Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Urethral diverticulum misdiagnosed with cystocele S. W. Lee, M. S. Kim, H. J. Hwang, Y. H. Chung & S. J. Lee To cite this article: S. W. Lee, M. S. Kim, H. J. Hwang, Y. H. Chung & S. J. Lee (2014) Urethral diverticulum misdiagnosed with cystocele, Journal of Obstetrics and Gynaecology, 34:5, 450-450 To link to this article: http://dx.doi.org/10.3109/01443615.2014.899331
Published online: 02 Apr 2014.
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Date: 11 November 2015, At: 21:56
450
Gynaecology Case Reports
Urethral diverticulum misdiagnosed with cystocele S. W. Lee1, M. S. Kim1, H. J. Hwang1, Y. H. Chung1 & S. J. Lee2 Departments of 1Obstetrics and Gynecology and 2Urology, College of Medicine, the Catholic University of Korea DOI: 10.3109/01443615.2014.899331 Correspondence: S.-J. Lee, Department of Urology, St. Vincent’s Hospital, 93-6 Ji-dong, Paldal-gu, Suwon 442–723, Korea. E-mail: [email protected]
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Introduction Vaginal wall cysts are estimated to affect about 0.5–1% of women and are classified as an embryologic derivative, ectopic tissue or urologic abnormality (Blaivas et al. 2004). Urethral diverticulum in females can be easily detected by physical examination. However, sometimes diagnosis can be difficult. The gynaecologist may only rarely encounter cystic formation of the anterior vaginal wall and so may misdiagnose it as cystocele. We present a case of urethral diverticulum misdiagnosed as cystocele during surgery.
Case report A 49-year-old gravida 3, para 3 woman visited our hospital with symptoms of a vaginal ‘bearing-down’ sensation and recurrent urinary tract infection. Using the pelvic organ prolapse quantification (POP-Q) system, the patient clinically appeared to have a stage III anterior vaginal prolapse, with: point Aa descending to ⫹ 3 cm; point Ba descending to ⫹ 4 cm; point C descending to –1 cm; point D descending to –2 cm; point Ap descending to ⫹ 1 cm; and point Bp descending to ⫹ 1 cm, with the patient maximally strained in the lithotomy position (Figure 1A). Urodynamic finding did not reveal urinary incontinence. We decided to perform an anterior vaginal wall reconstruction using a monofilament polypropylene mesh and posterior colpoperineorrhaphy. Under general anaesthesia, the patient was placed in the lithotomy position. We inserted a Foley catheter into the urethra to drain urine. However, only a small amount of urine was drained and anterior vaginal prolapse was retained. We found pus-like discharge and urine at digital compression of anterior vaginal wall. A vertical midline incision of the anterior vaginal wall mucosa was done and the following dissection of the anterior vaginal wall was performed. A cystic mass of the anterior vaginal wall, rather than cystocele, was suspected. A needle aspiration in the cyst-like lesion was performed, and pus-like fluid was aspirated. We regarded this condition as an infected anterior vaginal wall cyst and consulted with a urologist for the evaluation of vaginal wall cyst. We performed a dissection around the bladder neck and periurethral tissue. The cyst proved to be a urethral diverticulum with the stalk attached to the upper half of urethra (Figure 1B). The urethral diverticulum extended to the deep pelvic cavity and adhered to the periurethral tissue. The urethral diverticulum was excised, and the submucosal and muscle layers of the urethra and periurethral fascia were closed with an absorbable suture. The specimen consisted of a portion of tan-coloured tissue, with dimensions of 7 ⫻ 4 ⫻ 1.5 cm. The patient was on continuous drainage for seven days and had an uneventful postoperative period. The patient was continent and a cystoscopic examination showed normal findings. Histopathological examination confirmed urethral diverticulum and chronic inflammation and ulceration.
Discussion Benign masses of the periurethral tissues are rare, occurring in 3–4% of patients, whereas those of the anterior vaginal wall are less common, with an estimated prevalence of about 1% (Blaivas et al. 2004). Periurethral or anterior vaginal wall cysts include: caruncle, periurethral cyst (Skene’s duct cyst), urethral prolapse, ectopic ureterocele, urethral diverticulum, vaginal wall cyst of embryonic origin (Müllerian and Gartner’s duct) and malignant neoplasm of urethral and vaginal origin (Fletcher and Lemack 2008).
Figure 1. (A) Physical examination revealing anterior vaginal wall prolapse. (B) After a midline incision of the anterior vaginal wall mucosa, urethral diverticulum was observed.
Urethral diverticulum is usually located anteriorly over the midurethra, usually reported in 1–6% of women (Keefe et al. 1991). Initial work-up of urethral diverticulum includes urethroscopy, followed by a voiding cystourethrogram (VCUG). VCUG is not 100% sensitive, however, and any index of suspicion for a diverticulum should initiate further evaluation with magnetic resonance imaging (MRI) (Foster et al. 2007). MRI is highly sensitive and has an excellent positive and negative predictive value. Treatment of urethral diverticulum consists of surgical excision, including complete and partial diverticulectomy and urethral reconstruction. However, urethral diverticulum located in the anterior vaginal wall can be mistaken for cystocele and an imaging study may be overlooked. Case reports about urethral diverticulum misdiagnosed cystocele are rare. Jadhav et al. (2010) reported a 48-year-old multiparous woman with urethral diverticulum mimicking an anterior vaginal wall prolapse. The authors commented that transvaginal ultrasound and MRI did not reveal the actual origin of the mass. In the case the gynaecologist was not familiar with urethral diverticulum because it was usually referred to the urologist. We did not perform preoperative imaging study because of the confirmation of cystocele. However, we suspected the anterior vaginal wall cyst by pelvic examination during operation for the following reasons. First, despite urinary catheterisation, the anterior vaginal wall prolapse was not retained. Second, the discharge of turbid material and urine was noted at digital compression. Third, despite anterior vaginal wall prolapse, uterine cervix was not descended. Fourth, a needle aspiration in cyst-like lesion showed pus-like fluid instead of urine. The inexperienced gynaecologist may overlook the anterior vaginal wall cyst and an unnecessary procedure may be done. Careful preoperative investigations should be undertaken to rule out anterior vaginal wall cysts,
Gynaecology Case Reports 451 such as urethral diverticulum in the event of an unusual finding of cystocele.
Conclusion In summary, a high index of suspicion of anterior vaginal wall cyst is needed in cases of unusual anterior vaginal wall prolapse. Urethral diverticulum can be difficult to diagnose clinically and initial work-up of urethral diverticulum includes urethroscopy, VCUG and MRI. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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References Blaivas JG, Flisser AJ, Bleustein CB et al. 2004. Periurethral masses: etiology and diagnosis in a large series of women. Obstetrics and Gynecology 103:842–847. Fletcher SG, Lemack GE. 2008. Benign masses of the female periurethral tissues and anterior vaginal wall. Current Urology Reports 9:389–396. Foster RT, Amundsen CL, Webster GD. 2007. The utility of magnetic resonance imaging for diagnosis and surgical planning before transvaginal periurethral diverticulectomy in women. International Urogynecology Journal and Pelvic Floor Dysfunction 18:315–319. Jadhav J, Koukoura O, Joarder R et al. 2010. Urethral diverticulum mimicking anterior vaginal wall prolapse: case report. Journal of Minimally Invasive Gynecology 17:390–392. Keefe B, Warshauer DM, Tucker MS et al. 1991. Diverticula of the female urethra; diagnosis by endovaginal and transperineal sonography. American Journal of Roentgenology 156:1195–1197.
Bilateral vulvar mass mimicking Bartholin’s gland abscess in the postpartum period: Klippel–Trenaunay Syndrome N. Güdücü1, S. S. Kutay3, N. Başsüllü2, H. İşçi1 & İ. Dünder1 Departments of 1Obstetrics and Gynecology, 2Pathology, Avrupa Hospıtal, İstanbul Bilim Unıversıty and 3Cardiovascular Surgery, Marmara University, İstanbul, Turkey DOI: 10.3109/01443615.2014.900002 Correspondence: N. Güdücü, Department of Obstetrics and Gynecology, İstanbul Bilim University, Kısıklı cad. No. 106 Altunizade, 34692, İstanbul, Turkey. E-mail: [email protected]
Introduction Klippel–Trenaunay Syndrome (KTS) is a rare disease characterised by cutaneous haemangiomas, venous varicosities, abnormalities of the deep venous and lymphatic system and hypertrophy of the soft tissues and bones (Klippel and Trenaunay 1900). Vascular malformations may impair venous return and may cause venous pooling, as a result the risk of thromboembolic events increases. Blood trapped within vascular malformations may lead to destruction of platelets and a consumption coagulopathy may appear consequently. Pregnancy and the postpartum period are hypercoagulable states with increased risk of thromboembolic phenomena and may exacerbate the complications of KTS. We report a patient who presented with thrombosed vulvar haemangiomas in the postpartum period.
Figure 1. Multiloculated cavernous areas filled with blood (⫻ 40).
any complications. On physical examination, the left vulvar swelling was painful with palpation and looked like Bartholin’s gland abscess. We made a longitudinal incision to perform marsupialisation, but we drained a haematoma from a multilocular structure and then we excised the multilocular mass with very difficult dissection. Pathological examination of the mass revealed a cavernous haemangioma (Figures 1 and 2). Four days later, she presented with a similar mass on the right side of the vulva. The mass was painful, therefore it was excised with a similar operation and the pathological examination confirmed again as cavernous haemangioma. The vulvar masses did not look like typical vulvar varicoses at physical examination. In her last pregnancy, the patient had left-leg swelling, which disappeared spontaneously. She did not receive anticoagulant therapy during her first and last pregnancies. After removal of vulvar haemangiomas, we started treatment with low molecular weight heparin and advised elastic compressive stockings after consultation with a cardiovascular surgeon. MRI angiography revealed multiple haemangiomas at various sites of the body. The report conforms with the ethical guidelines of the Declaration of Helsinki.
Discussion KTS is a congenital disease with unknown aetiology. Complications related to vascular malformations increase with intervening conditions that predispose thromboembolic events. Our patient achieved pregnancy by in vitro fertilisation and gonadotropins used during this procedure are reported to increase the risk of thromboembolic events (Ulug et al. 2003). Anticoagulation with low molecular weight heparin is advised at the initiation of gonadotropins; then it is suspended for twelve hours before oocyte retrieval (Martin et al. 2011). The protocol should continue for at least one month and then during
Case report A 48-year-old woman presented with left-sided swelling and pain in the vulva to the gynaecology outpatient clinic of İstanbul Bilim University Avrupa Hospital. She had conceived with in vitro fertilisation and 20 days ago, she had delivered triplets with caesarean section at 34 gestational weeks of pregnancy. This was her second pregnancy; she had another caesarean section ten years ago without
Figure 2. Cavernous areas are lined by endothelial cells (⫻ 400).
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Urethral diverticulum misdiagnosed with cystocele S. W. Lee, M. S. Kim, H. J. Hwang, Y. H. Chung & S. J. Lee To cite this article: S. W. Lee, M. S. Kim, H. J. Hwang, Y. H. Chung & S. J. Lee (2014) Urethral diverticulum misdiagnosed with cystocele, Journal of Obstetrics and Gynaecology, 34:5, 450-450 To link to this article: http://dx.doi.org/10.3109/01443615.2014.899331
Published online: 02 Apr 2014.
Submit your article to this journal
Article views: 36
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [University of Florida]
Date: 11 November 2015, At: 21:56
450
Gynaecology Case Reports
Urethral diverticulum misdiagnosed with cystocele S. W. Lee1, M. S. Kim1, H. J. Hwang1, Y. H. Chung1 & S. J. Lee2 Departments of 1Obstetrics and Gynecology and 2Urology, College of Medicine, the Catholic University of Korea DOI: 10.3109/01443615.2014.899331 Correspondence: S.-J. Lee, Department of Urology, St. Vincent’s Hospital, 93-6 Ji-dong, Paldal-gu, Suwon 442–723, Korea. E-mail: [email protected]
Downloaded by [University of Florida] at 21:56 11 November 2015
Introduction Vaginal wall cysts are estimated to affect about 0.5–1% of women and are classified as an embryologic derivative, ectopic tissue or urologic abnormality (Blaivas et al. 2004). Urethral diverticulum in females can be easily detected by physical examination. However, sometimes diagnosis can be difficult. The gynaecologist may only rarely encounter cystic formation of the anterior vaginal wall and so may misdiagnose it as cystocele. We present a case of urethral diverticulum misdiagnosed as cystocele during surgery.
Case report A 49-year-old gravida 3, para 3 woman visited our hospital with symptoms of a vaginal ‘bearing-down’ sensation and recurrent urinary tract infection. Using the pelvic organ prolapse quantification (POP-Q) system, the patient clinically appeared to have a stage III anterior vaginal prolapse, with: point Aa descending to ⫹ 3 cm; point Ba descending to ⫹ 4 cm; point C descending to –1 cm; point D descending to –2 cm; point Ap descending to ⫹ 1 cm; and point Bp descending to ⫹ 1 cm, with the patient maximally strained in the lithotomy position (Figure 1A). Urodynamic finding did not reveal urinary incontinence. We decided to perform an anterior vaginal wall reconstruction using a monofilament polypropylene mesh and posterior colpoperineorrhaphy. Under general anaesthesia, the patient was placed in the lithotomy position. We inserted a Foley catheter into the urethra to drain urine. However, only a small amount of urine was drained and anterior vaginal prolapse was retained. We found pus-like discharge and urine at digital compression of anterior vaginal wall. A vertical midline incision of the anterior vaginal wall mucosa was done and the following dissection of the anterior vaginal wall was performed. A cystic mass of the anterior vaginal wall, rather than cystocele, was suspected. A needle aspiration in the cyst-like lesion was performed, and pus-like fluid was aspirated. We regarded this condition as an infected anterior vaginal wall cyst and consulted with a urologist for the evaluation of vaginal wall cyst. We performed a dissection around the bladder neck and periurethral tissue. The cyst proved to be a urethral diverticulum with the stalk attached to the upper half of urethra (Figure 1B). The urethral diverticulum extended to the deep pelvic cavity and adhered to the periurethral tissue. The urethral diverticulum was excised, and the submucosal and muscle layers of the urethra and periurethral fascia were closed with an absorbable suture. The specimen consisted of a portion of tan-coloured tissue, with dimensions of 7 ⫻ 4 ⫻ 1.5 cm. The patient was on continuous drainage for seven days and had an uneventful postoperative period. The patient was continent and a cystoscopic examination showed normal findings. Histopathological examination confirmed urethral diverticulum and chronic inflammation and ulceration.
Discussion Benign masses of the periurethral tissues are rare, occurring in 3–4% of patients, whereas those of the anterior vaginal wall are less common, with an estimated prevalence of about 1% (Blaivas et al. 2004). Periurethral or anterior vaginal wall cysts include: caruncle, periurethral cyst (Skene’s duct cyst), urethral prolapse, ectopic ureterocele, urethral diverticulum, vaginal wall cyst of embryonic origin (Müllerian and Gartner’s duct) and malignant neoplasm of urethral and vaginal origin (Fletcher and Lemack 2008).
Figure 1. (A) Physical examination revealing anterior vaginal wall prolapse. (B) After a midline incision of the anterior vaginal wall mucosa, urethral diverticulum was observed.
Urethral diverticulum is usually located anteriorly over the midurethra, usually reported in 1–6% of women (Keefe et al. 1991). Initial work-up of urethral diverticulum includes urethroscopy, followed by a voiding cystourethrogram (VCUG). VCUG is not 100% sensitive, however, and any index of suspicion for a diverticulum should initiate further evaluation with magnetic resonance imaging (MRI) (Foster et al. 2007). MRI is highly sensitive and has an excellent positive and negative predictive value. Treatment of urethral diverticulum consists of surgical excision, including complete and partial diverticulectomy and urethral reconstruction. However, urethral diverticulum located in the anterior vaginal wall can be mistaken for cystocele and an imaging study may be overlooked. Case reports about urethral diverticulum misdiagnosed cystocele are rare. Jadhav et al. (2010) reported a 48-year-old multiparous woman with urethral diverticulum mimicking an anterior vaginal wall prolapse. The authors commented that transvaginal ultrasound and MRI did not reveal the actual origin of the mass. In the case the gynaecologist was not familiar with urethral diverticulum because it was usually referred to the urologist. We did not perform preoperative imaging study because of the confirmation of cystocele. However, we suspected the anterior vaginal wall cyst by pelvic examination during operation for the following reasons. First, despite urinary catheterisation, the anterior vaginal wall prolapse was not retained. Second, the discharge of turbid material and urine was noted at digital compression. Third, despite anterior vaginal wall prolapse, uterine cervix was not descended. Fourth, a needle aspiration in cyst-like lesion showed pus-like fluid instead of urine. The inexperienced gynaecologist may overlook the anterior vaginal wall cyst and an unnecessary procedure may be done. Careful preoperative investigations should be undertaken to rule out anterior vaginal wall cysts,
Gynaecology Case Reports 451 such as urethral diverticulum in the event of an unusual finding of cystocele.
Conclusion In summary, a high index of suspicion of anterior vaginal wall cyst is needed in cases of unusual anterior vaginal wall prolapse. Urethral diverticulum can be difficult to diagnose clinically and initial work-up of urethral diverticulum includes urethroscopy, VCUG and MRI. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Downloaded by [University of Florida] at 21:56 11 November 2015
References Blaivas JG, Flisser AJ, Bleustein CB et al. 2004. Periurethral masses: etiology and diagnosis in a large series of women. Obstetrics and Gynecology 103:842–847. Fletcher SG, Lemack GE. 2008. Benign masses of the female periurethral tissues and anterior vaginal wall. Current Urology Reports 9:389–396. Foster RT, Amundsen CL, Webster GD. 2007. The utility of magnetic resonance imaging for diagnosis and surgical planning before transvaginal periurethral diverticulectomy in women. International Urogynecology Journal and Pelvic Floor Dysfunction 18:315–319. Jadhav J, Koukoura O, Joarder R et al. 2010. Urethral diverticulum mimicking anterior vaginal wall prolapse: case report. Journal of Minimally Invasive Gynecology 17:390–392. Keefe B, Warshauer DM, Tucker MS et al. 1991. Diverticula of the female urethra; diagnosis by endovaginal and transperineal sonography. American Journal of Roentgenology 156:1195–1197.
Bilateral vulvar mass mimicking Bartholin’s gland abscess in the postpartum period: Klippel–Trenaunay Syndrome N. Güdücü1, S. S. Kutay3, N. Başsüllü2, H. İşçi1 & İ. Dünder1 Departments of 1Obstetrics and Gynecology, 2Pathology, Avrupa Hospıtal, İstanbul Bilim Unıversıty and 3Cardiovascular Surgery, Marmara University, İstanbul, Turkey DOI: 10.3109/01443615.2014.900002 Correspondence: N. Güdücü, Department of Obstetrics and Gynecology, İstanbul Bilim University, Kısıklı cad. No. 106 Altunizade, 34692, İstanbul, Turkey. E-mail: [email protected]
Introduction Klippel–Trenaunay Syndrome (KTS) is a rare disease characterised by cutaneous haemangiomas, venous varicosities, abnormalities of the deep venous and lymphatic system and hypertrophy of the soft tissues and bones (Klippel and Trenaunay 1900). Vascular malformations may impair venous return and may cause venous pooling, as a result the risk of thromboembolic events increases. Blood trapped within vascular malformations may lead to destruction of platelets and a consumption coagulopathy may appear consequently. Pregnancy and the postpartum period are hypercoagulable states with increased risk of thromboembolic phenomena and may exacerbate the complications of KTS. We report a patient who presented with thrombosed vulvar haemangiomas in the postpartum period.
Figure 1. Multiloculated cavernous areas filled with blood (⫻ 40).
any complications. On physical examination, the left vulvar swelling was painful with palpation and looked like Bartholin’s gland abscess. We made a longitudinal incision to perform marsupialisation, but we drained a haematoma from a multilocular structure and then we excised the multilocular mass with very difficult dissection. Pathological examination of the mass revealed a cavernous haemangioma (Figures 1 and 2). Four days later, she presented with a similar mass on the right side of the vulva. The mass was painful, therefore it was excised with a similar operation and the pathological examination confirmed again as cavernous haemangioma. The vulvar masses did not look like typical vulvar varicoses at physical examination. In her last pregnancy, the patient had left-leg swelling, which disappeared spontaneously. She did not receive anticoagulant therapy during her first and last pregnancies. After removal of vulvar haemangiomas, we started treatment with low molecular weight heparin and advised elastic compressive stockings after consultation with a cardiovascular surgeon. MRI angiography revealed multiple haemangiomas at various sites of the body. The report conforms with the ethical guidelines of the Declaration of Helsinki.
Discussion KTS is a congenital disease with unknown aetiology. Complications related to vascular malformations increase with intervening conditions that predispose thromboembolic events. Our patient achieved pregnancy by in vitro fertilisation and gonadotropins used during this procedure are reported to increase the risk of thromboembolic events (Ulug et al. 2003). Anticoagulation with low molecular weight heparin is advised at the initiation of gonadotropins; then it is suspended for twelve hours before oocyte retrieval (Martin et al. 2011). The protocol should continue for at least one month and then during
Case report A 48-year-old woman presented with left-sided swelling and pain in the vulva to the gynaecology outpatient clinic of İstanbul Bilim University Avrupa Hospital. She had conceived with in vitro fertilisation and 20 days ago, she had delivered triplets with caesarean section at 34 gestational weeks of pregnancy. This was her second pregnancy; she had another caesarean section ten years ago without
Figure 2. Cavernous areas are lined by endothelial cells (⫻ 400).
