British Journal of Radiology (2005) 78, 675-676
© 2005 British Institute of Radiology
doi: 10.1259/bjr/13018586
Incidental finding on abdominal CT scan
J M Hanson, FFRRCSI, FRCR
Vascular and Interventional Radiology, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
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Introduction
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A 70-year-old female patient was being investigated for a 1-year history of chronic fatigue, lassitude and poor appetite. She was previously healthy. She had no past medical history of note; she had six full term pregnancies. She was taking anxiolytics for occasional panic attacks.
Her biochemistry revealed normal renal function, with a urea of 5.2 µmol l–1 and creatinine of 67 mmol l–1. She had an abnormal haematological profile and a CT scan was performed to exclude lymphomatous nodal disease. What is indicated from the CT (Figures 1 and 2
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Diagnosis and discussion
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The diagnosis is gross bilateral hydronephroureter, caused by prolapse of the pelvic floor.
The CT scan did not demonstrate any nodal disease, but revealed gross bilateral hydronephroureter. The obstruction was caused by prolapse of pelvic organs, with the bladder apex noted to be within the perineum, between the labia minora. The patient denied any symptoms related to her hydronephrosis which was an incidental finding her CT examination.
Hydronephroureter is a recognized complication of pelvic floor prolapse. It was first described in 1824 by Fiorep [1]. The incidence is variable, recent publications list prevalence of 25/323 (7.7%) and 31/189 (17.4%) [2, 3]. The hydronephrosis can be unilateral. The prevalence of hydronephrosis is higher in older patients and increases with increasing severity of prolapse. After adjusting for age and type of prolapse, those with uterine prolapse were more at risk of hydronephrosis [2, 3]. There is still debate as to the exact cause of the hydronephrosis. It has been postulated that with the laxity of the pelvic floor, the cardinal ligaments, which arch over the ureters prior to inserting into the cervix pull the ureters inferiorly causing them to kink. This does not fully explain the pathogenesis and it is most likely multifactorial, involving ligament laxity and the degree of prolapse [3]. If left untreated, there may be progressive deterioration in renal function.
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Figure 3. This midline sagittal reconstructed image demonstrates the pelvic organs prolapsed below the pubococcygeal line (black line). Note the fluid in the prolapsed bladder (white arrow).
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Figure 4. (a, b) Coronal reformatted images, note (a) the cystocoele (white arrow) and (b) the dilated ureters (arrowheads).
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Figure 5. Single axial CT slice showing the levator muscle loop (arrowheads). The distal right ureter is marked extending below this (white arrow).
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Figure 6. Lower pelvic axial CT slice, showing the distal extent of the prolapse, with the cystocoele extending into the introitus, note air anterior to the cystocoele in the introitus.
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Received for publication October 18, 2004.
Revision received February 8, 2005.
Accepted for publication February 24, 2005.
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References
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- Brettauer J, Ruben IC. Hydroureter and hydronephrosis: a frequent secondary finding in cases of prolapse of the uterus and bladder. Am J Obstet Gynecol 1923;6:696–709.
- Gemer O, Bergman M, Segal S. Prevalence of hydronephrosis in patients with genital prolapse. Eur J Obstet Gynecol Reprod Biol 1999;86:11–3.[Medline]
- Beverly CM, Walters MD, Weber AM, Piedmonte MR, Ballard LA. Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse. Obstet Gynecol 1997;90:37–41.[Abstract]
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Introduction
Diagnosis and discussion
