Voiding dysfunction related to a vaginal hematoma after a Perigee™ procedure

Abstract

About 0.9–7.8% of women develop voiding dysfunction following transobturator vaginal mesh (TVM) procedures1-4. Reported contributing factors include preoperative obstructive voiding or concomitant surgery4. We report a case of voiding dysfunction caused by a vaginal hematoma after a Perigee™ (American Medical Systems, Minnetonka, MN, USA) procedure, successfully managed with the help of ultrasonography. A 61-year-old woman, para 3, developed an inability to micturate and high post-void residuals upon removal of a transurethral catheter 2 days after uncomplicated pelvic reconstructive surgery consisting of total vaginal hysterectomy, Perigee procedure, posterior colporrhaphy and intraoperative cystourethroscopy for symptomatic pelvic organ prolapse. The patient's vital signs were stable. Pelvic examination and urinalysis yielded unremarkable findings. However, urination problems persisted after a 3-day voiding trial. Transvaginal ultrasound (TVS) revealed a distorted urethra and cranioventral displacement of the proximal urethra and lower urinary bladder. Following replacement of the transurethral catheter, TVS revealed an anterior vaginal hematoma, 5.7 × 4.8 cm in size and located between the catheterized urethra and the mesh. The mesh was dorsally deviated in a zigzag shape. Doppler angiography did not reveal a pelvic hematoma or abscess. A serial hemogram showed a decreasing hemoglobin level, from 14.4 g/dL preoperatively to 12.0 g/dL and then 10.2 g/dL on days 1 and 5 postsurgery, respectively. Given the situation of an uncomplicated vaginal hematoma with stable hemodynamic conditions, the patient was managed conservatively with serial ultrasound examinations. On day 9 following surgery, the patient experienced unexpected vaginal bleeding. Pelvic examination identified a disrupted vaginal wound with expulsion of blood clots. TVS revealed an almost completely evacuated vaginal hematoma, a linear mesh located beneath the bladder and proximal urethra, and normal configurations of the urethra and lower bladder (Figure 1). The patient resumed normal voiding with a hemoglobin level of 10.1 g/dL, and was discharged on day 10 after surgery. At follow-up assessments on days 13 and 30 postsurgery, the patient continued to have normal voiding and the vaginal wound appeared to be well healed. TVS exhibited a properly located mesh without vaginal hematoma. Hemorrhagic complications after Perigee procedures are rare1, 2. The vulnerable vessels during the passage of TVM needles include the median branch of the obturator vessels and the accessory pudendal artery5-7. Treatment includes conservative management5, interventional radiology with embolization8 or surgery5. In this case, the hemorrhage was self limiting and uncomplicated without compromising the patient's vital signs or leading to secondary infection. Conservative treatment may allow hemostasis through external compression by the vaginal hematoma on the damaged vessels. Under such treatment, close monitoring of the patient's clinical condition, including vital signs and extent of hemorrhage and hemoglobin levels, is mandatory. The use of ultrasound is valuable in assessing surgical outcomes after TVM procedures3, 9. In the present patient, ultrasound identified a vaginal hematoma that compressed and distorted the lower urinary tract as the probable etiology for voiding dysfunction. Urethral distortion has been shown to be related to voiding dysfunction after suburethral tape placement10. Ultrasound is advantageous not only in initial evaluation but also in formulating and adjusting the management strategy in such cases. In conclusion, vaginal hematoma should be considered as one of the differential diagnoses in patients presenting with voiding dysfunction after TVM procedures. W.-C. Huang†‡§ and J.-M. Yang*‡¶ †Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei, Taiwan; ‡Department of Obstetrics and Gynecology, Taipei Medical University, Taipei, Taiwan; §School of Medicine, Fu Jen Catholic University, Taipei, Taiwan; ¶Department of Obstetrics and Gynecology, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan