Procidentia as a Cause of Obstructive Uropathy and Acute Kidney Injury

Abstract

Pelvic organ prolapse can affect urinary tract function by reducing flow rates and increasing post void residual urine volumes secondary to outlet obstruction. If the diagnosis is missed or left untreated, pelvic organ prolapse can lead to acute renal injury, chronic renal failure or even end stage renal disease. Herein, we present a case of a patient who presented to Albert Einstein Medical Center in Philadelphia, PA with urinary retention and acute kidney injury secondary to complete uterine prolapse, also referred to as procidentia.

Introduction

Pelvic organ prolapse is a common cause of both obstructive and irritative urinary symptoms. It is estimated that as much as 50% of parous women living in the United States will be affected by pelvic organ prolapse [1]. However, only 10-20% will seek medical care to resolve their symptoms, 11% requiring surgery at least once in their lifetime [1]. Although often asymptomatic, these complaints may include vaginal fullness, sacral back or abdominal pain, dyspareunia, urinary frequency, urgency, dysuria and even difficulty voiding [2]. Pelvic organ prolapse can affect the urinary tract function by reducing flow rates and increasing the post void residual urine volumes secondary to outlet obstruction [3]. If the diagnosis is missed or left untreated, pelvic organ prolapse can lead to acute renal injury, chronic renal failure or even end stage renal disease [4]. Herein, we present a case of a patient who presented to Albert Einstein Medical Center in Philadelphia, with urinary retention and acute kidney injury secondary to complete uterine prolapse, also referred to as procidentia.

Case Report

An 85-year-old female was sent to the emergency room with 3 days of intermittent abdominal pain. Per nursing home records, the pain was mostly focused at the left lower quadrant and suprapubic regions. Her past medical history was significant for hypertension, diabetes mellitus, dementia, gout, atrial fibrillation, gastroesophageal reflux disease and a venous thromboembolism. On the day of admission, her labs revealed a WBC count of 10.4×10³/dl, Hb of 13.1g/dl and creatinine level of 2.1 mg/dl. Previous admissions showed that the patient's baseline creatinine was 1.0 mg/dl. Her urine analysis also revealed the presence of WBCs and RBCs. She was admitted to the medicine service with the diagnosis of acute kidney injury. She was initially hydrated and a renal bladder ultrasound was ordered, which showed bilateral mild to moderate hydroureteronephrosis and a distended bladder. The nursing staff and primary team were unable to place the foley catheter.

Urology was then consulted for urinary retention and difficult catheterization. Given the patient's dementia, she was unable to provide with an adequate history of presentation. On physical examination, her abdomen was soft, not-tender and non-distended. All vital signs were within normal limits. She had significant suprapubic tenderness to palpation, but no costovertebral angle tenderness. On pelvic exam, the patient was noted to have complete, grade 4, uterine prolapse. The urethral meatus was easily visualized, however, the catheter would not pass through the patient's urethra. After bedside manual reduction, a 16-french Foley catheter was placed without difficulty and instantly drained 600 ml of yellow urine. We recommended that the foley catheter stay in place until the creatinine nadirs, a repeat ultrasound to ensure the hydronephrosis resolved and for the gynecologic team to evaluate the patient. The gynecologic service was consulted and determined that due to her age and medical history, the patient was a poor surgical candidate. She therefore was fitted for a Gellhorn pessary size 3.5. After 2-3 days, her creatinine improved to 1.2 mg/dl and she was discharged with a foley catheter in place.

Discussion

Pelvic organ prolapse is a condition that often affects the urinary tract and can result in acute kidney injury secondary to obstruction. Proposed pathophysiologic mechanisms include kinking of the urethra or the bilateral ureters leading to an obstructive uropathy. In this case, we hypothesize the etiology of our patient's uropathy was secondary to a urethral obstruction, due to the imaging findings of both a distended bladder and bilateral hydroureteronephrosis. As the incidence of procidentia is proportional to increasing age, it is imperative that a gynecologic exam be performed in all women presenting with urinary obstruction or hydroureteronephrosis with an unknown cause [4]. The patient described was an elderly female who had complete uterine prolapse causing a urinary outlet obstruction, which led to her acute kidney injury. Our patient's history of dementia prevented her to have complaints of urinary dysfunction or a “bulge” as an outpatient that may have prevented this admission. This case also emphasizes the importance of an adequate physical examination, despite lack of a satisfactory history in a patient with dementia.

Due to being a poor surgical candidate, the patient was treated with a pessary. Pessary insertion is a conservative alternative approach that should be considered in patients who are poor surgical candidates. Although rare, complications can include vaginal discharge, odor, rectovaginal fistula, vesicovaginal fistula, and erosion [5].

There have been other reports of similar occurrences. Moslemi et al. [4] described two cases of women in their 8th decade with severe pelvic organ prolapse, secondary bilateral hydronephrosis and obstructive renal failure. One patient was initially treated with bilateral percutaneous nephrostomy tubes and eventual vaginal pessary placement, while the other patient was surgically managed with burch colposuspension and temporary double J stent insertion. Hydronephrosis and elevated creatinine resolved in both cases.

In another recent report, Yilmaz et al. [6] presented a case of procidentia causing bilateral ureteral obstruction. It was diagnosed with antegrade pyelography revealing a lack of contrast reaching the bladder and bilateral hydronephrosis. It was described that the ureteral compression was caused by the prolapsed uterus pushing on the bladder causing increased intraureteral pressure, positional changes, tension, and ureteral mucosal edema. The patient was temporarily treated with bilateral nephrostomy tubes and definitively treated with hysterectomy.

Another study out of Rush-Presebyterian-St. Luke's Medical Center showed an 89% success rate of normalizing post void residuals after surgical correction of pelvic prolapse [3]. Surgery, however, should not be considered for all patients as it does have adverse effects. In a study performed by Panicker et al. [2], difficulty in voiding was improved in all patients, yet no improvement of urinary frequency and, in fact, a rise in diurnal urinary frequency and dysuria occurred. Four out of the 50 patients (8%) studied developed stress urinary incontinence postoperatively.

In patients presenting with urinary dysfunction, suspicion must remain high as to pelvic organ prolapse being the causative agent. Without rapid correction of this anatomical obstruction, permanent renal damage may occur. Bae et al. [7] reported a case of a 74-year-old female complaining of general weakness and anorexia for twenty days. It was later discovered that she had a creatinine of 12.35 mg/dl and hydronephrosis induced by her uterine prolapse. Despite catheterization and hemodialysis, renal function was never recovered and the patient remained in end stage renal disease.

Conclusion

Procidentia is a rare, but potentially reversible, cause of kidney injury due to urethral or ureteral obstruction. Pessaries and surgical correction are the two modalities used to correct pelvic organ prolapse. Although both treatments may be successful, individual factors should be considered to determine which to use. Further studies should be performed to compare the effectiveness of pessaries and surgical correction in resolving urinary dysfunction.