Adenomyosis-Induced Urinary Retention: Case Analysis and Clinical Implications

Introduction

LITERATURE SEARCH:

Our research team conducted a search in the PubMed, Web of Science, and Science Direct databases using the following terms and combinations: “Adenomyosis and Urinary Retention”, “Retention, Urinary, and Adenomyosis”, “Adenomyosis and Dysuria.” The search was limited to articles published in English. We found 2 case reports related to adenomyosis and urinary retention (Table 1).

Case Report

PATIENT INFORMATION:

The patient was a 43-year-old Chinese woman who had experienced intermittent urinary retention since 2021. She reported sudden lower abdominal distension and pain when holding urine, accompanied by an inability to urinate. After treatment with an indwelling catheter and bladder drainage, the catheter was removed, and she resumed normal urination. This had occurred 6 times in total. The patient has regular bowel movements, and no signs of infection were observed in the perineal area. She has had 1 previous pregnancy with spontaneous delivery and no history of abortion. Twenty years ago, she developed dysmenorrhea and menorrhagia and was diagnosed with adenomyosis at an outside hospital, with no history of other gynecological diseases.

PHYSICAL EXAMINATION:

The indwelling catheter was in place and functioning normally. The vulva was normal, the vagina was patent, with no vaginal organisms. The uterus was anteriorly positioned, enlarged to the size of a 3-month pregnancy, with limited mobility. There was no pressure pain, and no abnormal masses or tenderness in the bilateral adnexal areas.

ADDITIONAL EXAMINATIONS:

Ultrasound: The uterus was retroverted with dimensions of approximately 78×85×75 mm. The shape was abnormal, and the size was globularly enlarged. The posterior wall of the uterus was significantly thickened (55 mm). Myometrial vascularization was disorganized, particularly in the posterior wall, but the blood flow signal was not significantly increased. The ultrasound image suggested adenomyosis. No obvious mass echoes were observed in the bilateral adnexal regions (Figure 1).

Urinary System CT: The uterus was enlarged, with a possible diagnosis of fibroids or adenomyosis. Both ovaries were slightly full, the left ureter was mildly dilated, and the mid-section was compressed by the left adnexal structure. Bilateral kidney stones were also noted (Figure 2).

Uroflow: The patient experienced recurrent urinary retention. During symptom relief, the uroflow test showed a maximum flow rate (Qmax) of 17 ml/s, a void volume (Vv) of 182 ml, and a post-void residual volume (PRV) of 0 ml.

LABORATORY TESTS:

Routine urinalysis and urine culture showed no abnormalities.

TREATMENT:

Given the recurrent symptoms and the patient’s lack of fertility requirements, a total hysterectomy was selected. The patient underwent a laparoscopic total hysterectomy. After anesthesia was administered, exploration revealed an enlarged uterus, comparable in size to that of a 3-month pregnancy, with a protrusion on the right wall and a narrow pelvic space. Both ovaries and fallopian tubes appeared normal. An ultrasonic scalpel was used to sever the fallopian tubes, round ligaments, and ovarian ligaments, thereby exposing and subsequently cutting the uterine vessels. The loose tissue between the cervix and bladder was dissected, the vaginal wall was incised, and the uterus was fully detached and removed through the vaginal route. The postoperative histopathology report revealed extensive scattered endometrial glands and stroma embedded within the myometrial wall, consistent with adenomyosis. Following the surgery, the patient’s urination returned to normal, and no further symptoms of urinary retention were reported.

Written informed consent was obtained from the patient for treatment and for publication of this case report. Approval for this case report was obtained from the Ethics Committee at the University of Hong Kong – Shenzhen Hospital, and it conforms to the CARE guidelines.

Discussion

Acute urinary retention (AUR) is a common emergency in urology that can lead to acute renal failure if not managed promptly. The etiology of AUR is not fully understood and may be multifactorial, with the main causes categorized as obstructive, inflammatory, medical, and neurological [11]. Obstructive causes include any mechanical resistance in the urethra, and in women, the shorter urethra lowers the likelihood of obstruction compared to men [11,12]. Bladder outlet obstruction in women may result from pubovaginal sling surgery, pelvic organ prolapse, or exogenous urethral compression [13–15]. Common causes of exogenous compression include constipation, uterine fibroids, tumors, sling surgery, and uterine impaction during pregnancy. Posterior uterine insertion may occur during pregnancy, with the fundus becoming embedded below the sacral promontory, causing the cervix to shift cephalad, moving above or near the pubic symphysis, potentially compressing the urethra and bladder, interfering with urination [16].

Our patient repeatedly experienced intermittent urinary retention, characterized by sudden lower abdominal distension, pain when holding urine, and an inability to urinate spontaneously. It was thought that the enlarged uterus was compressing the urethra at the cervix, and catheterization was performed to relieve the urinary retention temporarily, although it did not offer a permanent solution. Due to the recurrence of symptoms and the patient’s lack of further fertility requirements, a laparoscopic total hysterectomy was subsequently performed. After hysterectomy, the patient’s urination returned to normal, consistent with our hypothesis that uterine incarceration was causing bladder outlet obstruction. Urinary retention is very rare in cases of adenomyosis, and the pathophysiologic mechanism is unknown; the likely cause is that, similar to uterine impaction during pregnancy, adenomyosis enlarges the uterus, causing it to extrude backward against the sacrum. This shift pushes the cervix forward and downward toward the pubic symphysis, compressing the urethra [17]. Additionally, patients with adenomyosis often experience chronic pelvic pain and lower abdominal pressure, which may further exacerbate urinary obstruction.

Acute urinary retention should be immediately treated with catheterization for bladder decompression. Although rapid decompression can lead to complications such as hematuria, hypotension, and post-obstructive diuresis, there is no evidence that gradual bladder decompression reduces these complications. Therefore, rapid and complete bladder emptying is recommended [1]. In most cases, a detailed history, physical examination, and selected diagnostic tests can identify the cause of urinary retention. In female patients, taking a history requires specific questions about gynecologic diseases and pregnancy. A thorough physical examination is essential, with special attention to bladder, rectal, uterine prolapse, and enlargement of the uterus, ovaries, or adnexa [1]. Laboratory tests, such as urinalysis, serum urea nitrogen, creatinine, electrolytes, and serum glucose, help evaluate for urinary tract infections, renal failure, and diabetes mellitus in neurogenic bladder cases. Imaging tests, including abdominal and pelvic ultrasound, CT, and MRI, can assess suspected pelvic, abdominal, or retroperitoneal masses, while MRI scans of the brain and spine can evaluate intracranial pathologies (eg, tumors, stroke, multiple sclerosis) and spinal pathologies, including herniated discs, cauda equina syndrome, spinal tumors, and spinal cord compression, all of which can cause neurogenic bladder leading to urinary retention.

In the treatment of adenomyosis combined with urinary retention, catheterization should first be performed to drain and decompress the bladder. The severity of the disease and the patient’s fertility needs should then be assessed. If the patient is fertile and symptoms are mild, conservative treatment may be chosen, including the use of gonadotropin-releasing hormone (GnRH) agonists or the levonorgestrel intrauterine system (LNG-IUS). GnRH agonists are commonly used to inhibit estrogen production by the ovaries, mimicking the effects of ovarian removal. These drugs are highly effective for pelvic pain caused by endometriosis and offer the advantage of largely reversible hypoestrogenic effects after discontinuation [18]. LNG-IUS is associated with endometrial decidualization, reduction in bleeding, improved uterine contractility, and decreased dysmenorrhea by reducing prostaglandin production within the endometrium and inducing amenorrhea through estrogen receptor downregulation [19]. For patients with severe symptoms or ineffective conservative treatment and no fertility requirements, surgical intervention, such as hysterectomy, may be necessary.

Conclusions

Acute urinary retention (AUR) is uncommon in women, making timely and accurate diagnosis crucial. While adenomyosis is a common condition, it is extremely rare for it to cause AUR. This case report shows that uterine enlargement due to adenomyosis compressing the urethra is a possible cause of AUR in women. Based on our clinical experience and the literature, we propose the diagnostic and therapeutic process shown in Figure 3. Research is needed to investigate whether urinary retention results from simple compression or nerve-related mechanisms. Reporting rare cases raises clinical awareness, emphasizing the importance of including adenomyosis in differential diagnoses. Early recognition and individualized treatment can significantly improve prognosis and quality of life.