Obstructive Uropathy by Total Uterine Prolapse Leading to End-Stage Renal Disease

Abstract

A 74-year-old woman was admitted to our emergency room complaining of general weakness and anorexia that started 20 days earlier. She denied other underlying diseases that might have provoked chronic renal disease. Her serum creatinine was 12.35 mg/dL. A pelvic examination and computed tomography revealed severe bilateral hydroureteronephrosis with marked cortical thinning induced by total uterine prolapse. She was started on emergency hemodialysis due to her uremic symptoms and severe metabolic acidosis. Despite Foley catheter insertion and manual reduction of uterus for 1 month, renal function was not recovered. The department of gynecology was strongly opposed to performing a procedure to reverse the hydroureteronephrosis due to the irreversibility of her renal function. She is undergoing chronic maintenance hemodialysis. This is a case report of rare end-stage renal disease (ESRD) caused by obstructive uropathy due to pelvic organ prolapse (POP). We should consider POP as a cause of ESRD.

• end-stage renal disease
• hemodialysis
• uterine prolapse
• obstructive uropathy
• hydronephrosis

INTRODUCTION

Brettauer and Rubin first reported uterine prolapse (UP), also known as pelvic organ prolapse (POP), as a cause of urinary tract obstruction in the English literature in 1923.¹ It can cause bilateral hydroureteronephrosis due to ureteral obstruction, which if left untreated can also be the cause of hydronephrosis and impaired renal function leading to chronic renal failure (CRF) and arterial hypertension.² Obstructive uropathy occurs in 4–7% of patients with UP.³ However, few reports exist on end-stage renal disease (ESRD) associated with POP causing obstructive uropathy.^4,5 We report a rare case of POP leading to ESRD. This patient had minor symptoms or signs of POP before admission to the hospital.

CASE REPORT

A 74-year-old woman without underlying disease was referred to our hospital with general weakness and anorexia that started 20 days earlier. For several years, she had frequent urination, an urgent need to empty her bladder, and a sensation of heaviness or pressure in the lower abdomen. She had experienced a long-standing feeling of “coming down with something.” However, she had not sought medical help for these symptoms, but had adapted to them completely.

She had no history of taking medicines, exposure to toxic material, diabetes, hypertension, or glomerulonephritis. She had no family history of renal disease. She was a peasant. On physical examination, her temperature was 36.7°C, blood pressure was 174/84 mm Hg, pulse rate was 73 beats/min, and respiratory rate was 20 breaths/min. Both lungs were clear on auscultation; her abdomen was not distended and no abdominal bruit was heard. She had no pretibial pitting edema. On admission, her serum blood urea nitrogen was >100 mg/dL and the creatinine was 12.35 mg/dL. Other laboratory findings included Hb of 7.3 g/dL, total protein of 5.8 g/dL, albumin of 2.8 g/dL, sodium of 131.7 mmol/L, potassium of 4.5 mmol/L, chloride of 104 mmol/L, tCO₂ of 7 mmol/L, calcium of 6.8 mg/dL, and phosphorus of 7.3 mg/dL. Arterial blood gas analysis showed pH 7.24, pCO₂ 13 mm Hg, and HCO₃⁻ 5 mmol/L. Urinalysis showed pH 5.0, specific gravity 1.010, protein (2⁺), and blood (2⁺). The spot urine protein creatinine ratio was 2.3.

The pelvic examination revealed fifth-degree UP (Figure 1) and abdominal computed tomography showed that the bladder and uterus were prolapsed outside the vagina, leading to bilateral distal ureter compression and hydroureteronephrosis with severe cortical thinning (Figure 2A and B). Emergency hemodialysis via dual lumen catheter was started. Despite Foley catheter insertion and manual reduction of uterus for 1 month, renal function was not recovered. Hence, the hydroureteronephrosis resulting from severe UP was considered the primary cause of ESRD in our patient. The departments of urology and gynecology would not agree to perform surgical procedure to decompress this major obstruction because of the irreversibility of her renal function indicated by the severe cortical thinning. She is now undergoing hemodialysis via a radiocephalic fistula 3 times/week.

Figure 1.  Pelvic examination of the patient revealing the total UP throughout the vagina.

Figure 2.  Computed tomography scan showing bilateral hydroureteronephrosis with nearly absence of renal cortex (A: transverse view, B: coronal view).

DISCUSSION

POP refers to the protrusion of the pelvic organs, such as the bladder, uterus, and small or large bowel, into or out of the vaginal canal. It is usually associated with minor urinary complications, including urinary tract infection and incontinence.⁵ However, it may also produce severe disease, such as acute renal failure⁶ or CRF^7–10 including ESRD,^4,5 resulting from bilateral hydroureteronephrosis. We report a case of ESRD resulting from hydroureteronephrosis due to total UP.

POP is common in older women, who may not be aware of the importance of this condition. Its prevalence is 37% in the general population, but increases to 64.8% in older women.¹¹ The association of POP and hydronephrosis differs across studies. Costantini et al.¹² reported that the prevalence of hydronephrosis was 5% in patients with POP who were candidates for surgery, and bilateral in 3.1% versus unilateral in 1.9%. Beverly et al.¹³ reported radiographic evidence of hydronephrosis in 25 of 323 patients (mild in 13, moderate in 19, and severe in 3).¹³ Since these studies included symptomatic preoperative patients, the prevalence of hydronephrosis accompanying POP might differ if patients who did not visit a hospital with asymptomatic POP were included.

Common symptoms and signs of POP include stress incontinence, increased urinary frequency, urinary incontinence, pain during sexual intercourse, and increased susceptibility to urinary tract infection. The degree of POP does not necessarily reflect the severity of the symptoms that patients may experience.¹⁴ Sometimes, a patient has no symptoms despite marked vaginal prolapse, whereas other women complain of quite severe symptoms with only minimal prolapse.¹⁵ Our patient was not aware of the severity of her POP, as she had mild symptoms and signs, and her renal function had already shut down when she visited the hospital for the first time with non-gynecological symptoms and signs.

A plausible mechanism of obstructive uropathy caused by POP may be direct compression of the ureter. In UP, herniation of the bladder, uterus, and ureters occurs through the pelvic floor and the ureters are compressed between the fundus of the uterus and the bladder, against the levator ani muscles.^16,17 The association of POP and urinary obstruction is well known, but the diagnosis is often delayed and overlooked. This is partially explained by the insufficient attention POP receives in textbooks as a cause of obstructive uropathy.¹⁶ Since persistent hydroureteronephrosis caused by POP leads to irreversible renal damage, appropriate correction and repair will resolve the hydronephrosis and preserve renal function.

Renal failure accompanied by POP has been reported. Only one case was correlated with acute renal failure, and improved with surgery.⁶ Some other cases were associated with CRF^7–10 and to the best of our knowledge, two cases of ESRD required long-term dialysis.^4,5 Unlike our case, the previous patients were investigated in hospital for CRF of unknown etiology, and this progressed to ESRD resulting from POP 2 years later.⁵ We are often confronted with CRF of unknown etiology in older women in the outpatient department. We should suspect POP as the etiology of CRF, ask about symptoms and signs of POP, and conduct a diagnostic pelvic examination and imaging study. Furthermore, patients with POP should undergo renal function testing and renal ultrasonography to exclude obstruction of the urinary tract. Early diagnosis and management are necessary to prevent renal failure from POP.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.