CORRELATION OF UTERINE FIBROID MASS WITH UPPER RENAL …

i

THE RELATIONSHIP BETWEEN LOCATION AND SIZE OF

UTERINE FIBROID MASS AND UPPER RENAL TRACT

CHANGES USING SONOGRAPHY IN ILORIN, NIGERIA.

A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PART FULFILMENT FOR THE AWARD OF FELLOWSHIP OF THE MEDICAL COLLEGE IN RADIOLOGY (FMCR) NIGERIA

BY

DR HALIMAT JUMAI AKANDE MBBS (ILORIN) 1997

NOVEMBER 2005.

ii

CERTIFICATION

I certify that this work was carried out by Dr Halimat Jumai Akande of the department of

Radiology, University of Ilorin Teaching Hospital, Ilorin Nigeria under supervision of

……………………………..

PROF.D.A.NZEH

Consultant Radiologist,

Dept. of Radiology,

University of Ilorin Teaching Hospital,

Ilorin,Kwara State.

iii

TABLE OF CONTENTS

Page

Title page ----------------------------------------------------------------------- i

Certification ---------------------------------------------------------------------- ii

Table of contents------------------------------------------------------------------iii

Introduction ---------------------------------------------------------------------- 1-2

Gross Anatomy ----------------------------------------------------------------- 3-4

Ultrasonographic anatomy of the upper renal tract ------------------------ 4-7

Literature review ---------------------------------------------------------------- 8-15

Aims and objectives -------------------------------------------------------------16

Materials and method ----------------------------------------------------------- 17-22

Results ---------------------------------------------------------------------------- 23-36

Discussion ------------------------------------------------------------------------ 37-39

Limitations ----------------------------------------------------------------------- 40

Summary -------------------------------------------------------------------------- 41

References ------------------------------------------------------------------------ 42-46

1

INTRODUCTION

One of the most common human tumours and much the most frequent uterine neoplasm, is

the myoma 1 . Although arising in the muscular wall of the uterus, there is always some

admixture of fibrous tissue in these tumors, hence the term fibromyoma. Other terms in

common use include fibroid, myoma, leiomyoma 2.

The prevalence rate varies from 20 – 25 % of women depending on age, ethnicity, parity and

imaging techniques used to assess their presence 3,4. Studies have shown that it usually

occurs from age 25 years onwards 1,5-7.

Fibroids are generally said to be higher in blacks than in whites 2,8. Prospective studies show

that black women have a three-fold greater frequency of myomas and a relative risk two to

three times that in white women 9.

The precise aetiology of uterine fibroids is unknown, but occurrence mainly in the

childbearing age suggests at least a partial role for estrogen 2. Uterine fibroids are not a

clinical problem before puberty and should not grow after menopause 10. Factors such as

being parous, use of oral contraceptive and cigarette smoking have been reported to decrease

the risk of fibroids 11-13, while factors like obesity and high parity increase the risk of fibroids

13,14.

Uterine fibroids are frequently asymptomatic, but are a recognized cause of menorrhagia,

dysmenorrhea, irregular vaginal bleeding, lower abdominal mass and distension 15.

Apart from the symptoms related to the genital system, they can also give pressure effects

and cause compression or displacement of the ureters, bladder or rectum 10. The urinary

symptoms may be explained by the close relationship of the pelvic part of the ureter to the

lateral fornix of the vagina and the cervix which makes the pelvic part of the ureter

susceptible to compression by a fibroid mass 16-18 . This compression can lead to generation

of a backpressure effect manifested by the dilatation of the ureters and the pelvicalyceal

2

collecting systems from its mildest to severe forms. The upper renal tract changes associated

with uterine fibroid mass are usually chronic in nature 19.

This study is intended to make apparent the relationship between the size and location of

uterine fibroid and the upper renal tract changes as well as highlight the benefits of renal

ultrasound in these patients.

3

GROSS ANATOMY

The uterus, an important and essential female reproductive organ, is pear-shaped and lies

between the urinary bladder and the rectum. It is made up of the fundus, body and cervix and

it is about 7.5cm in length 17. The wider body narrows to become the cervical canal at the

isthmus. The internal os is at the upper end of the cervical canal and the external os at its

lower end. The fallopian tubes open into the cornua of the uterus superolaterally.

The wall of the uterus is very thick and consists of three layers: serous, muscular and

mucous 20. Any of these layers can give rise to uterine myoma.

The serous layer (perimetrium) is simply the peritoneal covering and is firmly adherent over

the fundus and most of the body. The myometrium is the muscular layer and majority of

uterine myomas arises from this later. This smooth muscle layer is made up of an outer part

which is weaker and composed of longitudinal fibres; and an inner,stronger part composed of

interlacing fibres. The mucous layer (endometrium) is soft and spongy and consists of tissue

resembling embryonic connective tissue. The surface consists of a single layer of ciliated

columnar epithelium and this characteristics makes it more likely to cause menorrhagia when

a myoma is located in this layer 7.

The anterior and posterior peritoneal reflections of the uterus form the uterovesical pouch

and the pouch of Douglas respectively. The lateral reflection forms the broad ligament

through which the ureters (pelvic portion), running posterior to the uterine artery, attain a

close lateral relation to the lateral vaginal fornix before entering the bladder. This makes the

ureters susceptible to compression by fibroid masses especially those located in the cervix

(cervical) or within the broad ligament (intra-ligamentary). The intrabdominal portion of the

ureter extending from the termination of the pelvis courses downwards and slightly medially

anterior to the psoas major muscle in the retroperitoneal space. The entire length spans a

distance of about 26-28cm with a diameter of approximately 3mm except at its areas of

constriction, these are: the junction of the pelvis and ureter; the pelvic brim and the entrance

4

into the bladder 18. The entire length of the ureters leading to the pelves and the renal

collecting systems can be dilated by backpressure effect secondary to compression of the

ureters. The kidney being an organ of excretion may lose its filtration and secretory abilities

in the event of obstruction. The kidneys are retroperitoneal in location and lie obliquely with

their upper poles more medial and posterior than the lower poles. The renal parenchyma is

composed of an outer cortex and an inner medulla. The collecting system is made up of

minor calyces combining to form two, three or more major calyces which in turn unite to

form the pelvis of the kidney. The pelvis most frequently is intrarenal but could partly or

entirely be extrarenal. The latter could be mistaken for hydronephrosis on ultrasound.

ULTRASONOGRAPHIC ANATOMY OF THE UPPER RENAL TRACT.

Ultrasound of the kidneys is done most preferrably with the patient prone or in oblique

position to allow demonstration of the entire length of the kidneys. With the liver and spleen

providing acoustic windows on the right and left respectively, the kidneys are seen to be oval

shaped on longitudinal scan and round on transverse scan. The parenchyma appears

relatively hypoechoic to that of the liver and spleen and this surrounds a dense echogenic fat

filled renal sinus.

The normal length is between 8-13cm . In the male, this averages 10.6cm on the left and

10.3cm on the right; while in the female the corresponding length is 10.2cm on the left and

9.94cm on the right respectively21. The parenchyma is composed of the centrally located

pyramids or medulla surrounded by the peripherally located cortex. The bases of the

triangular pyramids (medulla) are usually identified by bright dots denoting the arcuate

arteries and this area differentiates the cortex from the medulla on a good quality image. The

parenchyma is surrounded by the perinephric fat, which is seen as an echogenic rim. The

bright echogenic centre is largely produced by renal sinus fat with vessels and collecting

system contributing to it. The normal pelvicalyceal system is not easily seen but occasionally

5

in well-hydrated patients, it is seen as symmetrical anaechoic area occupying the centre of

the kidney (Fig.1a-c). An extrarenal pelvis, which is a normal variant may be demonstrated if

present.

The ureters, which arise from the renal pelves are difficult to demonstrate on ultrasound

when not dilated. The normal calibre is about 3mm 2. The entire length of the ureter may be

visualised in hydroureter secondary to distal compression of the ureter.22.

6

Liver

Cortex

Pyramid

Minor Calyx

Major Calyx

Pelvis

Papilla

Ureter

Fig. 1a Schematic diagram of the internal structure of the Kidney

Renal Column of cortex (of bertin)

Capsule

Cortex

Pyramids

Sinus echoes

Fig 1b Schematic diagram of the ultrasonographic appearance of the right kidney.

7

8

LITERATURE REVIEW

UTERINE FIBROIDS

Uterine myomas are benign clonal tumours that arise from the smooth-muscle cells of the

human uterus and are the most common pathological growth in the female reproductive tract.

It affects 20-25% of all women from the age of 25years onwards 1,5-7. The true clinical

prevalence may be higher with newer imaging techniques like the magnetic resonance

imaging (MRI). Careful pathological examination of surgical specimens suggests that the

prevalence is as high as 77% 23,24 and Entman in his study reported that the incidence of

fibroid had been estimated as high as 50% in autopsy series25. In the review carried out by

Aboyeji and Ijaiya 15, in Ilorin, it was found that fibroid constituted 13.4% of gynaecological

admission while 3.2%, 8.3% and 7.8% were the incidence recorded in Zaria, Ilesha and

Benin city respectively 26,27,28. These recorded incidences though low when compared to

figures from studies in Europe, may not be the actual incidence because of the low socio-

economic status in this enviroment which prevents patients from seeking medical treatment

in the hospitals. Other studies indicate a higher incidence in blacks when compared with

whites 2,24 . This claim has been disputed by Akinkugbe in Lagos, Nigeria 5.

The precise aetiology of uterine fibroid is not known. They are most often seen after

menarche and the majority atrophy after the menopause 29. Myoma has been reported in

female as young as 11yrs of age 1. Restriction mainly to the reproductive age suggests at least

a partial role for estrogen 2, but the occurrence of fibroid in just some women and not others,

since estrogen is produced in practically all women raises the possibility of genetic

predisposition 7,30. A study carried out on the heritability and risk factors of uterine fibroids

however concluded that reproductive and anthropometrical factors may have at least a large

role in pathogenesis of fibroids than genetic factors 14. Increased body mass index in obese

patients has been reported to increase the risk of uterine fibroid. This has led to the

postulation that body fat contributes to increase estrogen production via aromatization of

9

androgen31. Factors associated with reduced risk for fibroids include the use of oral

contraceptive and cigarette smoking. It has been reported that the use of oral contraceptive

for five consecutive years reduce the risk of fibroids by 17% and women who smoke 10

sticks of cigarette daily have an 18% lowered risk compared to non-smokers 13.

The pathogenesis of myoma involves the transformation of normal myocytes into abnormal

ones and their growth into clinically apparent tumour via clonal expansion 32,33. On histology,

they reveal a whorled pattern of smooth muscle and fibrous connective tissue in varying

proportions. Grossly, they are buff-colored, rounded, smooth and firm and usually lighter in

colour than the myometrium.

Uterine fibroids are usually asymptomatic.They may however present with menorrhagia and

hypermenorrhea which can lead to iron deficiency anaemia. It can also present with pain

secondary to degenerations within the tumour. The degeneration may be atrophic, hyaline,

cystic, calcific, septic, carneous(red), or myxomatous degenerations. Spontaneous abortion

and infertility are also frequent presentations by patients but the true incidence of

spontaneous abortion is unknown and the relationship with infertility remains controversial

13,20. Pressure symptoms can result from compression of surrounding structures like ureters,

bladder, rectum and blood vessels to produce ureteric obstruction with hydronephrosis, acute

urinary retention, constipation and oedema of the lower extremities respectively.

The urinary tract changes depend on the size and location of the uterine fibroid and are

reported to be commoner with anterior intramural, cervical and intraligamentary types. Also,

intraligamentary fibroids may stimulate erythropoietin production from the renal system

leading to polycythaemia 20.

The types of uterine fibroid depend on their locations as shown below in figure 2.

10

Subserosal

Submucosal

Intramural

Endometral LiningPedunculated

Cervix

Vagina

Subserosal

Submucosal

Intramural


Cervix

Vagina

Subserosal

Submucosal

Intramural


Cervix

Vagina

Subserosal

Submucosal

Intramural


Cervix

Vagina

Subserosal

Submucosal

Intramural


Cervix

Vagina

Fig. 2 Schematic Diagram showing the sites of Uterine Myomas. A, B, C are mixed types.

11

Uterine fibroids may be corporeal or cervical, the cervical constituting only a small fraction

of the total number 1. However, the close relationship of the ureters to the cervix makes the

cervical fibroids significant in terms of the possible urinary tract changes they can produce.

Depending on which layer of the uterus the corporeal fibroids arise from, they can further be

classified as subserous, interstitial (intramural) and submucous corresponding to growth just

beneath the serous coat, muscular wall and the mucosa respectively (Fig.2). Any of these

subtypes of myoma may acquire an extrauterine blood supply from omental vessels with its

pedicle becoming atrophied to form a parasitic fibroid. Intraligamentary fibroids are

subserous tumours arising laterally from within the two layers of the broad ligament. The

identification of any of these types of uterine fibroid, can readily be achieved by

ultrasonography.

Ultrasonography is cheap, readily available and relatively non-hazardous. It involves the use

of high frequency sound waves to visualise the body organs. A trans-abdominal ultrasound of

the pelvis requires a moderately full bladder to displace the small bowel into the abdominal

cavity and straighten out the body of the uterus (corpus uteri) relative to the cervix. The

distended bladder also provides an acoustic window whereby the pelvic organs can be seen.

A 3.5MHz transducer, most preferably sector is used. The ultrasound appearance of fibroid

varies considerably, but typically is seen as solid masses with a whorled stromal pattern 34.

Cystic degeneration is seen as an area of hypoechogenicity and calcifications seen as areas of

hyperechogenicity.These calcifications are most often amorphous in nature.However it has

been reported that ultrasound does not differentiate with consistent accuracy the difference

between uterine and ovarian masses moreso,if the fibroid is a subserous pedunculated type 10.

Other investigative modalities include conventional radiography, computed radiography and

magnetic resonance imaging35.

12

The presence of a fibroid mass may be suspected on a plain radiograph of an adult female

when a mass of soft tissue density with or without areas of calcification is seen. However,

plain radiography is contraindicated when there is possibility of pregnancy.

Magnetic resonance imaging (MRI) gives better visualization of individual myoma, but for

most clinical indications the extra cost is not justified. Moreover, it is yet to be readily

available in this environment.

Computed tomography (CT) will give individual characteristics of the fibroid but its use is

limited because of the high cost and the harmful effect of radiation .

Intravenous urography (IVU) is also used not in the diagnosis but in the work-up to show the

effects on the upper and lower urinary tracts. It reveals any ureteral deviation or compression

and identifies genitourinary anomaly 10. However, as in the other investigative modalities

utilizing ionizing radiation, the harmful effect of ionizing radiation is a limiting factor.

Reactions to contrast medium from the mildest to most severe types could occur. Moreover,

IVU depends on a functioning kidney, thus a compromised non-functioning kidney will not

be demonstrated. Ultrasound is usually the first radiological investigation of choice in this

situation. It is simple, non-invasive in nature and quickly ascertains presence and location

of the kidney and shows calyceal dilatation if present 19,36.

The complications of uterine fibroid include anaemia secondary to the abnormal uterine

bleeding 10, degenerative changes 2, infertility13,37, spontaneous abortions 13,37, abnormal lie

during pregnancy 1, obstruction during labour 1 and acute urinary retention secondary to

pressure effects38.

The management of uterine fibroid could be medical or surgical depending on the age, parity

and reproductive desirability of the patients. The surgical management could either be

myomectomy or hysterectomy 39.

13

PATHOPHYSIOLOGY OF OBSTRUCTION

In order to appreciate upper renal tract changes secondary to obstruction, an understanding of

the pathophysiology of obstructive uropathy is indispensable. Impedance to the flow of urine,

urinary tract dilatation, reduction in flow rate, varying intra-renal pressures and functional

impairment play sequential roles in producing these changes 19. These changes are

collectively referred to as obstructive uropathy.

Impedance to the flow of urine usually is as a result of compression of any part of the ureter

and this leads to increase in the renal pelvic pressure which normally is below 12mmHg with

mean being 6.5mmHg 40. The increased intraluminal pressure leads to more forceful

contractions of the muscles of the renal pelvis and ureter with resultant dilatation of the part

proximal to the obstruction.

In cases of chronic obstruction however, such as caused by pelvic masses like uterine fibroid,

hydrostatic pressure continues to rise despite ureteric dilatation. Energy is used preferentially

to maintain muscle tone rather than peristalsis and the ureter becomes a passive conduit 41.

There is gradual fall of pressure towards normal in addition to contributions from decrease

glomerular filtration rate and increase reabsorption of urine from the renal pelvis 42 .

Functional impairment may result following prolonged obstruction, causing hydronephrosis,

however, the function may still be preserved despite huge hydronephrosis according to

Green et al 43. On the other hand, hydronephrosis may be present without obstruction in

some patients in which there is congenital abnormal smooth muscle of the renal pelvis or

ureter causing ectasia 44.

Many investigative modalities can be used to diagnose obstructive changes.These include

intravenous urography, antegrade pyelogram, retrograde pyelogram, radionuclide studies,

perfusion pressure flow studies, cystometry, cystourethroscopy and of interest in this study

ultrasound.19.

14

The urographic studies are of greatest value in acute obstruction, permitting the site of

obstruction and anatomy of the urinary tract to be determined. The limitations however are

their invasiveness, reaction to contrast medium and radiation exposure.

Radionuclide studies are of most significance in assessing quantitatively and non-invasively

individual renal function 19. This procedure is becoming widely used in the developed

countries 45,46 .

Perfusion pressure flow study entails the percutaneous antegrade puncture of a dilated renal

pelvis or ureter and measurement of the pressure after perfusion with saline or contrast

medium. It is also invasive and reaction to contrast medium can occur. Furthermore,it gives

no information on renal function.

Ultrasound has been reported by Ellenbogen et al to be an effective screening test in patients

with obstruction 47. Ultrasound is cheap, non-invasive and non-hazardous. Ultrasound

overcomes many of the inherent limitations of excretory urography and provides an excellent

anatomic information of the renal systems with an added advantage of showing in most cases

the cause of obstruction 48. Ultrasound demonstrates dilated pelvicalyceal system as seen by

separation of the echogenic renal sinus complex. Hydronephrosis can exist in varying

degrees and duration, the residual parenchymal thickness serving as an important indicator of

severity 49.

The different grades of hydronephrosis are as follows:

Grade 0: central collecting system echoes compact and homogenous.

Grade 1: slight separation of the collecting system echoes with a central ovoid or

fusiform sonolucency.

Grade 2: further separation of collecting system echoes with a rounded sonolucency

seen centrally.

Grade 3: Major portion of the kidney replaced by a sonolucent sac.

The grades 2 and 3 are detected with 100% accuracy on ultrasound 47

15

Ultrasound, though an excellent screening modality has its own pitfalls. It could misdiagnose

a dilated renal pelvis not caused by an obstruction giving a false positive reading.It is also

operator dependent. However, these should not prevent ultrasound from being used as a

screening test in patients suspected of having features of obstruction.

16

AIMS AND OBJECTIVES

1. To determine the relationship between the size and location of the uterine fibroid mass

and the upper renal tract changes.

17

MATERIALS AND METHODS.

This study was carried out in the university of Ilorin Teaching Hospital between June 2004

and June 2005. The sample size was determined using Fisher’s formula. For population size

greater than 10,000:

n = z2 pq

d2

where: n = the desired sample size(when population is greater than 10,000)

z = standard normal deviate,usually set at 1.96

p = the proportion in the target population estimated to have a particular

characteristics.

q = 1.0 – p

d = degree of accuracy desired,usually set at 0.5 .

A total of seventy- six patients were used for the study as against One hundred and ten

patients calculated as stated above. The reason for this being that the ultrasound scan

machine at the maternity wing of the hospital broke down during the period of study leading

to reduction in the turn out of patients.

Patients clinically suspected or confirmed to have uterine fibroid referred to the radiology

department from June 2004 to June 2005 were included in this study.

Criteria for exclusion were:

1. Patients having uterine fibroid co-existing with pregnancy or other pelvic mass.

2. Patients with known renal pathology co-existing with uterine fibroid.

A concept/D Dynamic Imaging Ultrasound machine equipped with 3.5MHz and 5.0MHz

transducers was used for all the ultrasound scans.

All the patients were asked to take lots of fluid to achieve a full bladder needed for

evaluation of the pelvis organs. The uterus was scanned transabdominally in longitudinal and

tranverse planes with the patient in the supine position. The 5.0MHz transducer was used for

most patients while the 3.5MHz transducers was used for the obese patients. Localization of

18

a fibroid nodule was done by identifying any well circumscribed isoehoic or hypoehoic mass

lesion in any part of the uterine layer. Areas of cystic degeneration or calcification were

identified as hypoechoic or highly hyperechoic focus.

The location of the fibroid nodule was based on the uterine layer of origin, which are:

i) Submucus: fibroid intruding into or are contained in the endometrial cavity.

ii) Intramural/ Interstitial: fibroid located in the muscular wall.

iii) Subserous: fibroid located just below the serous layer.

iv) Mixed: combination of any of 1-3 above.

v) Cervical: fibroid located within the cervix.

For this study, the size was taken as the widest diameter of a fibroid mass. Some of the

patients for this study had more than one fibroid mass but the diameter of the largest fibroid

mass was taken to prevent any ambuiguity.

Patients were allowed to void and then placed in the prone position to assess the kidneys.

This was done for optimal visualization of the kidneys and to prevent false positive results in

assesement of calyceal dilatation. The longest distance between the upper and lower pole of

the right and left kidneys were measured to get their bipolar length (Fig. 3).

The renal parenchymal thickness assessed on longitudinal and transverse views was taken as

the distance between the echogenic edge of the central renal sinus to the echogenic renal

capsule (Figs. 4).

Degree of calyceal dilatation was graded as follows 49:

Grade 0: Central collecting system echoes compact and homogenous.

Grade 1: Slight separation of the collecting system echoes with a central ovoid or

fusiform sonolucency (Fig. 5).

Grade 2: Further separation of the collecting system echoes with a rounded

sonolucency centrally (Fig. 6).

Grade 3: Major portion of the kidney replaced by a sonolucent sac (Fig.7).

19

The right and left ureters were looked for and when visualised, the diameter of each was

taken and graded as below:

Grade 0: Non- visualised or ureter calibre less or equal to 3mm.

Grade 1: Ureter calibre between 4-6mm (Fig.7).

Grade 2: Ureter calibre between 7-9mm.

Grade 3: Ureter calibre greater than 10mm.

Data collected was collated and analysed using the EPINFO version 6.0. Data analysis was

done using descriptive analysis for mean and measure of dispersion, Chi square of

significance to compare proportions and Student’s t-test for comparism between the means of

two groups. The relationship between two variables was done by the Pearson correlation.

Sketch diagrams, histograms and pie charts used where necessary.

FIG.1 MEASUREMENT OF

RENAL LEANGH

20

Fig. 3 Longitudinal renal scan measuring the kidney bipolar lenght

Fig. 4 Longitudinal and transverse scans showing the measurement of the renal parenchyma thickness . Renal Parenchyma Thickness









21

Fig. 6 Longitudinal ultrasound scan of the kidney showing grade 2 hydrocalycosis.










22

Fig. 7 Longitudinal ultrasound scan of the kidney showing grade 3 hydrocalycosis and grade 2 hydroureter.Fig. 7 Longitudinal ultrasound scan of the kidney showing grade 3 hydrocalycosis and grade 2 hydroureter.Fig. 7 Longitudinal ultrasound scan of the kidney showing grade 3 hydrocalycosis and grade 2 hydroureter.Fig. 7 Longitudinal ultrasound scan of the kidney showing grade 3 hydrocalycosis and grade 2 hydroureter.Fig. 7 Longitudinal ultrasound scan of the kidney showing grade 3 hydrocalycosis and grade 2 hydroureter.

23

RESULTS

The result of this study has been analysed first, using the mean of each data for the entire

patients on one hand, and then using the mean of a data with the different fibroid locations

and their mean sizes.

A total of 76 clinically diagnosed uterine fibroid patients were recruited into the study over a

period of one year – June 2004 – June 2005.

Table 1 shows the age distribution of the patients.

The age of the patients was ranged between 19 and 70years (mean 33.8, SD+8.9 years).

Table 1: Age distribution of the patients.

Age(years)

Frequency

%

15-24

11

14.5

25-34

34

44.7

35-44

23

30.3

45-54

6

7.9

55+

2

2.6

Total

76

100.0

24

Table 2 shows the mean age by fibroid location.

The mean ages of submucus, intramural, subserous and cervical fibroid subjects were

30.4(SD+3.0), 34.4(SD+9.9), 39.4(SD+2.1) and 32.6(SD+10.4) years respectively.

Table 2: Mean age by fibroid location.

Mean Age (Years) Fibroid location

30.4 Submucous

34.4 Intramural

39.4 Subserous

32.6 Cervical

25

Table 3 and Figure 1 show the mean parity and mean parity by fibroid location respeactively.

The mean parity of the subjects was 2.18 (SD+2.40). Majority (82.9%) of the subjects had a

parity between 0-4, while 17.1% were between 5-9.

The mean parity for the submucus fibroid subjects was 1.8 (SD+2.6), 2.2(SD+2.5) for

intramural, 3.4(SD+1.6) for subserous, and 2(SD+2.0) for cervical fibroid subjects.

Table 3: Parity and mean age of the patients:

Parity

Mean age (years)

Frequency

%

0

28.4

31

40.8

1

34.8

9

11.8

2

31.8

4

5.3

3

34.4

7

9.2

4

34.3

12

15.8

5

45.0

5

6.6

6

43.2

5

6.6

7

48.0

1

1.3

9

54.0

2

2.6

Total

33.8

76

100.0

26

FIGURE 1: Pie chart showing the parity distribution of the patients.

Pie chart showing the Parity distribution of the subjects.

1

40%

2

12%

3

5%

4

9%

5

16%

6

7%

7

7%

8

1%

9

3%

KEY

1- Parity 0

2- Parity 1

3- Parity 2

4- Parity 3

5- Parity 4

6- Parity 5

7- Parity 6

8- Parity 7

9- Parity 9

27

Table 4 showed the frequency distribution of the subjects menarche age.

The mean of the menarche was 13.4 (SD+1.48) years. Majority of the subjects attained

menarche at between 12-14 years.

Table 4: The distribution of Menarche by patients.

Age of Menarche

Frequency

%

11 6

7.9

12 18

23.7

13 17

22.4

14 17

22.4

15 10

13.2

16 7

9.2

17 1

1.3

Total 76

100.0

28

The study revealed that the mean menstral flow duration was 6.9 (SD+1.6) days for

submucous fibroid, 5.1 (SD+1.8) days for the intramural fibroid, 6.4 (SD+0.6)days for

subserous and 5.2 (SD+0.4) for cervical fibroid. The mean duration of menstral flow in the

studied subjects was 5.6 (SD+1.8)days.

29

Table 5 show the frequency distribution of the fibroid locations and their mean sizes.

Table 5: Showing the distribution of the fibroid location and their mean sizes.

Fibroid location Frequency % Mean Size

Submucus 15 19.7 42.3

Intramural 51 67.1 47.4

Subserous 5 6.6 81.6

Cervical 5 6.6 40.8

TOTAL 76 100.0

30

The mean value of the right renal length was 108.9 (SD+12.9)mm, while that of the left renal

length was 109.1(SD+13.8)mm. There was no statistical significance(p >0.05) difference

between the right and left renal length when the fibroid location and size were used to

compare.

31

Table 6 shows the distribution of the degree of calyceal dilation.

Table 6: The distribution of the degree of calyceal dilatation.

Degree of

calyceal

dilatation

Total Right kidney % Left kidney %

Grade 0 81 41 53.9 40 52.6

Grade 1 48 22 28.9 26 34.2

Grade 2 20 12 15.8 8 10.5

Grade 3 3 1 1.3 2 2.6

TOTAL 152 76 100.0 76 100.0

A total of 41(53.9%) patients had normal calyces on the right while 28.9%, 15.8%, and 1.3%

had grades 1,2, and 3 respectively.

There was a weak correlation (r=0.4) between the mean right calyceal dilation (RCD) of 0.6

(SD+0.8)mm and mean fibroid size of 48.2 (SD+20.8)mm in this study.

For the submucous fibroid and intramural fibroids, weak correlations (r=0.3 and r=0.4

respectively) exist between RCD and these locations.

Subserous fibriod has no correlation with RCD while a strong correlation (r=0.6) exists with

the cervical fibroid.

Right calyceal dilatation correlated strongly (r=0.7) with the cervical mean fibroid size of

40.8(SD+13.3)mm and weakly (r=0.3) with mean fibroid sizes of 42.3(SD+11.8)mm and

32

47.4(SD+2.1)mm in the submucous and intramural locations respectively. However, there is

no relationship between RCD and the subserous mean fibroid size of 81.6(SD+17.6)mm.

On the left side, a total of 40(52.6%) patients had normal calyces while 34.2%, 10.5%, and

2.6% had grades 1,2, and 3 respectively.

The mean left calyceal dilation (LCD) was 0.6(SD+0.8)mm and this showed a weak

correlation (r=0.3)with the fibroid mean size of 48.2(SD+20.8)mm in this study.

The submucous fibroid showed a negative correlation (r= -0.3) with LCD.

The correlation (r=0.2) between LCD and the intramural fibroid is weakly positive while the

subserous fibroid showed a strong correlation(r=0.8).

There was no correlation (r=0.0) between the cervical fibroid and LCD.

A similar pattern of relationship as for LCD and fibroid locations is seen when LCD is

correlated with mean fibroid sizes.

No correlation exist with the cervical mean fibroid size of 40.8(SD+13.3)mm but a very

strong correlation(r=0.8) with the mean fibroid size of 81.6(SD+17.6)mm for the subserous

fibroid.

A weak correlation(r=0.2) with the intramural fibroid size of 47.4(SD+21)mm and a weak

negative correlation (r=-0.3) relationship with LCD and the submucous fibroid mean size of

42.3(SD+11.8)mm is shown.

33

Table 7 shows the grouping of the measured renal parenchymal thickness on the right and

left.

Table 7: The groupings of renal parenchyma thickness on the right and left.

Renal

parenchyma

thickness(mm)

Total Right Kidney

(No of cases)

% Left Kidney

(No of cases)

%

8.0- 12.9 2 2 2.6 0 0

13.0-17.9 53 29 38.2 24 31.6

18.0-22.9 95 44 57.9 51 67.1

>/23 2 1 1.3 1 1.3

Total 152 76 100.0 76 100.0

The mean right parenchymal thickness (RPT) was 18.1(SD+2.7)mm and showed a weak non

correlation with the mean fibroid size of 48.2(SD+ 20.8)mm.

Similarly, in the submucous, subserous and intramural fibroids, the mean RPT of

18.4(SD+2.2)mm, 17.4(SD+2.1)mm and 16.7(SD+4.9)mm respectively showed no

correlation (r= -0.1, -0.1 and -0.2 respectively) with these locations.

The strongest negative correlation (r= -0.7)was observed in the cervical location.

There is no demonstrable correlation between RPT and the various mean fibroid sizes.

The mean Left parenchyma thickness (LPT) was 18.8(SD+2.4)mm and this also showed a

weak non correlation relationship with the fibroid mean size of 48.2(SD+20.8)mm.

Likewise, in the cervical, subserous and intramural fibroids, the mean LPT of

19.5(SD+2.0)mm, 21.0(SD+1.8)mm and 18.6(SD+2.5)mm respectively showed negative

correlation (r= -0.3 -0.7 and -0.2 respectively) with these locations.

A weak correlation (r= 0.3)was observed in the submucous location.

34

There was no demonstrable correlation between LPT and mean fibroid sizes for the

intramural, subserous and cervical fibroid, however a weak correlation of r=0.3 was seen

with the submucous mean fibroid size.

35

Table 8 shows the distribution of the degree of ureteral dilatation.

Table 8: The distribution of the degree of ureteral dilatation.

Degree of

ureteral

dilatation(mm)

Total Right ureter

(No of cases)

% Left ureter

(No of cases)

%

0 133 62 81.6 71 93.4

1 17 12 15.8 5 6.6

2 2 2 2.6 0 0.0

Total 152 76 100.0 76 100.0

The mean right ureteral dilation (RUD) for this study was 0.2(SD+0.5)mm with a weak

correlation(r=0.4) with the mean fibroid size.

There is a strong correlation(r= 0.8) between RUD mean value of 1.4(SD+0.5)mm and the

subserous fibroid.

The intramural and cervical fibroids showed weak correlations (r= 0.3 and 0.2 respectively)

with mean RUD values each of 0.2(SD+0.4)mm.

The mean sizes of the intramural, subserous and cervical fibroids correlated with RUD while

no correlation was seen with the submucous fibroid.

The mean Left ureteral dilation (LUD) for this study was 0.0(SD+0.2)mm and shows a weak

correlation (r= 0.1) with the mean fibroid size.

There were no correlations (r= 0.0) of LUD with the subserous, cervical and submucous

fibroid locations. Intramural fibroid location however, has a weak correlation (r=0.1).

The mean sizes of the submucous, subserous and cervical fibroids also showed no correlation

with LUD, with a weak correlation (r= 0.1) seen with the mean size of the intramural fibroid.

36

Table 9 is a summary of all the tables, giving a descriptive statistics for each fibroid location.

Table 9. Descriptive statistics of the fibroid location.

KEY:

RPT – Right Renal Parenchymal Thickness

LPT – Left Renal Parenchymal Thickness

RCD – Right Calyceal dilatation

LCD – Left Calyceal dilatation

RUD – Right Ureteral Dilatation

LUD – Left Ureteral Dilatation

FS – Fibroid size

n – Number of cases

Location of

fibroid

n Mean

age

(years)

Mean

Menarche

(years)

Mean

Parity

Mean

Menstral

flow (days)

Mean

Right

renal length

(mm)

Mean

Left

renal length

(mm)

Mean

RPT

(mm)

Mean

LPT

(mm)

Mean

RCD

(mm)

Mean

LCD

(mm)

Mean

RUD

(mm)

Mean

LUD

(mm)

Mean

FS

(mm)

Submucous 15 30.4 12.7 1.8 6.9 108.8 108.8 18.4 18.7 0.5 0.4 0.0 0.0 42.3

Intramural 51 34.4 13.5 2.2 5.1 109.4 109.5 18.3 18.6 0.6 0.5 0.2 0.0 47.4

Subserous 5 39.4 14.6 3.4 6.4 108.4 112.4 17.4 21.0 1.0 1.8 1.4 0.0 81.6

Cervical 5 32.6 13.0 2.0 5.2 104.8 102.3 16.7 19.5 1.0 1.0 0.2 0.0 40.8

37

DISCUSSION

Uterine fibroid is a disease of women in the reproductive age group, it affects women from

the age of 25years onwards1,5-7. The mean age in this study was 33.8years. The submucus

variety is seen to present at an earlier age (30.4years) and this may be attributed to its

association with increased menstrual flow7 which makes the patient present to her

gynaecologist early.

Women who smoke 10 sticks of cigarettes daily have been said to have an 18% decreased

risk for fibroids13, but this could not be corroborated as most women in this enviroment do

not smoke and none of the patients had smoked before.

The use of oral contraceptives for five consecutive years has also been reported to reduce the

risk for fibroid by 17%12. Only one patient in this study used oral contraceptives

consecutively for eight years she had an intramural fibroid. The patient probably had fibroid

before she started taking the pills or she is a deviation from the norm.

The patients were mostly of low parity.This finding is in agreement with common finding

that fibroids are common in nulliparous or low parity women26,50. However, no conclusive

theory has been attributed to this but, a hypothesis put forward is that myoma formation may

be viewed as a response to injury, potentially from hypoxia in myometrial cells during

menstruation7. Nulliparous and low parous women (para0-2) constituted the largest

percentage(57.9%) in this study. On the other hand, a significant number of the women

(32.9%) were of high parity (para four and above) in this study. This is similar to findings

from other Nigerian authors15,27, which reflects the fact that most Nigerian women marry

early and are already grandmultiparous by age 30years.

The size of fibroid varies from tiny microscopic size to uterine size corresponding to or

greater than 12 weeks gestation10. In this study, the smallest size encountered was about

22mm and largest about 109mm with a mean size of 48.2mm.

38

Intramural fibroid remains the commonest with 67.1% in this study. This agrees with

previous documentations1-3. The relative ease at which intramural fibroid are picked on

ultrasound scan makes it easier to diagnose.

Hydronephrosis and hydroureters of various degrees(Grades 1-3) were observed in this study,

this as earlier stated, is due to the close relationship of the distal ureters to the lateral vagina

fornix which causes compression with resultant impedance to the flow of urine. Ellenbogen

et al47, in their study, highlighted the value of ultrasound scan as an effective screening test in

patients with obstruction.

A general overview of this study population shows that about half of the patients had no

calyceal dilatation. Grade 1 dilatation was the commonly observed. False- positive result has

been observed to be commoner with ultrasound appearance of grade 1 hydronephrosis51 and

some of the explanation for this includes: normal variant, increased urine flow, acute and

chronic inflammation and renal cystic disease. This study tried to minimise a false positive

result by ensuring that the patients emptied their urinary bladder before evaluation of the

renal system and excluded patients with renal disease from the study.

On the right side, calyceal dilatation (RCD) was related to cervical, submucus and the

intramural fibroids in terms of their location and sizes.

Left calyceal dilatation (LCD) showed a strong relationship with subserous fibroid in terms

of location and size. A weak relationship exist with submucus and intramural fibroids.

Cervical fibroid had no relationship with LCD.

The small number of patients seen with subserous and cervical fibroids could account for the

outcome of result. Another attributable factor may be the presence of the fibroid mass on

either the left or right half of the uterus as demonstrated on a transverse pelvic ultrasound

scan.

It has been reported that in the presence of various degrees of hydronephrosis, the residual

parenchymal thickness serves as an important indicator of its severity49. Dilatation of the

pelvicalyceal collecting system leads to gradual thinning of the surrounding renal

parenchyma and if this is prolonged, can result in functional impairment. It is also possible to

have a hugely dilated pelvicalyceal system with an apparently thin but merely attenuated and

potentially normal rim of parenchyma on its periphery19 .

39

Most of the patients in this study had renal parenchyma thickness between 13.0 to 22mm.

The highest grade of hydronephrosis (Grade 3) was seen to be associated with a significant

reduction in renal parenchymal thickness.

Correlation of the right and left parenchyma thickness (RPT and LPT) with fibroid locations

showed no relationship with any of them. The mean fibroid sizes have no relationship with

parenchyma thickness as well.

These findings, in line with previous studies, demonstrate that it is the degree of

hydronephrosis rather than the fibroid location and size that determines the residual

parenchymal thickness49.

The ureters when not dilated are difficult to visualise on ultrasound with a maximum calibre

of about 3mm 2. An attempt has been made to grade ureteral dilatation into four groups and

this shows a large percentage (87.5%) to be in the grade 0 group. This can be due to

peristaltic waves propelling bolus of urine along the ureter thereby making visualization of

the ureters difficult.

Right ureter dilatation (RUD) was more commonly encountered and showed a stronger

relationship with location and size of uterine fibroid compared to left ureter dilatation.

It is however interesting to note that calyceal and ureteral dilatation were strongly related to

the cervical fibroid on the right in terms of location and size ; and subserous fibroid showed a

strong relationship with ureteral dilatation on the right in terms of location and size but was

related to left side in terms of calyceal dilatation. The intramural fibroid also showed some

relationship with ureteral dilatation on the right with regards to location and size.

Ultrasound is invaluable as a screening test in patients with renal tract obstruction. It is

cheap, readily available, non-hazardous and non-invasive.

Ultrasound has been used to demonstrate the relationship between various location and size

of fibroid mass and upper renal tract changes. It should therefore be the first line of

investigation rather than subject all patients with uterine fibroid to intravenous urography to

determine involvement of the renal system. This will reduce the hazard of ionizing radiation

and inconveniences that patients are exposed to when they undergo such procedure and also

be cheaper for the patient in terms of cost.

40

LIMITATIONS

The break down of the ultrasound scanning machine at the maternity wing of the Hospital

prevented patients from going the extra mile of coming down to the General wing of the

Hospital to have their scan done. This accounted largely for the limited number of patients, in

addition to strike actions by hospital staff during the period of the study.

41

SUMMARY

The findings in seventy-six (76) patients to determine the relationship between location and

size of uterine fibroid mass and upper renal tract changes using ultrasound in the University

of Ilorin Teaching Hospital between a period of one year (June 2004-June 2005) has been

presented.

The study has shown the relationship of epidemiological, obstetrics and gynaecological

history in relation to the location and size of uterine fibroid. The observed upper renal tract

changes have also been highlighted with correlation with different fibroid locations and sizes.

It revealed that calyceal and ureteral dilatation were strongly related to the cervical fibroid on

the right in terms of location and size while fibroid in the subserous layer also has this strong

relationship with ureteral dilatation on the right in terms of location and size; but was related

to the left side in terms of calyceal dilatation.

There was no preference in the occurrence of calyceal dilatation on either side in regards of

location and size of the intramural and submucus fibroid. However, the intramural fibroid

showed some relationship with ureteral dilatation on the right in regards to location and size.

Ultrasound has been found to be useful as a screening test in patients with upper renal tract

changes secondary to uterine fibroid and this should be the first line of investigation.

42

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Documents

CORRELATION OF UTERINE FIBROID MASS WITH UPPER RENAL …