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Case Report  |   October 2018
Osteopathic Evaluation of Urinary Retention Caused by Atypical Presentation of Invasive Cervical Cancer Mimicking Primary Urothelial Tumor
Author Notes
  • From the Department of Obstetrics and Gynecology (Dr Martingano), the Division of Urogynecology (Dr Ramírez), and the Division of Urological Oncology (Dr Bjurlin) at the New York University Langone Hospital-Brooklyn. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Daniel Martingano, DO, New York University Langone Hospital-Brooklyn, Department of Obstetrics and Gynecology, 150 55th St, Brooklyn, NY 11220-2508. Email: daniel.martingano@nyumc.org
     
Article Information
Obstetrics and Gynecology / Urological Disorders
Case Report   |   October 2018
Osteopathic Evaluation of Urinary Retention Caused by Atypical Presentation of Invasive Cervical Cancer Mimicking Primary Urothelial Tumor
The Journal of the American Osteopathic Association, October 2018, Vol. 118, 685-688. doi:https://doi.org/10.7556/jaoa.2018.148
The Journal of the American Osteopathic Association, October 2018, Vol. 118, 685-688. doi:https://doi.org/10.7556/jaoa.2018.148
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. 
Report of Case
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. 
Figure 1.
Magnetic resonance images of the pelvis of a woman presenting with difficulty urinating. (A) Rounded hyperintense mass in the region of the urethra measuring 3.1×2.6 cm (arrow). The lesion extends into the region of (B) the bladder neck (arrowhead) with extension enhancement into the anterior vagina bilaterally, right greater than left, and (C) the left ischiorectal fossa and into the urogenital diaphragm and bilateral ischiocavernosus.
Figure 1.
Magnetic resonance images of the pelvis of a woman presenting with difficulty urinating. (A) Rounded hyperintense mass in the region of the urethra measuring 3.1×2.6 cm (arrow). The lesion extends into the region of (B) the bladder neck (arrowhead) with extension enhancement into the anterior vagina bilaterally, right greater than left, and (C) the left ischiorectal fossa and into the urogenital diaphragm and bilateral ischiocavernosus.
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. 
Figure 2.
Histopathologic analysis of a mass removed from the bladder of a woman presenting with difficulty urinating demonstrating moderately to poorly differentiated keratinizing squamous cell carcinoma: (A) hematoxylin-eosin, original magnification ×4; (B) hematoxylin-eosin, original magnification ×10; and (C) hematoxylin-eosin, original magnification ×20. (D) Invasion into the muscularis propria of the bladder was also demonstrated (hematoxylin-eosin, original magnification ×10). (E, F) The tumor stained positive for p16 (original magnification ×4 and ×10, respectively).
Figure 2.
Histopathologic analysis of a mass removed from the bladder of a woman presenting with difficulty urinating demonstrating moderately to poorly differentiated keratinizing squamous cell carcinoma: (A) hematoxylin-eosin, original magnification ×4; (B) hematoxylin-eosin, original magnification ×10; and (C) hematoxylin-eosin, original magnification ×20. (D) Invasion into the muscularis propria of the bladder was also demonstrated (hematoxylin-eosin, original magnification ×10). (E, F) The tumor stained positive for p16 (original magnification ×4 and ×10, respectively).
Discussion
Cervical cancer usually originates at the junction between the squamous epithelium of the ectocervix and the glandular epithelium of the endocervical canal. The lesion may manifest as superficial ulceration, exophytic tumor in the exocervix, or infiltration of the endocervix. Among cervical cancers, approximately 50% are exophytic, approximately 40% diffusely enlarge or ulcerate the cervix, and approximately 10% can present with no visible lesion because the carcinoma originates within the endocervical canal.12 In the current patient, late-stage disease was identified by urinary retention caused by bladder outlet obstruction with mass formation in the endocervical canal invading into the bladder, resulting in the cervix appearing otherwise normal on physical examination. This characteristic highlights the importance of screening for cervical cancer even in the absence of an overt cervical lesion. 
The OSE revealed somatic dysfunction and CRPs representing dysfunction of both the urethra and bladder.11 Frank Chapman, DO, noted that gangliform contractions found posteriorly at the upper edge of the transverse process of L2 represented inflammation associated with the urethra and bladder and that callous tissues around the umbilicus would also be related to the presence of cystitis.11 Owing to the chronic nature of the obstruction to these structures, it was expected that these findings would persist after the surgical procedures. Because the tumor was affecting the urethra and bladder in the presence of normal-appearing gynecologic structures, both OSE findings and clinical symptoms all directed the physicians involved to a problem with the patient's urologic structures, further confounding the ultimate diagnosis of invasive cervical cancer. 
Osteopathic concepts in the cases of neoplastic diseases are not well defined in the osteopathic medical literature and are limited to reviews,13-15 case reports,16 and expert opinion.17 Identification of somatic dysfunction and CRPs follows the principle that visceral dysfunction is mediated by the sympathetic arm of the autonomic nervous system; thus, excessive sympathetic tone from an irritated, diseased, or stressed organ leads to lymphatic stasis manifested by these myofascial nodules, or “points,” which may feel boggy, ropy, shotty, or thickened and always exhibit tenderness to palpation on physical examination.13 Applying this concept to neoplastic diseases, different types of tumors have distinct and respective routes of spread, patterns of invasion, etc, and can often arise independent of innervations. These otherwise significant pathologic states lacking afferent input to the central nervous system may not result in a significant viscerosomatic reflex response. In these cases, it is not until sufficient inflammation is established in the tissues displaced by the tumor that reflex somatic dysfunction may be identified.15 
The role of osteopathic manipulative treatment in neoplastic diseases has been debated among the osteopathic medical community. Despite speculation, no evidence has established that manipulations promote metastasis of malignant cells by increasing the circulation of blood and lymphatic fluid. An argument can be made that by enhancing lymphatic flow, the neoplastic cells would be subject to identification and removal by the natural antitumor components of the immune system17 that may reduce tumor burden as well as prevent cancer dissemination and metastasis, reduce the need for analgesics postoperatively, and enhance the body's immunity and return to homeostasis postoperatively.13 Complicating this debate is that the plethora of different neoplastic processes each exhibit its own specific and unique behavior, pathogenesis, and response to treatment. Therefore, a blanket treatment approach or statement relating the benefits or risks of the use of osteopathic manipulative treatment in the care of patients with cancer is not one that can be made with any accuracy or appropriateness. 
Conclusion
Cancer of the uterine cervix is often asymptomatic until it reaches an advanced stage, at which mass formation can cause urinary retention by means of bladder outlet obstruction. Gynecologic cancer should be considered in cases in which a mass is causing urinary outlet obstruction and there is suspicion of an atypical presentation of invasive cervical cancer mimicking primary urothelial tumor. Further studies are required to establish recommendations and use of osteopathic concepts in the area of neoplastic diseases. 
References
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Figure 1.
Magnetic resonance images of the pelvis of a woman presenting with difficulty urinating. (A) Rounded hyperintense mass in the region of the urethra measuring 3.1×2.6 cm (arrow). The lesion extends into the region of (B) the bladder neck (arrowhead) with extension enhancement into the anterior vagina bilaterally, right greater than left, and (C) the left ischiorectal fossa and into the urogenital diaphragm and bilateral ischiocavernosus.
Figure 1.
Magnetic resonance images of the pelvis of a woman presenting with difficulty urinating. (A) Rounded hyperintense mass in the region of the urethra measuring 3.1×2.6 cm (arrow). The lesion extends into the region of (B) the bladder neck (arrowhead) with extension enhancement into the anterior vagina bilaterally, right greater than left, and (C) the left ischiorectal fossa and into the urogenital diaphragm and bilateral ischiocavernosus.
Figure 2.
Histopathologic analysis of a mass removed from the bladder of a woman presenting with difficulty urinating demonstrating moderately to poorly differentiated keratinizing squamous cell carcinoma: (A) hematoxylin-eosin, original magnification ×4; (B) hematoxylin-eosin, original magnification ×10; and (C) hematoxylin-eosin, original magnification ×20. (D) Invasion into the muscularis propria of the bladder was also demonstrated (hematoxylin-eosin, original magnification ×10). (E, F) The tumor stained positive for p16 (original magnification ×4 and ×10, respectively).
Figure 2.
Histopathologic analysis of a mass removed from the bladder of a woman presenting with difficulty urinating demonstrating moderately to poorly differentiated keratinizing squamous cell carcinoma: (A) hematoxylin-eosin, original magnification ×4; (B) hematoxylin-eosin, original magnification ×10; and (C) hematoxylin-eosin, original magnification ×20. (D) Invasion into the muscularis propria of the bladder was also demonstrated (hematoxylin-eosin, original magnification ×10). (E, F) The tumor stained positive for p16 (original magnification ×4 and ×10, respectively).