Abstract
Cancer of the uterine cervix is the third most common gynecologic cancer diagnosis and cause of death among gynecologic cancers in the United States. Cervical cancer is frequently asymptomatic until it reaches a locally advanced stage. The authors present a case of urinary retention caused by an atypical presentation of invasive cervical cancer mimicking primary urothelial tumor. The patient was evaluated by a multidisciplinary team, with osteopathic structural examination, intraoperative examination, surgical resection, and histopathologic analysis.
Chronic urinary retention is the accumulation of urine in the bladder that results from incomplete bladder emptying, which is the most common cause of chronic urinary retention.
1 It is measured as the volume of urine left in the bladder after voiding, also known as
postvoid residual. The 2 most common causes of chronic urinary retention and incomplete bladder emptying are bladder muscle dysfunction and bladder outlet obstruction.
1 The latter cause is defined as a “generic term for obstruction during voiding.”
2 It is less common in women,
3,4 and the prevalence data range widely, owing to a lack of uniform definition and coexistence of storage and voiding disorders.
5 Any process that compresses the urethra may impair urine flow and result in an obstruction; potential causes include fibroids, constipation, and, uncommonly, cancer.
Cancer of the uterine cervix is the third most common gynecologic cancer diagnosis and cause of death in the United States,
6 with lower incidence and mortality rates than uterine corpus or ovarian cancer.
7 Human papillomavirus is central to the development of cervical neoplasia and can be detected in 99.7% of patients with cervical cancer.
8 The most common histologic types of cervical cancer are squamous cell (69% of cervical cancers) and adenocarcinoma (25%).
9 Early cervical cancer is frequently asymptomatic. Advanced disease may present with pelvic or lower back pain that may radiate along the posterior side of the lower extremities. Bowel or urinary symptoms, such as pressure-related complaints, hematuria, or urinary retention, are uncommon and suggest advanced disease.
10
We present a case of urinary retention caused by an atypical presentation of invasive cervical cancer mimicking primary urothelial cancer. The patient was evaluated and treated by a multidisciplinary team with osteopathic structural examination (OSE), intraoperative examination, surgical resection, and histopathologic analysis.
A 37-year-old woman (gravida 3, para 3) presented to the clinic with a 7-month history of worsening urinating difficulty that progressed to the point of urinary retention, which required intermittent self-catheterization. The patient had an unremarkable medical history and reported a surgical history of bilateral tubal ligation and loop electrosurgical excision procedure for cervical dysplasia. She also reported being a former smoker.
Pelvic examination revealed a suburethral mass with an otherwise normal-appearing vagina and cervix. An OSE revealed somatic dysfunction at spinal segments T11-L2, Chapman reflex points (CRPs) posteriorly at the upper edge of the transverse process of the second lumbar vertebra, and callous tissue around the umbilicus.
Magnetic resonance imaging demonstrated a rounded hyperintense mass in the region of the urethra measuring 3.1×2.6 cm (
Figure 1). The lesion extended into the region of the bladder neck with extension enhancement into the anterior vagina bilaterally, right greater than left. The lesion also extended into the region of the left ischiorectal fossa and into the urogenital diaphragm and bilateral ischiocavernosus. In light of these findings, the decision was made to schedule the patient for cystoscopy and transurethral resection of the tumor as an ambulatory procedure.
On cystoscopic examination, a firm mass was noted behind the pubic bone extending into the space of Retzius. A cystoscope was cannulated through the urethra into the bladder. The urethra was found to be stenotic, and a mass was noted in the bladder. A transurethral resection of the tumor was performed, which was then sent to a pathology laboratory for further evaluation. Osteopathic findings remained unchanged before and after the procedure.
Histopathologic analysis completed a week after the procedure identified the tumor as a moderately to poorly differentiated keratinizing squamous cell carcinoma with invasion into the muscularis propria (
Figure 2). The specimen stained positive for human papillomavirus consistent with a primary cervical cancer rather than urothelial origin. Ultimately, this patient was referred to the division of gynecologic oncology for the management of her cervical cancer, which, on the basis of invasion into the bladder, was diagnosed as stage IVA. This patient was treated with cisplatin plus fluorouracil chemotherapeutic agents. She no longer needs intermittent catheterization and is voiding to completion.