Perivesical mass and vertical bladder caused by massive prostatic enlargement

PERIVESICAL MASS AND VERTICAL BLADDER CAUSED BY MASSIVE PROSTATIC ENLARGEMENT*

DAVID B . SPRING, M .D . DAVID E . SCHROEDER, M .D . RICHARD A . WATSON . M .D . ROBERT E . AGEE, M .D . From the Department of Radiology, University of California School of Medicine, and the Department of Urology, Letterman Army Medical Center, The Presidio, San Francisco, California

ABSTRACT - Massive prostatic enlargement may present with the radiographic appearance of a perivesical mass and pear-shaped bladder . An explanation of this appearance, based on the computed tomographic findings, is offered . We discuss the differential diagnosis .

Roentgenographic soft tissue shadows in the pelvis can provide diagnostic information of clinical importance . Pelvic masses may be identified and related to pelvic organs and musculature ." Prostatie enlargement may present with hematuria, dysuria, or symptoms of bladder outlet obstruction . Marked prostatic enlargement can present as a large pelvic mass with a vertical bladder, as reported in this case . An explanation for the appearance of a perivesical mass with a vertical bladder is given with computed tomographic confirmation . The differential diagnosis will he commented on briefly . Case Report In a seventy-year-old man acute urinary retention developed after eye surgery . Repeated attempts were made to catheterize the bladder, but it was difficult because of a known fossa navicularis stricture . After being catheterized, gross hematuria developed . An intravenous urogram (Fig. IA) performed on the next day demonstrated a vertical blad*The opinions or assertions contained herein are the private views of the authors and are not to he construed as official or as reflecting the views of the Department of the Army or the Departuient of Defense .

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der, deviated slightly to the left . A right perivesical mass was seen . Because of a possible traumatic catheterization, the diagnosis of perivesical hemorrhage was considered . Attempts at cystoscopy were unsuccessful because of an enlarged prostate, previously noted by rectal examination . Computed tomography subsequently confirmed a markedly enlarged prostate without evidence of any other perivesical mass (Fig . 1B) . No abnormal fluid collection, lipomatosis, or edema was seen . Ultrasound findings confirmed those of computed tomography . At surgery no other collection was seen . A 245-Gm . prostate was removed by suprapubic prostatectomy through a rnidline incision . No bladder tumor or calculus was identified, and bladder wall thickness was normal . Comment The roentgenographic appearance of pelvic soft tissues provides valuable clues in making correct preoperative diagnoses mid should he evaluated carefully . An apparent perivesical mass in the setting of pelvic trauma should suggest possible extravesical pelvic hemorrhage or urine extravasation .a A vertical-appearing bladder may he seen also with other diffuse pelvic

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Fir-um 1 . (A) Excretory urogram reveals soft tissue mass (arrows) extending to right of vertically-oriented bladder . (B) Computed tomogram through pelvis above plane of femoral heads shows intravenous contrast material layering in dependent portion of bladder (B') anterior to massively enlarged prostate gland (P) . Arrow indicates right lateral margin of prostate seen in (A) .

masses, for example lymphoceles,' pelvic lymphadenopathy,s pelvic lipomatosis, 6, v prominent

differential diagnosis of perivesical mass and vertical bladder .

iliopsoas musculature,' and acute inferior vena caval obstruction .' Each one of these possibilities should be considered in light of patient's history, physical examination, and laboratory studies including roentgenography . Massive prostatic enlargement is uncommon but not rare . Glands weighing more than 200 Gm .

Department of Radiology, M-396 University of California School of Medicine San Francisco, California 94143 (DR . SPRING)

probably make up fewer than 1 per cent of resected specimens . Kelly et al .,' reporting on 337 consecutive suprapubic prostatectomies, had only one specimen greater than 150 Gm . and none greater than 200 Gm . Nevertheless, even giant prostates are occasionally encountered, Ockerblad10 having removed a prostate weighing 820 Gm . Computed tomography can provide quickly helpful information in assessing questionable pelvic masses . It also provides a clear explanation of the apparent perivesical mass seen on plain films and urography . Massive prostatic enlargement should be considered in the

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References 1 . Kalman MA: Radiologic soft tissue shadows in the pelvis : another look, AJR 130 : 493 (1978) . 2 . Bonney WW, Chui LC, and Culp DA : Computed tomography of the pelvis, J . Urol . 120 : 457 (1978) . 3 . Harris JH, et al : The roentgen diagnosis of pelvic extraperitoneal effusion, Radiology 125 : 343 (1977) . 4 . Steinberg A, et al : Demonstration of two unusually large pelvic lymphocysts by lymphangiography, J . Urol . 109 : 477 (1973) . 5 . Ambos MA, et al : The pear-shaped bladder, Radiology 122 : 85 (197 . 7 . Gerson ES, Geaof SG, and Robbins AH : CT confirmation of pelvic lipomatosis : two cases, AJR 129 : 338 (1977) . 7 . Levine E, Farber B, and Lee KR : Computed tomography in diagnosis of pelvic lipomatosis, Urology 12 : 606 (1978) . 8 . Chang SF : Pear-shaped bladder caused by large iliopsoas muscles, Radiology 128 : 349 (1978) . 9 . Kelly GG, et al : Suprapubic prostatectomy : a rep)rt of 337 cases, J . Urol . 92 : 215 (1964) . 10. Ockerblad F : Giant prostate : the largest recorded, ibid . 56 : 81 (1946) .

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