Uterine Prolapse: A Benign Condition?
Various mechanisms for how uterovaginal prolapse causes hydroureteronephrosis have been described. Although the prevalence of hydroureteronephrosis in uterine prolapse is not negligible, hydroureteronephrosis remains a rare cause of renal failure. Geriatricians and other healthcare providers treating the older patient should be aware of the significant morbidity and potential mortality associated with uterine prolapse. We present the case of an 82-year-old woman with sepsis and renal failure caused by obstructive uropathy secondary to complete uterovaginal prolapse. The prolapsed was reduced, but the patient developed septic complications and died.
An 82-year-old woman presented to the emergency department (ED) of a district general hospital with an acute deterioration in cognition and functional ability. The patient’s daughter, who accompanied her to the ED, reported that she had become increasingly confused and frail over the past few months, with a sharp decline in the past week. Blood tests taken in the ED revealed raised inflammatory markers and renal failure (serum creatinine, 4.23 mg/dL). No previous blood results were available for comparison. The patient was admitted to the hospital.
Following assessment by the on-call medical team, the initial clinical impression was of venous ulcer–related cellulitis of the left leg, with secondary dehydration causing renal failure. She was treated with appropriate intravenous antibiotic therapy and intravenous fluid resuscitation. Despite these measures, the patient’s renal function failed to improve by the next morning, and the medical consultant requested that a urinary catheter be placed. A geriatric consultation was also requested, and she was scheduled to be transferred to the hospital’s acute geriatric unit. Attempts at urethral catheterization by the ward nursing staff both before and after the patient’s transfer to the acute geriatric unit failed, and they reported that she had procidentia (complete uterovaginal prolapse). Subsequent attempts at urethral catheterization by urologists and gynecologists at the same facility were, unfortunately, also unsuccessful. The patient’s uterus was ulcerated, and the administration of topical estrogens and strong opioid analgesia at renal doses to control her pain was required. The antibiotic regimen was broadened to cover anaerobes as her inflammatory markers continued to climb.
Despite receiving continued intravenous fluid support, the patient’s creatinine level rose from 4.23 mg/dL (estimated glomerular filtration rate [eGFR], 9 mL/min/1.73 m2) on admission to 6.64 mg/dL (eGFR, 5 mL/min/1.73 m2) 4 days after admission, with no subsequent improvement. Renal ultrasonography revealed bilateral hydrocalyces, hydropelvis with bilateral proximal hydroureters, and an empty bladder.
Once the diagnosis of acute renal failure secondary to obstructive uropathy was made, urology and gynecology consultations were sought. Management options included bilateral nephrostomy insertion, reduction of the uterine prolapse, or hysterectomy. The patient had displayed hypoactive delirium throughout her admission and did not have the capacity to make healthcare decisions. After a discussion involving the geriatric, urology, and gynecology teams and the patient’s daughter, the decision was made to proceed with reduction of the uterovaginal prolapse under a general anesthetic and insertion of a urinary catheter. Following this procedure, the patient’s renal function improved with good urine output. Unfortunately, her clinical condition failed to improve in tandem with the biochemical improvement and she developed septic shock. The septic shock was thought to be related both to the reduction of the procidentia and the ongoing sepsis from her venous ulcers. In view of her frailty and poor premorbid functional status, the decision was made in consultation with her family to provide palliative care. The patient died peacefully 2 days later.
We present this case to highlight two issues: first, uterovaginal prolapse as a relatively rare cause of obstructive uropathy in women; and, second, the dilemma posed by choosing the best management strategy for bilateral ureteric obstruction caused by complete uterovaginal fistula. Although the decision to reduce the procidentia was a team decision involving all relevant specialties, the concern, which may have been realized, was that the reduction of an ulcerated uterus might put the patient at risk of septic complications. Conversely, the insertion of bilateral nephrostomies and hysterectomy in a frail elderly woman also carry significant risk.
While there are several case reports of obstructive uropathy following procidentia in the literature dating back to 1824,1 this condition remains fairly uncommonly encountered and poorly understood.2-4 Several mechanisms of procidentia-induced ureteric obstruction and renal failure have been proposed. In the 1970s, it was postulated that the lateral cervical ligaments (Mackenrodt’s ligament) compress the ureters as the uterus descends.5 Other authors later suggested that the ureters may become trapped by the hiatus genitalis against the fundus of a fully prolapsed uterus.6 More recently, the literature has expanded on this theory, suggesting that it may be the downward traction of the uterine arteries causing the bladder trigone and lower ureters to be dragged outside the pelvis, thus trapping the ureters.7
Uterine prolapse is known to be common, but estimates of its prevalence vary widely according to the differing population studied, with rates increasing with both advancing age and parity. A Swedish study found that 55% of women between 50 and 59 years of age had some degree of prolapse on clinical examination,8 and a UK study examining postmenopausal women reported rates of approximately 40% for all degrees of vaginal prolapse, with 6% of cases classified as severe.9
Uterine prolapse is associated with considerable morbidity due to its effects on bowel and bladder function, its interference with sexual activity, and the propensity for patients with prolapse to develop recurrent urinary tract infections. Beverly et al10 reported a prevalence of hydronephrosis of 7.7% in patients undergoing surgery for pelvic organ prolapse. The majority of these cases were deemed mild, and only two cases (0.6%) showed biochemical evidence of renal failure. In rare cases, uterine prolapse is associated with end-stage renal failure necessitating hemodialysis despite invasive management with JJ stenting and intravaginal ring insertion.11
Due to the frequency with which geriatricians and acute physicians encounter renal impairment in acutely ill older adults, it is important not to miss potentially reversible obstructive causes. While this is often high on the list of differential diagnoses in older men due to prostatic pathology, it may be easy to overlook in older women. As uterine prolapse is common but often not reported by patients, it is important that healthcare professionals are aware of the significant morbidity and potential mortality of this condition. The case we describe is rare, but it serves as a reminder that conditions we often consider to be benign, such as uterine prolapse, can have fatal consequences.
The authors report no relevant financial relationships.
1. Froriep R. Chirurgische Kupfertafeln. Weimar, Germany: 1824.
2. Chuang FR, Lee CH, Chen CS, Weng HH, Wang IK. Bilateral moderate hydroureteronephrosis due to uterine prolapse: two case reports and review of the literature. Ren Fail. 2003;25(5):879-884.
3. Stabler J. Uterine prolapse and urinary tract obstruction. Br J Radiol. 1977;50(595):493-498.
4. Sudhakar AS, Reddi VG, Schein M, Gerst PH. Bilateral hydroureter and hydronephrosis causing renal failure due to a procidentia uteri: a case report. Int Surg. 2001;86(3):173-175.
5. Chapman RH. Ureteric obstruction due to uterine prolapse. Br J Urol. 1975;47(5):531-534.
6. Hadar H, Meiraz D. Total uterine prolapse causing hydroureteronephrosis. Surg Gynecol Obstet. 1980;150(5):711-714.
7. Yanik FF, Akpolat T, Koçak I. Acute renal failure—an unusual consequence of uterine prolapse. Nephrol Dial Transplant. 1998;13(10):2648-2650.
8. Bland DR, Earle BB, Vitolins MZ, et al. Use of the Pelvic Organ Prolapse staging system of the International Continence Society, American Urogynecologic Society, and Society of Gynecologic Surgeons in perimenopausal women. Am J Obstet Gynecol. 1999;181:1324-1328.
9. Versi E, Harvey MA, Cardozo L, et al. Urogenital prolapse and atrophy at menopause: a prevalence study. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12:107-110.
10. Beverly CM, Walters MD, Weber AM, Piedmonte MR, Ballard LA. Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 1997;90(1):37-41.
11. Sanai T, Yamashiro Y, Nakayama M, Uesugi N, Kubo N, Iguchi A. End-stage renal failure due to total uterine prolapse. Urology. 2006;67(3):622.e5-622.e7.