Case records of the Massachusetts General Hospital. Case 6-2006. A 71-year-old woman with urinary incontinence and a mass in the bladder.

Dr. Donald S. Kaufman: A 71-year-old woman was referred to this hospital for a second opinion on the management of a malignant tumor of the urinary bladder. Urinary incontinence had developed suddenly, six months earlier. One month after the onset of incontinence, the patient saw her primary care physician, who referred her to an incontinence clinic. An ultrasonographic study of the pelvis was obtained at another hospital, and the patient was told to see her gynecologist. On pelvic examination, the cervix was normal; there was marked thickening along the anterior wall of the vagina and bladder. No discrete pelvic mass was detected. The rectovaginal septum was smooth, and the stool was guaiac-negative. A Papanicolaou smear, an endometrial biopsy, and cytologic examination of the endometrial fluid revealed no abnormalities. Computed tomographic (CT) scanning of the abdomen and pelvis at the other hospital showed bilateral hydronephrosis and bilateral solid ovarian masses; the mass in the right ovary measured 4.4 cm by 2.5 cm, and the mass in the left ovary measured 5.6 cm by 4.5 cm. In addition, there was an enlarged aortocaval lymph node, 1.4 cm in diameter. The bladder wall was asymmetrically thickened on the anterior, posterior, and left lateral aspects. A repeated pelvic ultrasonographic study showed a heterogeneous myometrium, with a possible fibroid on the left side and solid bilateral adnexal masses. Cystoscopy with transurethral resection of the tumor in the bladder was performed at the other hospital two weeks before the patient’s evaluation at this hospital. The posterior bladder mucosa was thickened and friable. The muscular wall was distorted and effaced by a rigid, infiltrating mass. The ureters were narrowed, and stents were placed during the cystoscopy. An examination of specimens obtained from the resected tumor revealed invasive transitional-cell carcinoma, grade 3 out of 3, with invasion of the muscularis propria. A radical cystectomy was advised. However, on consultation with a medical oncologist for consideration of preoperative chemotherapy, it was recommended that the primary treatment should be chemotherapy, since the disease was metastatic Case 6-2006: A 71-Year-Old Woman with Urinary Incontinence and a Mass in the Bladder