The menstruating bladder, an unusual cause of haematuria

Albert P. Scerri MD, FRCOG Department of Obstetrics and Gynaecology, Mater Dei Hospital Abstract A 39 year old lady presented with flank pain and haematuria. Radiological investigations showed unilateral hydronephrosis and a serum creatinine of 102μmol/l. At cystoscopy, a soft tissue mass was found in the region of the left ureteric orifice and was causing obstruction of the ureter. A resection biopsy of this lesion was taken. A CT scan and DTPA renogram showed a non-functioning left kidney secondary to chronic obstruction by a soft tissue mass at the left vesico-ureteric junction. Histological analysis of the endoscopic resection specimen showed that the mass contained tubal-type epithelium compatible with a diagnosis of endosalpingiosis (a rare variant of Mullerianosis of the urinary tract). In view of persistent symptoms, it was decided to proceed to surgery. A hysterectomy, bilateral salpingo-oophorectomy and partial cystectomy were performed. The patient has recovered well and is currently asymptomatic. Formal histology of the resection specimen showed the presence of endometriosis. Case report A 39 year old lady presented with a long standing history of left flank pain and this was associated with episodes of haematuria during the time of menstruation. There were no symptoms of fever, dysuria, chronic pelvic pain or dyspareunia. Physical examination was unremarkable. Initial investigations showed a normal full blood count, eGFR of 56 ml/min/1.73m2, normal serum creatinine and liver function. Urine analysis, microscopy and cultures were normal. Ultrasound of the renal tract showed severe left sided hydronephrosis and hydroureter and parenchymal thinning (Figure 1). There was a normal right kidney. The CT scan revealed a solid mass at the left vesico-ureteric junction as the cause of the obstruction of the left ureter. The marked parenchymal loss was suggestive of long-standing obstruction of the left kidney. A DTPA renogram confirmed non-function of the left kidney and normal function of the right kidney with compensatory hypertrophy. At cystoscopy, a soft tissue mass was identified in the region of the left ureteric orifice (Figure 2). The intravesical component of this mass was resected endoscopically. On resection of the lesion, there was a small collection of old blood within the mass itself, however the ureteric lumen could not be identified despite deep resection. Histology revealed the presence of tubal type epithelium, compatible with a diagnosis of endosalpingiosis (Figures 3 and 4). In view of the on-going symptoms of pain and haematuria, the gynaecological opinion was to proceed to surgery. At operation, the macroscopic extent of endometriosis was limited