Bilateral Moderate Hydroureteronephrosis Due to Uterine Prolapse: Two Case Reports and Review of the Literature

Abstract

Uterine prolapse resulting in hydronephrosis was uncommon. We report two cases of complete uterine prolapse and bilateral moderate hydronephrosis. Case 1, she was admitted due to fever with pyuria. Uterine prolapse was noted by incidental finding. Urine culture showed Escherichia coli. She received total vaginal hysterectomy, which corrected the obstruction and bladder dysfunction. Case 2, she had a history of liver cirrhosis and was denied further operation due to bleeding tendency. Renal echo and intravenous pyelography showed bilateral moderate hydronephrosis with hydroureter in the two cases. Normal renal function was found in the two cases. We suggest early diagnosis and management are necessary in order to prevent renal failure and urinary tract infection.

• Uterine prolapse
• Hydronephrosis

Introduction

Uterine prolapse resulting in hydronephrosis was uncommon. The association between uterine prolapse and obstructive renal disease was first recognized in 1824 and reviewed in 1931 by Frank.[[1]] There were at least 10 reports publishes in the English literature between since 1931.[[2]], [[3]], [[4]], [[5]], [[6]], [[7]], [[8]], [[9]], [[10]], [[11]], [[12]], [[13]], [[14]] Uterine prolapse and renal dysfunction were found due to long term hydronephrosis in some papers.[[4]], [[5]], [[6]], [[7]], [[8]], [[9]], [[10]], [[11]] We report two cases of complete uterine prolapse with bilateral moderate hydronephrosis.

Case Reports

Case 1

A 67-year-old woman presented complete but reducible uterine prolapse for 30 years. A cystocele and rectocele was also found. But she was not to care about it. There was no history of trauma or D&C. Her delivery history had Para 5(A6P5) with spontaneous delivery. She was referred to our hospital on May 24, 2002 due to fever with pyuria. Her general condition was fair. Urinary frequency, dysuria and voiding difficulty were present. Physical examination revealed no abnormality apart from third degree uterine prolapse. Blood pressure was 160/98. Laboratory investigation revealed pyuria due to Escherichia coli and slight anemia (Hb 10.3 g/dL). The serum creatinine value was 0.9 mg/dL. Pre-operative intravenous pyelogram (Fig. 1) showed bilateral moderate hydronephrosis with hydroureter. Pre-operative renal sonogram (Fig. 2a) showed moderate hydronephrosis of the left kidney. A vaginal total hysterectomy, anterior and posterior colporrhaphy were performed in June 2002. The operative course was smooth without complication. Transient post-obstructive diuresis about 3000–4000 cc/day was found post operation. Symptoms of frequency, voiding difficulty and dysuria were improved. Postoperative renal sonogram (Fig. 2b) showed no obstructive uropathy of left kidney one month post-operation. No recurrent urinary tract infection was noted three months post-operation.

Figure 1. IVP showed bilateral moderate hydronephrosis with hydroureter.

Figure 2a. Renal echo showed moderate hydronephrosis of left kidney pre-operation.

Figure 2b. Renal echo showed no obstructive uropathy of left kidney one month postoperation.

Case 2

A 46-year-old woman presented complete uterine prolapse for one year. There was no history of trauma or D&C. Her delivery history had Para 4(A4P4) with spontaneous delivery. She had a history of decompensated liver cirrhosis with ascites. She was referred to our hospital on September 8, 2002 because of bilateral lower legs allergic dermatitis with secondary infection. Chillness was present. Her general condition was malnutrition and weakness. Physical examination revealed abdominal distension, leg edema and third degree uterine prolapse. Blood pressure was 80/60. Laboratory investigation revealed AST 104 U/L, total bilirubin 4.5 mg/dL and slight anemia (Hb 11.4 g/dL). The serum creatinine value was 0.8 mg/dL. Pre-operative intravenous pyelogram and renal sonogram showed bilateral moderate hydronephrosis with hydroureter. The above symptoms were improved after the therapy. She had uterine prolapse but was denied further operation due to a high risk of bleeding tendency.

Discussion

Uterine prolapse is usually found in the multiparous but elderly urological complication is uncommon. Our two patients had multiparous history.

Uterine prolapse can cause significant ureteral obstruction and may lead to renal failure. Hydronephrosis is one of the most serious complications and if left untreated may lead to renal insufficiency.[[4]], [[5]], [[6]], [[7]], [[8]], [[9]], [[10]], [[11]] The mechanism of renal failure may be related to the obstruction.[[8]] In our two patients, Cases 1 and 2 uterine prolapses were by incidental finding during admission. Complete physical examination was necessary. In our two patients, moderate hydronephrosis differed from previous severe hydronephrosis. Normal renal function was found in the two cases. Although case 1 had uterine prolapse for 30 years, it could be reducible and normal renal function regained. Case 2 had only one-year history of uterine prolapse. We suggest a supporting pessary is fitted due to contraindication to operation. Undue delay in correcting the prolapse may result in permanent renal damage.

The incidence of urinary tract infection may be associated with third-degree uterine prolapse.[[8]] In our two patients, Cases 1 and 2 had third-degree uterine prolapse. Only Case 1 had urinary tract infection history. We suggest early diagnosis and management are necessary in order to prevent renal failure with urinary tract infection.