What are the implications of uterine calcifications with hematuria and pelvic pain?

Implications of Uterine Calcifications with Hematuria and Pelvic Pain

Uterine calcifications associated with hematuria and pelvic pain require comprehensive evaluation with pelvic ultrasound as first-line imaging, followed by CT urography to rule out urinary tract pathology, as these findings suggest possible urinary tract involvement or migration of calcified material into the urinary system.

Diagnostic Approach

Initial Evaluation

• Pelvic ultrasound (transvaginal + transabdominal) is the first-line imaging modality for evaluating uterine calcifications 1
• Given the presence of hematuria, CT urography (CTU) should be performed to evaluate the urinary tract 2
• The combination of hematuria and pelvic pain raises concern for possible communication between the calcifications and urinary tract

Clinical Significance of Uterine Calcifications

Uterine calcifications can have several clinical implications:

1. Degenerative changes in uterine fibroids

   • Calcification in fibroids represents degenerative changes 3
   • Generally indicates a benign process with good prognosis 3
   • May cause pelvic pain due to pressure on surrounding structures

2. Intrauterine foreign bodies

   • Calcifications may form around retained intrauterine devices or other foreign material 4
   • Can erode into adjacent structures including the bladder, causing hematuria 4, 5

3. Uterine lithiasis

   • Rare condition with stone formation within the uterine cavity 6
   • Can cause chronic pelvic pain and abnormal bleeding
   • May be associated with prior uterine instrumentation or cesarean section 6

4. Endometrial calcifications

   • Associated with prior endometrial trauma, infection, or inflammation 7
   • Can affect fertility and pregnancy outcomes 7

Evaluation of Hematuria with Pelvic Pain

The presence of hematuria requires specific attention:

1. CT urography is the preferred imaging study for evaluating hematuria 2

   • Includes unenhanced images followed by IV contrast-enhanced images
   • Should include nephrographic and excretory phases
   • Thin-slice acquisition with maximum intensity projection or 3D volume rendering

2. Potential causes of hematuria with pelvic pain:

   • Direct extension of calcified material into the bladder 5
   • Urolithiasis (kidney or bladder stones) 2
   • Bladder injury or inflammation secondary to adjacent calcifications 2
   • Urinary tract infection secondary to anatomical distortion 2

Management Recommendations

Based on the imaging findings of uterine calcifications with hematuria and pelvic pain:

1. Complete urologic workup is necessary due to the presence of gross hematuria 2

   • CT urography to evaluate the entire urinary tract
   • Cystoscopy may be indicated to directly visualize the bladder and rule out erosion into the bladder

2. Gynecologic evaluation:

   • Hysteroscopy may be indicated to directly visualize and potentially remove intrauterine calcifications 6
   • MRI pelvis may provide additional information about the relationship between the calcifications and surrounding structures 2, 1

3. Consider surgical intervention if:

   • Calcifications are causing persistent symptoms
   • There is evidence of erosion into the bladder or urinary tract
   • Conservative management fails to resolve symptoms

Pitfalls and Caveats

• Don't assume hematuria is solely from gynecologic origin - the urinary tract must be thoroughly evaluated 2
• Don't overlook the possibility of malignancy - although calcifications in gynecologic tumors are often associated with lower-grade disease, comprehensive evaluation is still necessary 3
• Avoid attributing symptoms solely to incidental calcifications - other causes of pelvic pain and hematuria should be ruled out
• Be aware that calcifications can migrate - what appears contained within the uterus on initial imaging may have extensions not readily apparent 4, 5

In this case, the combination of uterine calcifications, hematuria, and pelvic pain suggests a possible communication between the calcified material and the urinary tract, warranting thorough evaluation of both systems to determine appropriate management.