POSTPARTUM ONSET OF URINARY INCONTINENCE

ASSOCIATED

WITH

URETERAL ECTOPIA RALPH

C. BENSON,

LAURENCE DAVID

JR.,

F. GREENE,

C. UTZ,

M.D. M.D.

M.D.

From the Mayo Clinic Rochester, Minnesota

and Mayo Foundation,

The onset of urinary incontinence in adult women in association with extrasphincteric ureteral ectopia is rare. Herein we report 2 cases of this unusual occurrence. The incontinence in both patients began after signijkant obstetric trauma. Ureteral ectopia should be included in the differential diagnosis of incontinence beginning in the immediate postpartum period.

ABSTRACT

Ureteral ectopia in the female is a relatively common genitourinary anomaly. Because of the embryologic development of the wolffian duct, the ectopic ureter usually drains the upper segment of a duplicated kidney. The contralateral kidney is usually normal but may be completely or incompletely duplicated. In 50 women with 54 ectopic ureters, Greene’ found the ectopic orifice to be located in the vestibule of the vagina in 22, in the urethra in 15, in the vesical neck in 7, and in the vagina in 4; the site was not discovered in 6. In the 12 patients who were continent, the ectopic orifice was located in the vesical neck in 6, in the urethra in 4, and in the vestibule in 1; in 1 patient it was not identified. Patients with ectopic ureters generally seek medical advice because of urinary incontinence, or both. The time-honored urinary infection, clinical observation that urinary incontinence in a patient with a normal voiding pattern indicates ureteral ectopia remains accurate. However, we wish to emphasize that such a voiding pattern

Presented at the annual meeting of the Section, American Urological Association, Arizona, October 5, 1975.

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need not be present since birth - it can begin in adulthood. Urinary continence in a patient with extrasphincteric ureteral ectopia is distinctly rare. We have found only 5 such cases in the literature.2-6 Even more unusual in these women is subsequent development of incontinence. Herein we report two cases of this occurrence; the incontinence in both patients began after parturition. Case Reports Case 1 A twenty-five-year-old woman came to the Mayo Clinic in June, 1974, complaining of constant urinary leakage that had developed six years earlier immediately after vaginal delivery of twins. She denied prior incontinence except that, as a teenager, she had lost small amounts of urine when she was tickled. The constant seepage of urine, accentuated by walking or sexual intercourse, necessitated continuous wearing of pads to protect her clothing. The incontinence was unaffected by two subsequent pregnancies. Her past urologic history included a “vaginal cyst that was removed at one year of age,” several episodes of pyelonephritis during her pregnancies, and occasional infections of the lower urinary

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FIGURE

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(A)

Excretory

urogram shows bijid collecting system on right and “drooping” Jew configuration of pelvis and calyces on left; (B) retrograde pyelogram of ectopic ureter shows atrophic upper segment.

tract. An excretory urogram in 1968 reportedly showed a hypoplastic left kidney. Several urologic procedures including three internal urethrotomies had been performed because of the incontinence. On admission, physical examination revealed only abdominal striae and a retroverted uterus. Routine laboratory tests were normal except for minimal pyuria (four white cells per highpowered field). Urine culture was negative. The excretory urogram disclosed spina bifida occulta and a bifid collecting system on the right. The pelvis and calyces of the left kidney had a that suggested “drooping flower” configuration renal duplication (Fig. 1A). Prior to cystoscopy under anesthesia the urethral orifice, vestibule, and vagina were observed for a prolonged time, and escape of urine was not seen even with significant hydration and the intravenous administration of mannitol. Cytoscopy showed the right uretral orifice to be located closer to the vesical neck and more lateral than usual. The trigone was well developed. A left ureteral orifice that opened at the vesical neck was noted, along with an ectopic ureteral orifice opening into a shallow pocket in the midurethra. The latter was catheterized, and retrograde pyelography outlined an atrophic upper segment (Fig. 1B). Subsequent cinecystourethrography revealed no reflux into the ectopic ureter. The patient underwent left partial nephrectomy and partial ureterectomy, and urinary continence was restored. Case 2 This case was previously reported by Chidlow and Utz’ as a case of perimeatal ureteral ectopia

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with urinary continence. We considered this case important enough to report it again with emphasis on the development of incontinence after parturition A thirty-three-year-old woman was referred in March, 1969, for repair of what was thought to be a vesicovaginal fistula. She stated that incontinence began after the birth of her first child. The delivery was difficult because of face presentation and resulted in severe vaginal lacerations. Thereafter incontinence was so severe that she wore a pad continuously. Three subsequent normal deliveries had no effect on the incontinence. Because the leakage had some stress component, it was thought to be secondary to a cystourethrocele, and she underwent vaginal hysterectomy with anterior and posterior repair elsewhere in November, 1965. After surgery, incontinence was more severe. Pelvic examination on admission revealed 5 to 10 ml. of clear urine in the vagina. Postoperative scarring and two areas of granulation tissue along the old suture line were seen, but a fistulous tract could not be visualized. Routine laboratory tests were normal except for grade 3 pyuria. Urine culture was negative. Excretory urogram disclosed a bifid right renal pelvis with some thinning of the renal cortex over the lateral aspect ofthe upper pole calyx (Fig. 2A). There was complete duplication on the left, and both segments were normal. Both ureters were visualized as separate to the level of the bladder. Methylene blue introduced into the bladder via a urethral catheter did not discolor a previously inserted vaginal sponge. However, after indigo carmine had been injected intravenously, the distal portion of the sponge was stained.

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FIGURE 2. (A) Excretory urogram shows bi$d right collecting system and thinning of renal cortex over lateral aspect of upper pole calyx; note duplicated collecting system on left with atrophy of cortex and caliectasis in upper segment. (B) Retrograde ureterogram of ectopic ureter shows dilatation of pelvic portion. (From Chidlow and Utz’by permission of the Southern Medical Association.)

ters that open outside the urinary tract or distal to the external sphincter. The upper segment may be atrophic and nonfunctioning. The dilated ureter may act as a reservoir for urine and empty unnoticed with perineal muscle relaxation at the times ofvoiding. Obstructive phenomena, such as stenosis of the ectopic ureteral orifice or extrinsic pressure on the ectopic ureter due to constricting bands, may be involved. Even more speculation is needed to explain incontinence in previously continent patients with extrasphincteric ureteral ectopia. Certainly infection and dilatation of the renal pelvis and ureter might enlarge a stenotic orifice and subsequently cause incontinence to develop. The patients in our report, however, were not infected. The only other logical explanation for development of incontinence in these patients is that a traumatic event either released some extrinsic pressure on the ectopic ureter or changed the positional relationship of its orifice to the sphincter. We think that this hypothesis best explains the incontinence in our patients which developed immediately following significant obstetric trauma. Edson postulated in his case that incontinence followed the rupture and fistulization of an incomplete ureterovaginal ectopia caused by tension trauma associated with parturition.

Cystoscopy revealed an asymmetric trigone with a single ureteral orifice on each side. The left orifice was more medial than the right. A left retrograde pyelogram identified the lower segment only. Careful examination of the external meatus detected spurts of urine coming from the parameatal region. This orifice was catheterized, and a ureterogram was obtained; but only the dilated pelvic portion of the ectopic ureter was visualized (Fig. 2B). The patient underwent left partial nephrectomy and partial ureterectomy and has been continent since then. Comment We have presented reports of 2 patients in whom urinary incontinence, associated with extrasphincteric ectopic ureters, first appeared after significant obstetric trauma. Twins were delivered in Case 1 and a difficult face presentation resulted in vaginal lacerations in Case 2. The only similar case report that we have been able to find also cites incontinence as starting immediately after delivery of the patient’s first child.6 It is tempting to postulate that the removal of a “vaginal cyst” in Case 1was in reality incision of an ectopic ureterocele. Several theories can be invoked to explain urinary continence in patients with ectopic ure-

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The correct diagnosis of incontinence secondary to ureteral ectopia is understandably elusive in a previously continent patient. It can be made using persistent, meticulous physical examination and careful endoscopic and radiologic studies. However, the most useful aid in the diagnosis of ureteral ectopia in a patient with persistent incontinence and a normal voiding pattern is a high index of clinical suspicion. This is especially true in adult patients with onset of incontinence immediately after obstetric trauma. Mayo Clinic, Section of Publications 200 First Street Southwest Rochester, Minnesota 55901 (DR. BENSON)

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References 1. GREENE, L. F.: Ureteral ectopy in females, Clin. Obstet. Gynecol. 10:147 (1967). 2. WESSON, M. B. : Incontinence of vesical and renal origin (relaxed urethra and a vaginal ectopic ureter): a case report, J. Urol. 32: 141 (1934). 3. HONKE, E. M.: Ectopic ureter, ibid. 55: 460 (1946). 4. MOORE, T. : Ectopic openings of the ureter, Br. J. Ural. 24: 3 (1952). 5. DEWEERD, J. H., and LITIN, R. B.: Ectopia ofureteral orifice (vestibular) without incontinence: report of case, Proc. Staff. Meet. Mayo Clin. 33: 81 (1958). 6. EDSON, M. : Post partum urinary incontinence and ureteral ectopia, Urologists’ Correspondence Club, August, 1974. 7. CHIDLOW, J. H., and UTZ, D. C.: Ureteral ectopia in vestibule ofvagina with urinary continence, South. Med. J. 63: 423 (1970).

UROLOGY / JANUARY 1976 / VOLUME VII, NUMBER 1

Postpartum onset of urinary incontinence associated with ureteral ectopia.

The onset of urinary incontinence in adult women in association with extrasphincteric ureteral ectopia is rare. Herein we report 2 cases of this unusu...
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