Diagnosis of distal ureteric stones on routine gynecological ultrasound examination in women presenting with pelvic pain.

Abstract

Women presenting with typical symptoms of ureteric stones, such as renal colic, are referred to urologists for further examination and treatment. Atypical presentation includes pelvic pain which may be misdiagnosed as being of gynecological origin. Previous studies1-3 have shown that distal ureteric stones can be diagnosed using transvaginal ultrasound (TVS) examination in women with clinical suspicion of renal colic. There are no data, however, on the prevalence of ureteric stones in women presenting to gynecological clinics with pelvic pain. In 2012 we developed a technique for visualizing ureters on routine TVS4 examination and, subsequently, visualization of both ureters has been integrated into every pelvic ultrasound examination undertaken in our unit since January 2013. We used a previously described systematic approach for assessment of women presenting with pain5. The ureters were examined using TVS, at rest and during peristalsis, to identify any evidence of ureteric dilatation or abnormal bending. Ureteric dilatation was diagnosed in women who had widening of the ureter proximal to the level of obstruction and in those who demonstrated evidence of fluid retention within the ureteric lumen at rest. We evaluated the impact of our new policy for detection of distal ureteric stones in women presenting with acute and chronic pelvic pain. Records of 5594 women presenting with pelvic pain between January 2013 and August 2014 were reviewed retrospectively. In total, seven (0.1%) women were diagnosed with ureteric calculi (Table 1). Other urinary tract abnormalities observed were simple renal cyst (11/5594 (0.2%)), ureteric obstruction secondary to severe endometriosis (6/5594 (0.1%)), ureterocele (7/5594 (0.1%)), bladder endometriosis (2/5594 (0.04%)) and bladder polyp (2/5594 (0.04%)). All stones seen on TVS examination had the appearance of hyperechoic swellings located within the lumen of the ureter. Acoustic shadowing was seen in six of seven (85.7%) cases (Figure 1). Our results show that a policy of routine TVS examination of the ureters enables the detection of distal ureteric stones in women presenting with pelvic pain. In most units, visualization of the ureters is not included in standard TVS examinations. Since our examination protocols were changed, we have identified seven cases of ureteric stones whilst no cases were detected in the previous 20 years. Timely diagnosis of ureteric stones is important as the pain can be debilitating and, in women presenting with atypical symptoms, the cause of the pain may be missed on both TVS examination and laparoscopy. A proportion of women may not pass the stones spontaneously and may suffer prolonged distress and develop renal obstruction, with consequent loss of kidney function. Our technique of visualizing the ureters is highly effective and it usually takes less than 1 min to locate and examine each ureter on TVS examination. Although the number of women presenting to gynecology clinics with ureteric stones is relatively small, prompt ultrasound diagnosis avoids delays in treating the severe pain caused by ureterolithiasis and helps prevent loss of renal function in women with complete ureteric obstruction. In view of this, we believe that routine visualization of the ureters should become a standard part of the examination of any woman presenting with pelvic pain. T. Holland*, K. Pateman, J. Knez, G. Dardelis, X. Foo and D. Jurkovic Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospital, London, UK *Correspondence. (e-mail: [email protected])