
==== Front
Urol Case Rep
Urol Case Rep
Urology Case Reports
2214-4420
Elsevier

S2214-4420(24)00146-3
10.1016/j.eucr.2024.102792
102792
Functional Urology
Acute urinary retention from hyperangulation of the urinary bladder neck secondary to uterine leiomyoma, a case report
Poston Courtney postonc2@ccf.org
a⁎
Odunlami Titilopemi b
Hurtado Eric c
a Department of Gynecology, Cleveland Clinic Florida, Weston, FL, USA
b American University of the Caribbean School of Medicine, Miramar, FL, USA
c Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Gynecology, Cleveland Clinic Florida, Weston, FL, USA
⁎ Corresponding author. Department of Minimally Invasive Gynecologic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, 33331, USA. postonc2@ccf.org
09 7 2024
9 2024
09 7 2024
56 10279225 6 2024
2 7 2024
8 7 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
We present a case of acute urinary retention (AUR) with hyper-angulation of the urinary bladder neck secondary to uterine leiomyoma. Our patient is a 45-year-old female who presented with AUR and suprapubic pain requiring catheterization. CT images highlight the level of obstruction secondary to suspension of the urinary bladder rather than direct urethral compression. This case highlights this unique manifestation of AUR demonstrating the necessity for understanding its different mechanisms. Clinicians should maintain a high index of suspicion for AUR in patients with leiomyoma and lower urinary tract symptoms. Heightened awareness and timely intervention are crucial in preventing potential complications.

Keywords

Urinary retention
Acute urinary retention
Uterine leiomyoma
Colposuspension
Female voiding dysfunction
==== Body
pmc1 Introduction

Acute urinary retention (AUR) is a rare urologic emergency involving a sudden inability to urinate. This condition is rare among women, occurring at a rate of 3–7 cases per 100,000 annually.1 Various mechanisms can contribute to AUR, including outflow obstruction, neurological dysfunction, or impaired detrusor muscle function.2 Obstetric and Gynecologic conditions can also be associated with AUR such as benign or malignant pelvic tumors, postoperative effects, or postpartum vulvar edema. This case focuses on uterine leiomyoma as a cause of acute urinary retention.

Uterine leiomyomas are the most prevalent benign uterine tumors, predominantly affecting reproductive-age women. Approximately 26 million women in the United States are estimated to have uterine leiomyoma, with around 80 % of African-American women and 70 % of Caucasian women diagnosed by age 50.3 Women with symptomatic uterine leiomyoma usually present with one or a combination of three symptoms, pelvic pain, abnormal uterine bleeding, or pelvic pressure/bulk symptoms. The varying intensity and frequency of symptoms, such as pelvic pain and abnormal uterine bleeding, emphasize the necessity of a multidisciplinary approach to effectively address the impact on a patient's quality of life.3

Acute urinary retention remains a rare presentation of symptomatic uterine leiomyoma. Proposed mechanisms for AUR include direct compression by fibroids on the bladder neck or urethra, directly obstructing urine flow or hyper-elevation of the bladder neck causing a “kinking” of the urethra similar to an over tensioned retropubic colposuspension.4

Diagnosis of AUR involves a comprehensive assessment of medical history, physical examination, and imaging studies. Published evidence linking AUR to uterine leiomyomas remains limited, and existing guidelines lack precise directives for the management of AUR in this context.1 Although there are no standardized guidelines for treatment of AUR secondary to uterine leiomyoma, short-term treatment often involves urethral catheterization to facilitate bladder emptying in those with urinary retention. Surgical intervention usually is the best long-term solution to alleviate the obstruction.4 We present a case of acute urinary retention with hyperangulation of the urinary bladder neck secondary to uterine leiomyoma.

2 Case presentation

We present a case of acute urinary retention with hyperangulation of the urinary bladder neck secondary to uterine leiomyoma. Our patient is a 45 year old female who presented to the emergency department with acute urinary retention and suprapubic pain, ultimately requiring foley catheterization. Computed tomography (CT) of the abdomen/pelvis (Fig. 1) demonstrated a posterior leiomyoma causing cephalad displacement of the uterus with resultant hyperangulation of the bladder neck, similar to the mechanism of urinary continence achieved with an over-tensioned retropubic colposuspension. CT images highlight the level of obstruction secondary to suspension of the urinary bladder as seen in Fig. 1, rather than direct urethral compression. The patient otherwise denied concomitant abnormal uterine bleeding or pelvic pain. The patient ultimately underwent definitive surgical management with total laparoscopic hysterectomy. Postoperatively, her foley catheter was removed and her acute urinary retention and suprapubic pain resolved.Fig. 1 Non-Contrast Computed Tomography Abdomen/Pelvis image with foley catheter in place, demonstrating mechanism of retention by suspension of urinary bladder neck by posterior uterine leiomyoma. Yellow outline demonstrating urinary bladder. Pink outline demonstrating uterus. Blue outline demonstrating posterior uterine myoma. Red arrow demonstrating urinary bladder neck. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 1

3 Conclusion

The rarity of AUR in association with fibroids underlines the importance of awareness and a comprehensive diagnostic approach in patients with urinary retention and fibroids. Physical exam of the urethral angle with a noted hyper-elevation of the bladder neck or direct compression of fibroids upon the urethra should lead to consideration of the fibroid as a cause of AUR.

Imaging studies, including non-contrast computed tomography and pelvic ultrasound, also may play a crucial role in identifying the anatomical relationship between the fibroid and the urinary bladder, revealing the mechanism of urinary retention. Integrating patient history, physical examination, and imaging studies, is fundamental in coming to a diagnosis and expediting appropriate management.

This case sheds light on the unique manifestation of acute urinary retention in the presence of fibroids without direct compression of the urethra, highlighting the necessity for understanding the many different mechanisms of AUR. Clinicians should exercise caution and maintain a high index of suspicion for AUR in patients with fibroids and direct uretha/bladder neck compression or hyperangulation of the bladder neck who also have lower urinary tract symptoms. Heightened awareness and timely intervention are crucial in preventing potential complications and avoiding numerous trips to the emergency department and/or repeated catheterization. Further research and reporting of similar cases are imperative to enhance the understanding, incidence, and management of this unusual but significant clinical case.

Disclosure statement

The authors declare that they have no declarations of interest and nothing to disclose.

CRediT authorship contribution statement

Courtney Poston: Writing – review & editing, Writing – original draft, Visualization, Supervision, Resources. Titilopemi Odunlami: Writing – original draft. Eric Hurtado: Writing – review & editing, Supervision.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
==== Refs
References

1 Leslie S.W. Rawla P. Dougherty J.M. Female urinary retention. 2023 may 30 [Internet] StatPearls 2023 Jan StatPearls Publishing Treasure Island (FL) PMID: 30860732
2 Wu C.Q. Lefebvre G. Frecker H. Husslein H. Urinary retention and uterine leiomyomas: a case series and systematic review of the literature Int Urogynecol J 26 9 2015 Sep 1277 1284 10.1007/s00192-015-2665-1 Epub 2015 Mar 10. PMID: 25752469 25752469
3 Giuliani E. As-Sanie S. Marsh E.E. Epidemiology and management of uterine fibroids Int J Gynaecol Obstet 149 1 2020 Apr 3 9 10.1002/ijgo.13102 Epub 2020 Feb 17. PMID: 31960950 31960950
4 Mavromatidis G. Dinas K. Mamopoulos A. Delkos D. Rousso D. Acute urinary retention due to a uterine fibroid in a non-pregnant woman Clin Exp Obstet Gynecol 36 1 2009 62 63 PMID: 19400423 19400423
