Introduction

1. Urinary Retention as a Complication of Non-gravid Uterine Fibroid: two case reports in University Malaya Medical Centre (UMMC) Shazni Izana Shahruddin MD(UNIMAS), Khong Su Yen MBChB (UK) MRCOG (London) FRANZCOG Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya Discussion 2. Compression of fibroid causing bladder outlet obstruction During daytime, overdistension of the bladder is prevented due to frequent micturition caused by irritability of the compressed bladder on a standing position (4,7). This could also be habitual. In a supine position such as during sleep, the large posterior uterine fibroid displaces the cervix anteriorly and superiorly, and thus compresses on the lower part of the bladder. This results in bladder outlet obstruction and can lead to urinary retention. Valsalva manoeuvre can further increase the pressure to the lower part of the bladder and worsen bladder impaction from the uterine fibroid (7,13). Yang and Huang (7) suggested a few preventive measures to avoid urinary retention: 1) Restriction of liquid before going to bed 2) Urination before going to bed and preventive urination during the night 3) Crede’s manoeuvre, consisting of leaning forward in a sitting position at the beginning of urination 4) Moving from a supine to prone position before getting up 5) Avoidance of valsalva manoeuvre Therefore, a careful pelvic examination (12) is important to identify patients with posterior fibroid as preventive measures listed above may reduce voiding dysfunction. Generally, in a non-gravid uterus, complete resolution of urinary retention is possible with surgical removal of the uterine fibroid. However in complex cases which include younger age women for fertility conservation, this may be a challenge. Medical and other alternative treatments such as with gonadotrophin-releasing hormone agonist (16), uterine artery embolization (17) and high-intensity focused ultrasound (18) have been reported to reduce the size of uterine fibroid. However, efficacy and treatment success depend on the number and size of fibroids as well as renal status. Although urinary retention secondary to uterine fibroid is uncommon, we should maintain a high index of suspicion when a woman, especially in the reproductive age group, presents with voiding dysfunction. A careful assessment should be undertaken and if a non gravid uterine fibroid is present, specific advice and special maneouvres can be undertaken to prevent urinary retention. Introduction Uterine fibroid is remarkably common. A random sampling of women aged 35 to 45 who were screened by self-report, medical record review and sonography found that by the age of 35, the incidence of uterine fibroid was 60% among African-American women; the incidence increased to over 80% by age 50. Caucasian women have an incidence of 40% by age 35 and almost 70% by age 50 (1). Fibroids were also the primary indication for surgery in 199,000 hysterectomies and 30,000 myomectomies in the United State in 1997 (2). Uterine fibroid is an uncommon cause of urinary retention affecting only 7 in 100,000 young women per year (3). However, the resulting obstructive uropathy can lead to serious sequelae such as hydronephrosis and renal impairment. To improve our understanding of the mechanism involved when a non-gravid uterine fibroid causes urinary retention. Case reports of two non-pregnant patients who presented with urinary retention secondary to uterine fibroid in University Malaya Medical Centre (UMMC) and discussion based on current literatures.  • Urinary retention is defined as the inability to void voluntarily when the volume of urine in the bladder exceeds its normal capacity (4). • Uterine fibroid, although rarely causes acute urinary retention in the gravid uterus, mostly present with persistent urinary retention (5-10). However, the occurrence of urinary retention is not well studied and reported in cases of non-gravid uterus. • Most reports of urinary retention involve incarcerated or retroverted gravid uterus (5,6,11-13). In these cases, the problem with urinary retention is usually transient, occurring at the start of pregnancy (12) but resolves spontaneously as the uterus enlarges with increasing gestation and becomes an abdominal organ. However, in our two non pregnant patients with uterine fibroids, the severity of urinary retention worsened as the fibroids enlarged. The pressure resulting from an enlarging uterine fibroid likely aggravated the bladder outlet obstruction thus worsening the urinary retention (7). • POSSIBLE MECHANISMS OF URINARY RETENTION • Progesterone causing fibroid enlargement • Interestingly, voiding dysfunction worsened in both Patient A and B during menses. This may be because progesterone plays an important role in uterine fibroid pathophysiology. As fibroids have increased concentrations of progesterone receptors A and B compared with normal myometrium (14,15), they may increase in size during the secretory phase when progesterone production peaks. In addition, lowered uterine artery impedance at the time of menstruation may cause increases in intrauterine pressure and uterine volume from menstrual flow (4). Eadematous bladder due to overdistension Objectives References Methods (1)    Day Bird D, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003; 188:100-7 (2)    Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol 2002;99:229-34 (3)    Choong S, Emberton M. Acute urinary retention. BJU Int 2000;85:186-201 (4)    Barnacle S, Muir T. Intermittent urinary retention secondary to a uterine leiomyoma. Int urogynecol J 2007;18:339-341 (5)    Schwartz Z, Dgani R, Katz Z, lancet M. Urinary retention caused by impaction of a leiomyoma in pregnancy. Acta Obstet Gynecol Scand 1986;65:525-526 (6)    Nitti A, Feusner AH, Muller PD. Incarceration of a gravid fibroid uterus. Ann Emerg Med 1997;30(6);821-624 (7)    Yang JM, Huang WC. Sonographic findings of acute urinary retention secondary to an impacted pelvic mass. J Ultrasound med 2002;21(10);1165-1169 (8)    Kondo A, Toshikazu O, Takita T, Hayashi H, Kihira M, Itoh F. urinary retention caused by impaction of enlarged uterus. Urol Int 1992;37:87-90 (9)   Varras M, Polyzos D, Alexopoulus C, Pappa P, Akrvis C.Torsion of a non-gravid leiomyomatous uterus in a patient with myotonic dystrophy complaining of acute urinary retention: anesthetic management for total abdominal hysterectomy. Clin Exp Obstet Gynecol 2003;30(2-3):147-150 (10) Novi JM, Dolan TS, Cespedes RD. Acute urinary retention caused by a uterine leiomyomas: case report. J Reprod med 2004;49(2):131-132 (11) Yang JM, Huang WC. Sonographic findings in acute urinary retention secondary to retroverted gravid uterus: pathophysiology and preventive measures. Ultrasound Obstet Gynecol 2004;23:490-495 (12) Love JN, Howell JM. Urinary retention resulting from incarceration of a retroverted, gravid uterus. J Emerg Med 2000;19(4):351-354 (13) Chauleur C, Velliez L, Seffert P. Acute urine retention in early pregnancy resulting from fibroid incarceration: proposition for management. J Fert Stert 2008;90(4):1198.e7-1198.210 (14) Englund K, Blanck A, Gustavsson I, Lundkvist U, Sjoblom P, Norgren A, et al. Sex steroids receotors in human myometrium and fibroid: changes during the menstrual cycle and gonadotrophin-releasing hormone treatment. J Clin Endocrinol Metab 1998;83:4092-4096 (15) Nisolle M, Gillerot S, Casanas-Roux F, Squifflet J, Berliere M, Donnez J. Immunohistochemical study of the proliferation index, oestrogen receptors and progesterone receptor A and B in leiomyomata and normal myometrium during the menstrual cycle and under gonadotrophin-releasing hormone agonist therapy. Hum Reprod 1999;14:2844-2850         (16) Parker WH. Etiology, symptomtology, and diagnosis of uterine myomas. J Fert Stert 2007;87(4):725-736 (17) Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids; clinical results in 400 women with imaging follow up.  Int J Obstet Gynaecol 2002;109(11):1262-1272 (18) Morita Y, Ito N, Hikida H, et al. Non-invasive magnetic resonance imaging-guided focused ultrasound treatment for uterine fibroids- early experience. Euro J Obstet Gynecol Repro Bio 2007;139:199-203 Posterior uterine fibroid Results Conclusion Background poster image from http://www.fibroidssolutions.com/wp-content/uploads/2011/04/Fibroids-Symptoms.jpg