Xanthogranulomatous cystitis presenting as a large pelvic mass invading bladder and causing obstructive uropathy: A rare case report

Obstructive Uropathy with Acute Pyelonephritis Induced by a Voluminous Postmenopausal Uterine Leiomyoma

Purpose: Introduction: Patients with AIDS remain at increased risk for high-grade B cell lymphoma. The incidence of Burkitt lymphoma has dramatically increased since HIV appearance. However, in the era of HAART, only a few cases of colorectal Burkitt lymphoma have been reported these days. Burkitt lymphoma associated with AIDS is characterized by extensive lymphadenopathy and extranodal involvement. Case Presentation: A 32-yearold male with AIDS presented with rectal pain. The patient was noncompliant with HAART, and his last CD4 count was 156 cells per μl 2 months prior. He also admitted suprapubic abdominal pain associated with difficult urination. His vital signs were T 99.1F, HR 110/min, BP 149/85 mmHg, SpO2 98% on room air. Fullness with tenderness was observed in the suprapubic area. Rectal exam revealed a circumferential polypoid mass above the anal junction. Labs were significant for WBC 3800/μl, HGB 10.8 g/dL, PLT 103 K/μl and LDH 1901 U/L. The abdominal CT demonstrated multiple large soft tissue masses throughout the abdomen arising from the small bowel with the largest measuring 8.7 x 15 cm. Right hydronephrosis was also found. CTguided biopsy revealed high-grade B cell lymphoma with Burkitt's feature. Immunohistochemistry was positive for CD45, CD20, CD10, BCL-2, BCL-6, and negative for CD3, CD5, CD23, Cyclin D1. Proliferation index was more than 90%. Colonoscopy showed single large circumferential friable mass in the rectum. The patient was treated with chemotherapy consisting of etoposid, predonisone, vincristine, cyclophosphamide, and doxorubicin (EPOCH) with good clinical response. His rectal/abdominal pain and urinary symptoms improved. Discussion: A majority of AIDS-related lymphomas are high-grade B-cell tumors. Advanced stage at presentation is more frequent in the setting of HIV infection. However, with recent advances in HAART, colorectal involvement with the most aggressive type of B-cell lymphoma, Burkitt lymphoma, is not common. In our case, the patient was noncompliant with HAART and presented with extensive abdominal lymphadenopahy. Generalized lymphadenopathy is one of the main symptoms for Burkitt lymphoma associated with AIDS. Those patients can be presented with bowel obstruction, gastrointestinal bleeding or obstructive uropathy. Therefore, rectal pain or voiding symptoms in HIV patients should raise a suspicion for colorectal involvement of Burkitt lymphoma. In addition, unusual presentation of Burkitt lymphoma warrants an aggressive search for coexisting HIV infection.

Involvement of the cervix with acute lymphoblastic leukaemia (ALL) is extremely rare. In this case report, we discuss an unmarried woman in her early 20s, who presented in the emergency...

Endometriosis presents as-1. superficial, 2. ovarian endometrioma, and 3. deep infiltrating endometriosis. Obstructive uropathy can rarely result from endometriosis, especially in premenopausal women-incidence being 0.3%-12%. A 40-year-old married, working female presented to ER with severe left-sided flank pain radiating, lump abdomen, heavy menstrual bleeding, and inability to pass urine. Physical examination revealed a large 24-week lump abdomen. Imaging studies were done with USG showing a large cystic left adnexal mass which was followed by CT urography showing hydroureteronephrosis and a large cystic mass of 10 cm compressing the urinary bladder and ureter, along with uterine adenomyosis. Emergency cystoscopy and left DJ stenting was done to relieve the obstruction which resulted in relief from flank pain. This was followed by laparoscopic hysterectomy with left salpingo-oophorectomy with right salpingectomy and adhesiolysis. Postoperative imaging showed complete resolution of ureteral obstruction and hydronephrosis. Histopathology confirmed endometriotic cyst and adenomyosis. Endometriosis can present with a wide spectrum of symptoms. Involvement of the urinary system in cases of endometriosis might result in compromise of renal function over time. Prompt surgical management is essential in cases of obstructive uropathy. Cases similar to ours have demonstrated the importance of prompt decompression of urinary tract by emergency DJ stenting followed by definitive surgical management of underlying endometriosis. Modern endometriosis management included the conservative laparoscopic surgery and ureterolysis followed by the resection of concomitant endometriosis and a broad-based multidisciplinary approach, centered on a patient's symptoms and priorities. This case underscores the importance of considering endometriosis as a differential diagnosis of women presenting with urological symptoms as well as the need for collaboration between urologist and gynecologist in such cases solidifying that the rapid intervention and multidisciplinary line of management is essential for optimal patient outcome.

Large cervical leiomyomas (≥10cm) are extremely rare. Our case report concerns the surgical treatment of a patient with a large cervical leiomyoma associated with chronic pelvic pain, bilateral hydroureteronephrosis and significant impairment of renal function. A 47-year-old patient of reproductive age with a normal menstrual cycle and a medical history of chronic pelvic pain presented to the gynecology clinic for examination. Clinically, the presence of a large pelvic mass was found, the upper margins of which were palpable at the level of the umbilicus. A preoperative assessment revealed bilateral hydroureteronephrosis due to obstructive uropathy and renal dysfunction. Hydroureteronephrosis, as a consequence of the large pelvic mass, probably originating from the cervix of the uterus, was evaluated as the main cause of renal dysfunction. Tumor markers were negative. The imaging studies confirmed the clinical diagnosis of uterine leiomyoma, and the surgical treatment of the patient with laparotomy was decided. Intraoperatively, the presence of a large uterine cervical fibroid was detected, and a total abdominal hysterectomy and bilateral adnexectomy were performed. Operating was difficult, with significant surgical difficulties. The postoperative course was uneventful, without immediate complications. The patient's symptom relief began gradually, immediately after surgery. Three months after surgery, the patient reported complete relief of her pelvic pain. A re-examination of the urinary tract revealed complete recovery of renal morphology and function. In the paper, after the presentation of the case, a brief review of cervical leiomyomas is attempted based on the literature, mainly regarding the diagnostic and therapeutic approach.

Primary signet ring cell carcinoma (SRCC) of the prostate is a rare entity, characterised by its aggressive nature and dismal prognosis. We report a case of an advanced SRCC of...

INTRODUCTION: Fecal impaction is a known complication of chronic constipation and is particularly bothersome in the elderly. Common complications of fecal impaction include hemorrhoids, megacolon, overflow diarrhea and obstructive uropathy among others. Overflow diarrhea is often misdiagnosed and treated with antidiarrheal medications leading to further worsening of impaction. Obstructive uropathy is a well-established complication of fecal impaction with obstruction occurring at any level of the urinary tract. Children and young adults are at high risk as are the elderly due to multiple risk factors including but not limited to diabetes mellitus, dementia, opioid use and depression. Many case reports have been published with fecal impaction and obstructive uropathy though none have reported overflow diarrhea as a presentation. CASE DESCRIPTION/METHODS: An 82-year-old male patient presented with diarrhea and acute kidney injury that was caused by fecal impaction that led to obstructive uropathy. He had a 4-week history of non-bloody watery diarrhea with associated fecal incontinence and generalized abdominal pain. He reported a long-standing history of constipation prior to this. Generalized abdominal tenderness with mild diffuse distention and a distended urinary bladder were noted on exam, along with normal rectal tone with loose brown stool in absence of hemorrhoids or prostate enlargement. Lab work showed elevated creatinine and hypokalemia. Upon IV fluid resuscitation and foley catheter placement, CT abdomen was done which showed bilateral hydronephrosis. Stool studies showed no evidence of infection. He was managed with laxatives and had significant improvement in kidney function as well as significantly reduced stool burden. DISCUSSION: Our patient had multiple risk factors for impaction including age, immobility, diabetes, and medications including azacitidine. Chronic constipation in our patient led to fecal impaction which eventually led to overflow diarrhea and obstructive uropathy. It is important to consider impaction as a cause of fecal incontinence and diarrhea in the elderly as it can lead to high morbidity and mortality. The treatment of this diarrhea is counter-intuitive since the impaction benefits from catharsis not antidiarrheals. Diet counseling, biofeedback, and rarely surgical intervention can be used in refractory cases.Figure 1.: Computed Tomography imaging showing bilateral hydronephrosis (A) and dilation of rectum (B).Figure 2.: Computed Tomography imaging showing improvement in hydronephrosis and stool burden post catharsis.

Magnetic resonance (MR) imaging is often used in the detection and staging of large pelvic masses. Many large masses in the female pelvis arise from the reproductive organs (eg, uterus, cervix, ovaries, fallopian tubes). In addition, these masses may arise from the gastrointestinal system, urinary system, adjacent soft tissues, peritoneum, or retroperitoneum or from metastases. The majority of large masses in the female pelvis represent such commonly encountered entities as uterine fibroid tumor, dermoid tumor, ovarian cyst, and ovarian cancer. However, uncommon pelvic masses such as mesothelioma, adenocarcinoma, carcinosarcoma, leiomyosarcoma, and desmoid tumor may also be seen. Thus, the differential diagnosis for female pelvic masses is extensive. However, the site of origin, MR imaging characteristics, and clinical history may all help narrow the differential diagnosis. Although with large tumors it may not always be possible to determine the site of origin or distinguish between various tumors at radiology, familiarity with the clinicopathologic and MR imaging features of common and uncommon pelvic masses is important for diagnosis and treatment.

GIANT MULTILOCULAR PROSTATIC CYSTADENOMA

Fecal impaction is a known complication of chronic constipation and is particularly bothersome in the elderly population. Common complications of fecal impaction include hemorrhoids, megacolon, overflow diarrhea, and obstructive uropathy among others. Many case reports have been reported with fecal impaction and obstructive uropathy though none have reported overflow diarrhea as a presentation. In this case report, we present an elderly male who came in with overflow diarrhea and acute kidney injury that resulted from fecal impaction that caused obstructive uropathy. He was managed with catharsis and early recognition of the condition led to a good outcome. Recognition and management of fecal impaction can be challenging especially in patients who present with diarrhea. We, therefore, outline and discuss the importance of recognition of overflow diarrhea as a complication of fecal impaction and the management of such patients.

Very-late-onset multiple sclerosis (VLOMS), defined as disease onset after the age of 60, is a rare and often diagnostically challenging entity that may present with atypical features. We describe the case of a 67-year-old man who presented with progressive urinary symptoms culminating in obstructive uropathy and acute kidney injury (AKI), ultimately diagnosed as progressive multiple sclerosis (MS). The patient had a three-year history of left upper limb weakness and gait difficulty, which had been previously unexplored. He presented acutely following a fall, with new-onset left-sided facial droop and worsening lower limb weakness. Laboratory investigations revealed severe hyperkalemia (serum potassium: 9.8 mmol/L), uremia, and elevated creatinine (731 µmol/L), indicating significant renal impairment (estimated glomerular filtration rate (eGFR): 7 mL/min/1.73 m²). Urinary tract imaging revealed bilateral hydronephrosis and a trabeculated bladder, suggestive of chronic urinary retention; the prostate was enlarged but without significant prostate-specific antigen (PSA) elevation. Catheterization led to immediate bladder decompression, and the patient received medical treatment for hyperkalemia. Neuroimaging (MRI brain and spine) revealed multifocal demyelinating lesions involving periventricular, temporal, pontine, and cervical cord regions, while a lumbar puncture confirmed the presence of oligoclonal bands in both CSF and serum. Neurological examination demonstrated upper motor neuron signs, including facial asymmetry, limb spasticity, and pyramidal weakness, further supporting a central nervous system etiology. Despite the presence of benign prostatic hyperplasia (BPH) and cervical spondylosis, the degree of neurological impairment, distribution of MRI lesions, and cerebrospinal fluid analysis collectively pointed to a diagnosis of progressive MS with neurogenic bladder dysfunction. This led to urinary retention, obstructive uropathy, and subsequent AKI. While lower urinary tract dysfunction is a common complication of MS, its initial manifestation as acute renal failure is rare, especially in patients without a prior diagnosis. This case highlights the diagnostic complexity in elderly patients where structural (BPH, spinal stenosis) and neurological causes may overlap. It also underscores the importance of a high index of suspicion for demyelinating disease in patients with unexplained bladder dysfunction, progressive motor deficits, and renal impairment. Early multidisciplinary involvement, including neurology, urology, nephrology, and rehabilitation, is essential for prompt diagnosis, bladder decompression, and prevention of irreversible renal damage. Long-term catheterization was instituted, with outpatient follow-up arranged to assess suitability for clean intermittent self-catheterization and continued neurological monitoring. This case illustrates that in older adults, especially men, attributing urinary symptoms solely to common urological conditions may overlook more insidious neurologic diseases such as MS. Timely recognition and appropriate intervention can significantly alter prognosis by preserving renal function and optimizing functional outcomes.

We report a case of patient with documented SLE who displayed dysuria, gastrointestinal (GI) symptoms and renal insufficiency associated with the unusual occurrence of bilateral hydroureteronephrosis due to urterovesical junction stricture (obstructive uropathy). Pathologic investigations disclosed chronic interstitial cystitis (IC) with evidence of focal immune complex deposition in the blood vessel walls of the bladder. The GI symptoms and dysuria regressed with initial therapy for SLE with steroids. However, the persistent obstructive uropathy (OU) and renal insufficiency required bilateral nephrostomy followed by steroids plus intravenous pulse injection of cyclophosphamide. The obstructive uropathy was relieved even after removing the nephrostomy tube and renal function remained stable. Including this case, nineteen SLE patients associated with clinical and radiographic findings of OU were found in the world literature and reviewed to find any consistent pattern of clinical features. Most of the patients with OU in SLE were female (mean age, 31.7 yr) and orientals (63%), and had interstitial cystitis (89%) as a common underlying cause with concomitant involvement of the GI tract (89%) and WHO class IV or V advanced glomerulonephritis (67%). Despite the remarkable response (68%) to steroids in majority of OU patients associated with SLE, certain patients still required surgical correction (32%) and some even died (32%). OU, potentially reversible, was not an exception in patients with SLE, which might be overshadowed by other major organ involvement of SLE.

BackgroundStevens-Johnson Syndrome (SJS) is an acute mucocutaneous eruption with blisters of the skin and haemorrhagic erosions of mucous membranes. This report describes air-leak syndrome and obstructive uropathy occurring simultaneously in a teenage patient affected by SJS.Case presentationA 17-year-old Malay female with SJS suffered from bilateral pneumothoraces, pneumomediastinum, and obstructive uropathy as early complications of her disease. She required intubation, chest tube insertion, and bilateral ureteric stenting as part of her intensive care management. These extra-cutaneous complications of renal and pulmonary systems were likely secondary to widespread epithelial detachment.ConclusionDespite paucity of cases in adult literature, post-renal causes for acute kidney injury must be considered in SJS, especially in the setting of gross haematuria. Bedside point-of-care ultrasonography may be a useful tool for excluding obstructive uropathy. Pneumothorax is a rare but documented complication of SJS in paediatric cases and, to a lesser extent, adult patients. Extra care should be exercised when caring for mechanically ventilated patients suffering from SJS.

Lung adenocarcinoma with metastasis to the uterine cervix is rare, as is ureteral obstruction attributed to metastasis from lung adenocarcinoma. We report a case of lung adenocarcinoma with metastases to both the uterine cervix and retroperitoneal lymph nodes resulting in obstructive uropathy. We used immunohistochemical staining, the epidermal growth factor receptor gene and the clinical course to differentiate lung adenocarcinoma from cervical adenocarcinoma. An excellent response was achieved with first-line gefitinib treatment for 3 months-both the hydronephrosis and the metastatic cervical tumor had almost disappeared. This is the first case report of metastatic retroperitoneal lymphadenopathy with ureteral obstruction resulting from lung adenocarcinoma treated effectively and safely with gefitinib.

Objective The aim of this work was to assess the value of multislice computed tomography (CT) urography in patients presenting with obstructive uropathy. Background Obstructive uropathy is a structural impedance to the flow of urine anywhere along the urinary tract. Multidetector computed tomography urography (MDCTU) has the advantage of being able to detect not only the level of obstruction but also its cause, including urinary stones, pelviureteric junction stenosis, ureteric strictures, ureteric injury, retroperitoneal fibrosis, and pelvic masses. Patients and methods This study included 30 patients of variable ages, complaining of urinary tract obstruction manifestations referred from urology and urosurgery clinics. MDCTU was performed for all patients. Results Causes of obstructive uropathy as detected by MDCTU were as follow: 14 (46.6%) cases caused by urinary tract stones, four (13.3%) with urinary bladder masses involving ureteric orifices, three (10%) with pelviureteric junction obstruction (PUJ) obstruction, three (10%) with compression of ureters, three (10%) with ureteric injuries, two (6.6%) with bladder neck obstruction, and one (3.3%) case with ureteric stricture. Conclusion MDCTU enabled an accurate diagnosis of the level of obstruction and its etiology, including nephroureterolithiasis, pelviureteric junction stenosis, ureteric strictures, ureteric injury, retroperitoneal fibrosis, and pelvic masses.