Voiding Dysfunction in Women | Anatomical cause of Voiding Dysfunction | Fibroid Uterus | Dr Dheera

Main ideas / case overview

• This video is a teaching case discussion (urogynecology for beginners) about voiding dysfunction in a woman, ultimately linked to an anatomical obstruction caused by a posterior wall uterine fibroid.
• The clinicians emphasize that the patient’s course began with chronic incomplete bladder emptying and progressed to acute urinary retention, and that missing earlier warning signs can lead to complications.
• Although imaging suggested a dermoid cyst (adnexal mass), intraoperative findings revealed the true diagnosis was uterine pathology (posterior wall fibroid), demonstrating how diagnosis can be misleading, especially in postmenopausal patients.

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Detailed chronology and diagnostic reasoning (method-like)

1) Presenting complaint and “red flag” message

• Patient: Mrs. X, 56 years old, postmenopausal (~6 years since menopause), from Karkala.
• Symptoms:
  • Incomplete bladder evacuation for 5–6 months
  • Vague lower abdominal pain for 2 months
  • Progression to acute urinary retention 2 months prior, requiring emergency catheterization
  • Retained urine volume drained: ~800–900 mL
• Key clinical lesson (stated explicitly):
  • Acute urinary retention is not “just catheterize and forget.”
  • It often means an underlying issue was missed earlier (e.g., incomplete voiding, weak stream, double voiding, sensation of residual urine).
  • In women, if there is voiding dysfunction history, clinicians must obtain it properly—sometimes patients don’t volunteer it, and clinicians may not ask targeted questions.

2) Potential complications of untreated residual urine

Chronic incomplete emptying and recurrent retention can lead to:

• UTIs
• Possible progression to pyelonephritis (patient can become very sick)
• Prolonged bladder distension causing irreversible bladder muscle damage, including detrusor underactivity, leading to persistent voiding dysfunction

3) Exam finding: differentiate pelvic mass type

• Exam findings:
  • Obese/overweight (BMI ~31 kg/m²)
  • Firm pelvic mass ~18–20 weeks size uterus
  • Mass is well-defined, firm, not tender
  • Lower border not felt separately
  • Cervix pulled up and pushed anteriorly on PV/speculum exam
  • Bilateral fornicial fullness
• Diagnostic reasoning taught:
  • When assessing a pelvic mass in retention cases, start by asking: “Could it be a full bladder?”
  • After retention history and exam reduce that possibility, decide whether the mass is:
    • Uterine (e.g., fibroid) or
    • Adnexal (ovarian)
  • Cervix position can help: if the cervix is pushed anteriorly, the mass is likely posterior relative to the uterus.

4) Imaging pathway used in the case

• Ultrasound:
  • Showed uterus with a separate large posterior mass (~11 × 11 cm), described as hypoechoic/hypodense
  • Ovaries not visualized (common in postmenopausal women)
• Working differential:
  • Benign solid ovarian tumor vs
  • Subserosal posterior fibroid
• CT decision and rationale:
  • Discussion of MRI vs CT principles:
    • MRI: better soft tissue delineation; better for characterizing tissue and local invasion
    • CT: better “bird’s-eye view” for spread/metastatic deposits/lymph nodes
  • In this scenario, the patient already had a CT report, so clinicians avoided repeating imaging due to cost/financial burden
• CT report interpretation:
  • CT suggested a ~12 × 12 cm hypodense mass with fat attenuation
  • Most likely diagnosis by CT: right dermoid cyst
  • Clinicians noted a theoretical possibility: an impacted dermoid (e.g., in the pouch of Douglas) could cause urinary retention by altering uterine position and urethral mechanics.

5) Surgery and the diagnostic twist

• The team proceeded to surgery under the presumed diagnosis (dermoid cyst).
• Intraoperative findings (key “result”):
  • Ovaries looked normal (“two shining ovaries”)
  • Posterior wall fibroid identified, pushing uterus anteriorly just above cervix
  • The patient underwent hysterectomy (with fibroid removal as part of the procedure)
• Additional intraoperative concern:
  • During vaginal specimen extraction (“morsellation”), the mass appeared soft with contents seeming to leak.
  • This raised concern for leiomyosarcoma (malignancy).
• Pathology uncertainty:
  • The pathologist requested additional histochemical work (took ~2 more days).
  • Final ongoing differential included:
    • Leiomyosarcoma / lipoleiomyosarcoma vs
    • Degenerated fibroid (fatty degeneration was considered uncommon and confusing radiologically)
  • LDH normal was mentioned as reassuring against sarcoma (LDH often higher in malignancy, as noted by the clinicians).

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Methodological / instruction-style lessons

A) History-taking (avoid missing the cause)

• Always ask targeted urinary emptying questions in women who:
  • Have any history of fibroids/myomas (even if urinary symptoms are not prominent)
  • Have known pelvic masses
• Use leading/clarifying questions to detect:
  • Incomplete emptying
  • Poor stream
  • Double voiding
  • Sensation of needing to void again
• Rationale: prevent progression to acute urinary retention by identifying and treating earlier.

B) Clinical examination (distinguish uterine vs adnexal mass)

Assess pelvic masses for:

• Borders
• Consistency
• Mobility
• Uterine size
• Cervical position/deviation
• Specifically:
  • Cervix pulled/pushed anteriorly suggests a posterior pelvic mass affecting uterine orientation
  • Use how the mass effect fits to decide fibroid vs ovarian/adnexal pathology

C) Imaging selection principles (CT vs MRI)

• Choose MRI when you need:
  • Soft tissue characterization
  • Better differentiation of tissue planes
  • More precise evaluation of benign vs malignant nature
  • Assessment of local spread into adjacent tissues
• Choose CT when you need:
  • A global abdominal survey for metastases/lymph nodes
• If a CT report already exists and repeating imaging is financially burdensome, clinicians may rely on existing data—but should recognize diagnostic limitations.

D) Surgical precautions for large fibroids causing retention (TLH principles)

When performing hysterectomy for suspected posterior fibroid causing retention:

• Protect ureters by staying within the capsule
• Enucleate the fibroid/myomectomy first, especially if in the lower segment
  • Reason: uterine vessels can be pushed laterally, bringing them closer to the ureter; early coagulation risks thermal ureter injury
• Then proceed with uterine vessel control more safely (described as closer to cervix/internal os)
• Rationale emphasized: you may need extra time, but avoiding ureter proximity is safer.

E) Postoperative / team communication

• Follow up pathology and discuss diagnostic dilemmas with the pathologist
  • Share clinical/radiologic suspicion and concerns (e.g., benign degeneration vs sarcoma/rare variants)
• Communicate with radiologists about discrepancies
  • Feedback strengthens the diagnostic team and helps reduce future errors

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Speakers / sources featured

• Dr Dheera (main presenter; gynecology/urogynecology case discussion)
• Dr Dira (fellow mentioned throughout; co-presenter/respondent)
• Pathologist (source of pathology/histochemistry request; not a named person)
• Radiologist (source of CT interpretation and discussion about why it was labeled dermoid; not a named person)