The use of transvaginal ultrasonography to diagnose bladder carcinoma in women presenting with postmenopausal bleeding

The aim of a gynecological ‘one-stop bleeding clinic’ is to identify the cause of the bleeding and, if possible, to exclude endometrial carcinoma. Most of these outpatient clinics are based on the use of transvaginal sonography (TVS) with endometrial biopsy if indicated and/or a diagnostic hysteroscopy. One additional advantage of TVS is that it enables the examiner to investigate the entire pelvis1. If no endometrial pathology is detected, a detailed examination of the bladder during TVS scanning may be indicated, certainly when the patient is postmenopausal. Bladder carcinoma is a rather rare finding in patients presenting at a gynecological clinic for abnormal vaginal bleeding. In a series of 673 consecutive patients evaluated at our department's one-stop bleeding clinic, only two patients (0.3%) were diagnosed with primary bladder cancer. In our first case, a 75-year-old white female, gravida 3 para 3, was referred to the clinic with postmenopausal bleeding. She had been postmenopausal for 23 years. She reported irregular vaginal bleeding (spotting) during the previous 36 months, which occurred during, as well as after, passing urine. Clinical examination was unremarkable. On ultrasonography (Voluson E8, GE Medical Systems, Zipf, Austria) the uterus and ovaries were normal for her age. Ultrasound examination and gel infusion sonography revealed a normal endometrial cavity and a thin endometrium. No free fluid was identified in the pouch of Douglas. The bladder was incompletely emptied, which allowed the identification of several irregular solid lesions of up to 29 mm in diameter (Figure 1). On color Doppler imaging, these were found to be highly vascular, with a ‘color score’ of 42. She subsequently underwent further urological investigation and a papillary transitional cell carcinoma (TCC), with stromal invasion but an intact muscularis, was revealed (stage T1N0M0). Two-dimensional power Doppler (a) and three-dimen- sional surface-rendered (b) ultrasound images of the bladder in Case 1 demonstrating an irregular papillary lesion which is shown to be highly-vascularized in (a). In the second case, a 75-year-old white female, gravida 1 para 1, who had been postmenopausal for 25 years, was referred with a 3-month history of irregular minimal vaginal bleeding which became obvious during and after micturition. Again, gynecological ultrasound examination was normal, but in the bladder several irregular, highly perfused (color score of 4) lesions of up to 30 mm in diameter were visualized (Figure 2). Cystoscopy revealed a papillary TCC carcinoma, with stromal invasion not affecting the muscularis (stage T1N0M0). Two-dimensional power Doppler imaging of the bladder in Case 2 demonstrating a highly-vascularized irregular papillary lesion. Both these patients were postmenopausal, indicating that in our series we found bladder malignancy in 0.8% of postmenopausal women attending the bleeding clinic, which is in accordance with a previous series3. However, it is possible that we have a selected population at our bleeding clinic, including those women with persistent bleeding after initial negative investigation. Therefore our data may not reflect the true incidence of bladder cancer in women with abnormal bleeding. Although most cases of abnormal bleeding in women are of gynecological origin (principally the endometrium, but also the cervix, vagina or hormone-producing ovarian tumors), other non-gynecological causes (e.g. pathologies of the rectum, anus, urethra or bladder) must also be considered. Particularly when endometrial pathology cannot be identified as the cause for the bleeding, there should be a high index of suspicion for other gynecological1, 4 and non-gynecological causes3. A detailed examination of the bladder during TVS of the pelvis could be part of the standard examination procedure, especially in postmenopausal women. In order to achieve adequate visualization of its wall, the bladder should be filled with at least a moderate amount of urine—about 50 mL—to act as a negative contrast agent. Filling of the bladder facilitates identification of focal intravesical pathology, and is analogous to hydrosonography for the endometrial cavity. The contrast between tissue and fluid means that tissue interfaces in the bladder are relatively easy to visualize on ultrasound. Previous studies have described the use of TVS to diagnose several causes of intravesical pathology, such as bladder endometrosis, stones and carcinoma3, 5, 6. However, underfilling of the bladder and trabeculation due to bladder wall thickening associated with detrusor overactivity could lead to false-positive results6 when mucosal folds are present. As most ultrasonographers are used to examining patients with an empty bladder during TVS, the opportunity for an accurate evaluation of the bladder may be lost. In selected patients with symptomatology pointing to hematuria or irritative bladder symptoms, or by extension when no gynecological pathology is found, one may insist on more optimal conditions, and ultrasound scanning should start prior to emptying of the bladder. In case of an empty bladder, the ultrasound examination should be repeated after proper filling. Translabial ultrasound has also been used to diagnose intravesical pathology such as foreign bodies or tumors7, 8. In both cases described in this report, the patients mentioned ‘irregular spotting during and after passing urine’, suggesting painless hematuria rather than postmenopausal bleeding. Therefore a proper history-taking is also of great importance in order to define the possible origin of the abnormal bleeding. Ultrasonography has been shown to have a 63% specificity and a 99% sensitivity for the detection of bladder tumors9. Finding a solid, highly vascularized and irregularly shaped intravesical tumor could prevent the delayed diagnosis of a bladder malignancy without using any extra resources. While the main goal of a gynecological one-stop bleeding clinic is to exclude endometrial cancer, other possible causes of bleeding should be considered. As in the cases we present, bladder pathology may be obvious, and so an examination of the bladder should be considered for women presenting with postmenopausal bleeding. However, there are few data on the overall performance of TVS in this context and prospective studies are needed to optimize the use of this technique.