What are the treatment recommendations for a 47-year-old premenopausal female with menorrhagia, presenting with a large uterine mass causing hydronephrosis and urinary retention?

Treatment of Large Uterine Mass with Hydronephrosis and Urinary Retention

Surgical intervention with total hysterectomy is the recommended treatment for this 47-year-old premenopausal female with a large uterine mass causing hydronephrosis and urinary retention.

Initial Management of Urinary Retention

1. Immediate Bladder Decompression

   • Urgent bladder catheterization is necessary to relieve the acute urinary retention
   • Consider suprapubic catheterization if urethral catheterization is difficult 1
   • This provides immediate symptomatic relief while preparing for definitive treatment

2. Renal Function Assessment

   • Evaluate creatinine and estimated glomerular filtration rate (eGFR)
   • Hydronephrosis suggests obstructive uropathy which may affect renal function
   • If eGFR is significantly decreased (<15), more urgent intervention is needed 2

Imaging Evaluation

• CT abdomen has already confirmed a large uterine mass (13.4 × 9.8 × 9.4 cm)
• Hydronephrosis is present, indicating significant compression of the urinary tract
• Additional imaging considerations:
  • Transvaginal ultrasound to better characterize the uterine mass
  • MRI pelvis may help differentiate between fibroids, adenomyosis, or other pathology
  • Cystoscopy may be considered to evaluate for bladder involvement

Definitive Treatment Options

Primary Recommendation: Total Hysterectomy

• Given the size of the mass, presence of hydronephrosis, and urinary retention, total abdominal hysterectomy with bilateral salpingo-oophorectomy is the most appropriate definitive treatment 3
• This approach:
  • Provides immediate relief of urinary tract compression
  • Eliminates the source of menorrhagia
  • Prevents recurrence of symptoms
  • Allows for complete pathological evaluation

Alternative Options (If Surgery Contraindicated)

1. Temporary Urinary Diversion

   • If immediate hysterectomy is not possible, consider:
     • Retrograde ureteral stenting for temporary relief of hydronephrosis 2
     • Percutaneous nephrostomy (PCN) if retrograde stenting fails or in cases of severe infection 2

2. Medical Management (Limited Role)

   • GnRH agonists may temporarily reduce uterine size but are not definitive solutions
   • Can be used as bridge therapy while preparing for surgery
   • Limited efficacy given the size of the mass and severity of symptoms

3. Uterine Artery Embolization

   • Generally not recommended for masses of this size causing hydronephrosis
   • Risk of post-embolization syndrome and incomplete symptom resolution

Important Considerations

• Malignancy Risk Assessment

  • The large size of the uterine mass warrants evaluation for potential malignancy
  • Endometrial sampling should be performed prior to definitive surgery if possible
  • The presence of hydronephrosis increases concern for potential malignant invasion 2

• Perioperative Management

  • Maintain urinary drainage until definitive treatment
  • Monitor renal function closely
  • Consider preoperative iron supplementation or transfusion if significant anemia from menorrhagia

• Post-Treatment Follow-up

  • Removal of urinary catheter after definitive treatment
  • Follow-up imaging to confirm resolution of hydronephrosis
  • Pathology review to guide any additional treatment if malignancy is found

Clinical Pearls and Pitfalls

• Pearl: Complete surgical removal provides the best chance for symptom resolution and prevents recurrence 4, 3
• Pitfall: Delaying definitive treatment may lead to worsening hydronephrosis and permanent renal damage
• Pearl: In cases of adenomyosis with urinary retention, total hysterectomy has been shown to completely resolve symptoms 4
• Pitfall: Attempting conservative management for masses of this size with hydronephrosis may prolong patient suffering and increase risk of complications

The presence of both hydronephrosis and urinary retention indicates significant compression of the urinary tract by this large uterine mass, making definitive surgical management the most appropriate approach for this patient.