, Ito N, Hikida H, et al. Non-invasive magnetic resonance imaging-guided focused ultrasound treatment for uterine
fibroids- early experience. Euro J Obstet Gynecol Repro Bio 2007;139:199-203
Background poster image from http://www.fibroidssolutions.com/wp-content/uploads/2011/04/Fibroids-Symptoms.jpg