Acute Urinary Retention due to Deep Infiltrating Endometriosis
[1]dr. M. Dimas Abdi Putra, Sp.OG
[1]Obstetrics and Gynecology Department of Arafah – Anwar Medika Hospital, Sidoarjo
Abstract
Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis. Dysmenorrhea and chronic pelvic pain are the most reported symptoms. Urinary symptoms are rarely reported, particularly preoperative urinary retention. A 48-year-old married woman, P2, was reported in this case report due to acute urinary retention. The failure of pharmacological treatment for chronic pelvic pain results surgical procedure being the management of choice. The gentle and careful operative technique is mandatory to prevent further complications.
Keywords: endometriosis, hysterectomy, urinary, DIE, dysmenorrhea
Correspondence: m.dimas.ap@gmail.com;
Introduction
Endometriosis is a chronic inflammatory disease caused by the presence of ectopic endometrial tissue, which reacts to changes in the ovarian steroids, estrogen, and progesterone as expressed by proliferation, differentiation, and bleeding[1].
The prevalence of endometriosis for about 7-10% in reproductive aged women and 50% of women with subfertility[2,3]. Symptoms associated with endometriosis may vary including a combination of painful periods, chronic pelvic pain, pain during and/or after sexual intercourse, painful bowel movements, painful urination, fatigue, depression or anxiety, abdominal bloating, and nausea[4]. Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis, approximately affecting 1-2 % of reproductive women, mostly presents as a single nodule, larger than 1 cm in diameter, in the vesicouterine fold or close to the lower 20 cm of the bowel[5]. DIE lesions appear widely distributed, preferentially in the pouch of Douglas, with expansion to the uterosacral ligaments, torus uterinum, cardinal ligament with uterine artery involvement, ureters, or bladder, with a preferential invasion into the anterior rectal wall[3]. In the clinical diagnosis of DIE, the most common symptoms seen in DIE are dysmenorrhea, severe dyspareunia, severe chronic pain and dyspareunia, but urinary tract symptoms are less common[5].
Case:
A married woman, 48 year-old, P2, came to the emergency department because of unable to micturition for approximately 36 hours. Patient had history of severe dysmenorrhea affecting her daily activities. The symptoms occurred during almost half of the menstruation cycle, and the used of analgesic could not reduce the pain effectively. Painful bowel movements were also felt in certain time. She had also history of having twice caesarean section. She had used medroxyprogesterone acetate every three months for two years. Physical examination had been performed to find what the cause was. Bimanual palpation exhibited that the uterine enlargement was equal to 16 weeks of pregnancy. The uterus was retroflexion, and it might have impacted to the bladder or urethra so that urinary retention occurred. No adnexal mass. Rectovaginal examination had suspected severe adhesion.
An indwelling urinary catheter was set up to help the micturition, and 1800 ml clear urine was collected. After some emergency managements and consents were performed, she and her husband decided to have an operation to relieve the symptoms, and the schedule of surgery was arranged.
During operation, uterine enlargement and retroflexion were confirmed. The bladder was withdrawn to anterior wall of uterus. Dark endometriosis foci were found spreading around the uterus. Bilateral hydrosalpinx and severe adhesion of rectosigmoid to the posterior wall of uterus were found. Some challenging operation techniques were performed. Combination of sharp and blunt adhesiolysis to relieve those organs was applied; the bladder separation and total abdominal hysterectomy with bilateral salpingo-oophorectomy had been performed cautiously. The postoperative patient was discharged without complications and had normal urinary function.
Postoperative evaluation reported that pain was significantly decreased, micturition back into normal, and painful bowel movement was no longer exist. Histological examination results confirmed the adenomyosis and bilateral hydrosalpinx.
Discussion
Urinary retention after surgical treatment of deep pelvic endometriosis is rarely found. Some studies mentioned approximately 3.5-14.3% of DIE patients still have urinary retention 30 days following surgical treatments[7]. Postoperative urinary retention frequently occurs in bladder endometriosis. In addition, it is related to the size of the excised node. The larger the resected nodule, the more likely it is to cause urinary retention[5]. A case study reported urinary retention due to DIE, unfortunately, it was in Arabic. This study showed that urinary retention due to anterior and upward displacement of the cervix results in a large, solid, and tender mass that is palpable on the symphysis pubis[9]. Similarly to this case report, urinary retention occurs due to uterine enlargement that not only had impacted and pushed the cervix anteriorly but also withdrawn the bladder to anterior wall of uterus. Surgical procedures should be done with care, to prevent further complications. In this case report, combination of blunt and sharp adhesiolysis was performed. Dark and deep infiltrating endometriosis nodules, clearly found in the posterior wall of the uterine, and a few nodules found in anterior wall of uterine near to the bladder. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed.
Figure 1. Posterior wall of uterus with characteristics of severe adhesions
Figure 2. Anterior wall of the uterus
Surgical treatment could be definitive treatment when medical treatment has no significant impact to reduce the pain[3]. In this case report, hysterectomy was selected because of the patient's age and multiparity history. Age and history of multiparity are important factors to be considered before undergoing a hysterectomy[11]. Retroverted uterus due to severe adhesion also found in this patient, similar to the research reported by Riazi, et al.[12]. The researchers state that fixed or decrease uterine mobility can be found during clinical examination due to adhesion. Urinary retention due to fixed retroverted uterus seems more frequent in pregnancy[13,14]. It may happen because the fixed retroverted uterus in pregnancy getting enlarged and causes extrinsic compression of the urethra. A serious complication can occur if it is not treated appropriately[13,14,15].
Postoperative care for this case report, proceeds without any complication. The urinary retention finally disappears. The indwelling catheter is removed 24 hours following operation, and urinary function is normal. Urinary retention is widely reported as postoperative complication of deep endometriosis[7], most of the cause is due to the resected nodule in the bladder that interfered the parasympathetic nerve function[5]. Parasympathetic nerve fibers are branch from pelvic splanchnic nerves (S2-S4), that maintain contraction of the detrusor and release of sphincter and then urination[16,17]. The bladder performance seems to depend on the preservation of splanchnic nerves[17].
Conclusion
Urinary retention is uncommon complication of deep infiltrating endometriosis. Enlargement, fixed, and retroverted uterus due to severe adhesion that compressed the bladder may cause this complication. Surgical management in adenomyosis should be performed when pharmacological treatment had no significant improvement in reducing pain A comprehensive of evaluation and management, including surgery, should be considered to improve quality of life for the DIE survivors. The gentle and careful operative technique is mandatory to prevent further complications.
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