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Recurrent Postcoital Hematuria. A Case of Fibroepithelial Urethral Polyp in an Adult Female
612
CASE REPORTS Recurrent Postcoital Hematuria. A Case of Fibroepithelial Urethral Polyp in an Adult Female jsm_2006
612..616
Cesare Battaglia, MD, PhD, Bruno Battaglia, MS, Angela Ramacieri, MS, Roberto Paradisi, MD, and Stefano Venturoli, MD Department of Gynecology and Pathophysiology of Human Reproduction, Alma Mater Studiorum, University of Bologna, Bologna, Italy DOI: 10.1111/j.1743-6109.2010.02006.x
ABSTRACT
Introduction. In males, an isolated gross postcoital hematuria is a very rare clinical phenomenon. No cases of postcoital macroscopic hematuria have been previously reported in females. Aim. To report a case of female urethral fibroepithelial polyp (FEP) associated with recurrent postcoital hematuria. Methods. A young (31 years old), eumenorrheic woman complained of three episodes of postcoital macrohematuria. The patient was assessed with a detailed history, with a bimanual pelvic examination and with bidimensional and tridimensional ultrasonographic and color Doppler analyses of the internal genitalia and of the urethrovaginal space. Main Outcomes Measures. Transvaginal two-dimensional (2-D) ultrasonographic evaluation of internal genitalia, bladder and urethra and three-dimensional (3-D) analysis of the urethra and paraurethral structures. Results. The 2-D transvaginal evaluation and the 3-D reconstruction showed a polypoid hypervascularized structure arising from the anterior urethral wall. A cystourethroscopy confirmed the presence of a FEP arising from the anterior wall of the urethra and allowed its removal. Conclusions. A gross postcoital hematuria may be associated with a urethral polyp. The ultrasonographic evaluation of the urethrovaginal space can facilitate the diagnosis. Battaglia C, Battaglia B, Ramacieri A, Paradisi R, and Venturoli S. Recurrent postcoital hematuria. A case of fibroepithelial urethral polyp in an adult female. J Sex Med 2011;8:612–616. Key Words. Urethra; Hematuria; Coitus; Ultrasonography; Polyp; Three-Dimensional Ultrasound of the Paraurethral Structures
Introduction
M
icroscopic hematuria is generally not associated with significant disease and can be detected as an incidental finding in 0.2–21% of asymptomatic individuals [1]. In females, a probable association between sexual intercourse and microscopic hematuria has been recently proposed [2]. On the contrary, an isolated gross postcoital hematuria is a very rare clinical phenomenon. Normally, this distressing symptom is present in males and is often associated with serious pathologies of the urinary tract (i.e., urinary or prostatic neoplasm, pudendal and obturator arterial bleedJ Sex Med 2011;8:612–616
ing, urethral varicosities, urethral coital trauma) [3–7]. To the best of our knowledge, no cases of postcoital macroscopic hematuria have been reported in females. In this article, we describe the ultrasonographic findings of an uncommon case of urethral polyp diagnosed in a young woman with gross recurrent postcoital hematuria. Case Report
In March 2010, B.S., a 31-year-old Italian eumenorrheic; para 0, woman with a stable heterosexual relationship, referred to our clinic complaining of © 2010 International Society for Sexual Medicine
Hematuria and Fibroepithelial Urethral Polyp three episodes of postcoital macrohematuria. The symptom had suddenly occurred 10–15 minutes after the intercourse. The hematuria was painless. No dyspareunia, dysuria, a distorting voiding stream, or a vaginal discharge was reported. The patient did not have a history of recurrent cystitis or of any other urological pathology. She had previously submitted, in another Department, to: urine examination, urinoculture, urine cytology for malignant cells, vaginal swab, renal and vesical ultrasonography. All the exams were normal and the urinalysis did not reveal leukocytosis or bacteruria. The vaginal swab was negative for common organisms (i.e., Escherichia coli, Gonococcus, and Chlamydia, Trichomonas vaginalis, mycetes). General and systemic examination was unremarkable. On bimanual pelvic examination, no gynecological alterations were evidenced. No vaginal or labial lesions were observed. The external urethral meatus was normal and no urethral discharge was noted. Immediately after the gynecological exam, the patient was submitted to transvaginal twodimensional (2-D) ultrasonographic evaluation of internal genitalia, bladder, and urethra, and to 3-D analysis of the urethra and paraurethral structures [8–11]. The ultrasonographic evaluation of the pelvic organs was performed by using a multifrequency vaginal transducer (Voluson 730 Expert Sonography System; GE Healthcare Ultrasound; Medex, Padua, Italy). To better analyze the bladder contour and the urethra, the bladder was not completely voided (~50 mL). The urethra and paraurethral structures were also scanned with a high resolution ultrasound transducer (RSP-16 multifrequency 4D linear array transducer; -Voluson 730 Expert-) and the power Doppler mode were used. To avoid any anatomical distortion, the ultrasonographic approach was translabial and care was taken to avoid excessive pressure on the vulva. The images were stored and analyzed offline. During the analysis and calculation, the tomographic ultrasound imaging (TUI) method was used. TUI shows the studied volumes displayed as parallel slices. This method of visualization is consistent with the way other medical systems such as computed tomography or magnetic resonance imaging present the data to the user. The 2-D transvaginal evaluation demonstrated that uterus, endometrium, ovaries, and bladder were normal. At the level of the distal part of the urethra (which normally appears as a narrow hypo/ anechoic funnel-like structure) was found a single small (7 ¥ 6 ¥ 6 mm) polypoid structure arising
613
Figure 1 (A) 2-D appearance of the polypoid mass. The urethra appears dilated. In proximity of the external meatus, a small polypoid structure is evident. (B) 3-D reconstruction of the urethral polyp. The polyp appears as a single irregular cylindrical structure (white dots) at about 5 mm from the external meatus.
from the anterior urethral wall (Figure 1A). The 3-D reconstruction confirmed the presence of a single irregular cylindrical polyp (Figure 1B). The structure was hypervascularizated and presented angiomatous features (Figure 2). A large feeding vessel of the polyp was evidenced (Figure 2). The TUI analysis allowed to exactly demonstrating the extension of the polyp (Figure 3). A cystourethroscopy, elsewhere performed 1 week later, allowed the direct visualization of the polyp (arising from the anterior wall of the urethra about 0.5–1 cm proximal to the external meatus) and its removal. No urethral catheter was required and the patient was discharged few hours after endoscopy. The pathologist made the diagnosis of fibroepithelial polyp (FEP). Seven days postoperative urinalysis was good and the patient, at the moment (about 2 months after surgical removal of the polyp), did not experience any recurrence of postcoital hematuria and the ultrasonography of the urethrovaginal space was unremarkable. J Sex Med 2011;8:612–616
614
Battaglia et al.
Figure 2 Render mode of the fibroepithelial polyp vascularization. In the sagittal view, the arrow indicates the main feeding vessels of the polyp. The white dots circumscribe the polyp. The arrowhead indicates the urethra. In the 3-D reconstruction, angiomatous features of the polyp are evident.
Discussion
FEP of the lower urinary tract is a rare benign condition. The etiology is controversial. Lam and coworkers supposed that the FEPs are congenital slow-growing lesions [12]. Other possible causative factors are: allergy, trauma, or hormonal imbalance [13]. The majority of the reported cases occurs in newborns or children, may be associated with urogenital malformations and has a marked male predominance [14]. Few cases have been reported in the second decade [10]. Its recurrence in adult women (>second decade) is exceptional [14,15]. In general, the polyps are indistinguishable from the menopausal urethral caruncles, have 1–6 cm in the maximum diameter, and exteriorize through the external urethral meatus [16]. Although FEPs may be aymptomatic and the lesion incidentally diagnosed, urinary hesitancy, diminished urinary stream, enuresis, urge incontinence, dysuria, and pyuria are the main clinical manifestations. Hematuria is another common symptom with a reported incidence of 30–60% in children [17]. In the adult females, gross hematuria has been occasionally described [14]. The optimal investigation for nonglomerular (i.e., lower urinary tract) is unclear. Voiding cystourethrography and renal/vesical ultrasonography are normally used for the diagnosis of FEPs. The increased use of spiral computerized tomography has improved the diagnosis [18]. Cystourethroscopy, and, recently, flexible urethroscopy may be considered the gold standard techniques for the J Sex Med 2011;8:612–616
Figure 3 (A) Tomographic ultrasound imaging (TUI): sagittal view of the urethra and the fibroepithelial polyp (FEP). TUI shows the studied volumes displayed as parallel slices and allows analyzing the relationship between the polyp (white dots) and the urethral wall (from the posterior to the anterior wall). The FEP does not occlude the urethral lumen. (B) TUI: coronal view of the urethra and the FEP. The FEP (white dots) does not occlude the urethral lumen.
615
Hematuria and Fibroepithelial Urethral Polyp diagnosis of urethral lesions. However, the two methods are invasive, and, especially in the small, tense, and with smooth surface polyps located in the lower part of the urethra, may fail to determine a precise source of bleeding in up 68% of the cases [1,19]. To the best of our knowledge, we present the first case of recurrent postcoital macrohematuria in an otherwise asymptomatic adult female patient. The 2-D and 3-D ultrasonography, with the auxilium of a new ultrasonographic technique (TUI), allowed a diagnosis of a small hypervasularized polypoid mass and was useful for the postoperative follow-up. The mass was not associated with low urinary tract symptoms (-LUTS- i.e., distorting voiding stream, diminished urinary stream, dysuria) [16–18]: We think that, as evidenced by TUI, the small measures of the mass (7 mm in the maximum diameter) and its distance from the urethral meatus (8 mm) did not determine the occlusion of the urethra and the correlated LUTS. Because of this, the urologist decided to just use the ultrasonographic information and of avoid further unnecessary diagnostic evaluations (i.e., uroflometry and explorative cystoscopy). We think that the translabial ultrasonographic evaluation of the urethra and the periurethral space may be a multidisciplinary, adequate, easy, cheap, fast, and noninvasive because of its first clinical manifestation in adulthood, it is unreasonable that the FEP showed no clinical manifestation for up three decades. Thus, it is unlikely that the lesion may be a congenital slow-growing anomaly [12]. The angiomatous features of the polyp, that we observed by power Doppler and 3-D reconstruction, in association with the vascular smooth muscular response to the changes in autonomic innervation and the consequent increased urethrovaginal blood flow during arousal/orgasm and the increased peniene urethral pressure during the coitus, may be responsible of this unique case of gross post-coital hematuria. Conclusions
A small FEP may be the cause of a sudden postcoital macrohematuria in adult females. The lesions may be asymptomatic for a long time. Thus, probably, FEPs are more common than the incidence reported in the clinical literature. The translabial ultrasonographic study of the urethrovaginal space [8–11] may integrate the gyne-
cological exam and may be a useful method for diagnosing the pathophysiology of this important anatomic area. Corresponding Author: Cesare Battaglia, MD, PhD, Obstetrics and Gynecology, University of Bologna, Via Massarenti, 13-40138 Bologna, Bologna 40138, Italy. Tel: 39-051-6364377; Fax: 39-051-6364377; E-mail: [email protected] Conflict of Interest: None. Statement of Authorship
Category 1 (a) Conception and Design Cesare Battaglia (b) Acquisition of Data Cesare Battaglia; Angela Ramacieri (c) Analysis and Interpretation of Data Cesare Battaglia; Bruno Battaglia
Category 2 (a) Drafting the Article Cesare Battaglia; Bruno Battaglia (b) Revising It for Intellectual Content Roberto Paradisi; Stefano Venturoli
Category 3 (a) Final Approval of the Completed Article Cesare Battaglia References 1 Grossfeld GD, Carroll PR. Evaluation of asymptomatic microscopic hematuria. Urol Clin North Am 1998;25:661–76. 2 Hosseini SR, Mohseni MG, Atharikia D. Role of sexual intercourse in hematuria and proteinuria in males and females. Urol Int 2008;81:271–4. 3 Mulhall JP, Albertsen PC. Hemospermia: Diagnosis and management. Urology 1995;46:463–7. 4 Tsui KH, Wang LJ, Chang PL, Huang ST, Hsieh ML, Lee SH. Hematuria from left internal pudendal and obturator arterial bleeding following sexual intercourse. Arch Androl 2003;49:453–5. 5 Gkougkousis EG, Khan M, Terry TR, Mellon JK, Ann R. Urethral venous malformation: An unusual cause of recurrent post-coital gross haematuria in association with haematospermia. Ann R Coll Surg Engl 2009;91:532–4. 6 Kumar R, Kesarwani P, Shrivastava DN, Hemal AK. Post coital hematuria: Presentation of an uncommon case. J Postgrad Med 2004;50:312–3. 7 Cheng YS, Lin JS, Lin YM. Isolated posterior urethral injury: An unusual complication and presentation following male coital trauma. Asian J Androl 2006;8:379–81. 8 Battaglia C, Nappi RE, Mancini F, Alvisi S, Del Forno S, Battaglia B, Venturoli S. 3-D volumetric and vascular analysis of the urethrovaginal space in young women with or without vaginal orgasm. J Sex Med 2010;7:1445–53. 9 Battaglia C, Nappi RE, Mancini F, Alvisi S, Del Forno S, Battaglia B, Venturoli S. PCOS and urethrovaginal space: 3-D Volumetric and Vascular Analysis. J Sex Med In press.
J Sex Med 2011;8:612–616
616 10 Battaglia C, Venturoli S. 3-D ultrasonographic appearance of two intermittent paraurethral cysts: A case report. J Sex Med In press. 11 Battaglia C, Nappi RE, Sisti G, Persico N, Busacchi P, Venturoli S. The role of 3-D ultrasonography in the evaluation of menstrual cycle-related vascular modifications of the clitoris. A prospective pilot study. J Sex Med 2009;6:2715–21. 12 Lam JS, Bingham JB, Gupta M. Endoscopic treatment of fibroepithelial polyps of the renal pelvis and ureter. Urology 2003;62:810–3. 13 Bhalla RS, Schulsinger DA, Wasnik RJ. Case report: Treatment of bilateral fibroepithelial polyps in a child. J Endourol 2002;16:581–2. 14 Tsuzuki T, Epstein JI. Fibroepithelial polyp of the lower urinary tract in adults. Am J Surg Pathol 2005;29:460–6.
J Sex Med 2011;8:612–616
Battaglia et al. 15 Yamashita T, Masuda H, Yano M, Kobayashi T, Kawano K, Kihara K. Female urethral fibroepithelial polyp with stricture. J Urol 2004;171:357. 16 Williams TR, Wagner BJ, Corse WR, Vestevich JC. Fibroepithelial polyps of the urinary tract. Abdom Imaging 2002;27: 217–21. 17 Demircan M, Ceran C, Karaman A, Uguralp S, Mizrac B. Urethral polyps in children: A review of the literature and report of two cases. Int J Urol 2006;13:841–3. 18 Lang EK, Macchia RJ, Thomas R, Ruiz-Deya G, Watson RA, Richter F, Irwin RR, Marberger M, Mydlo J, Lechner G, Cho KC, Gayle B. Tailored CT for assessment of microscopic hematuria. J Urol 2001;165:357. 19 Harris NM, Basketter YV, Holmes SAV. Is sexual intercourse a significant cause of hematuria? BJU Int 2002;89:344–6.
CASE REPORTS Recurrent Postcoital Hematuria. A Case of Fibroepithelial Urethral Polyp in an Adult Female jsm_2006
612..616
Cesare Battaglia, MD, PhD, Bruno Battaglia, MS, Angela Ramacieri, MS, Roberto Paradisi, MD, and Stefano Venturoli, MD Department of Gynecology and Pathophysiology of Human Reproduction, Alma Mater Studiorum, University of Bologna, Bologna, Italy DOI: 10.1111/j.1743-6109.2010.02006.x
ABSTRACT
Introduction. In males, an isolated gross postcoital hematuria is a very rare clinical phenomenon. No cases of postcoital macroscopic hematuria have been previously reported in females. Aim. To report a case of female urethral fibroepithelial polyp (FEP) associated with recurrent postcoital hematuria. Methods. A young (31 years old), eumenorrheic woman complained of three episodes of postcoital macrohematuria. The patient was assessed with a detailed history, with a bimanual pelvic examination and with bidimensional and tridimensional ultrasonographic and color Doppler analyses of the internal genitalia and of the urethrovaginal space. Main Outcomes Measures. Transvaginal two-dimensional (2-D) ultrasonographic evaluation of internal genitalia, bladder and urethra and three-dimensional (3-D) analysis of the urethra and paraurethral structures. Results. The 2-D transvaginal evaluation and the 3-D reconstruction showed a polypoid hypervascularized structure arising from the anterior urethral wall. A cystourethroscopy confirmed the presence of a FEP arising from the anterior wall of the urethra and allowed its removal. Conclusions. A gross postcoital hematuria may be associated with a urethral polyp. The ultrasonographic evaluation of the urethrovaginal space can facilitate the diagnosis. Battaglia C, Battaglia B, Ramacieri A, Paradisi R, and Venturoli S. Recurrent postcoital hematuria. A case of fibroepithelial urethral polyp in an adult female. J Sex Med 2011;8:612–616. Key Words. Urethra; Hematuria; Coitus; Ultrasonography; Polyp; Three-Dimensional Ultrasound of the Paraurethral Structures
Introduction
M
icroscopic hematuria is generally not associated with significant disease and can be detected as an incidental finding in 0.2–21% of asymptomatic individuals [1]. In females, a probable association between sexual intercourse and microscopic hematuria has been recently proposed [2]. On the contrary, an isolated gross postcoital hematuria is a very rare clinical phenomenon. Normally, this distressing symptom is present in males and is often associated with serious pathologies of the urinary tract (i.e., urinary or prostatic neoplasm, pudendal and obturator arterial bleedJ Sex Med 2011;8:612–616
ing, urethral varicosities, urethral coital trauma) [3–7]. To the best of our knowledge, no cases of postcoital macroscopic hematuria have been reported in females. In this article, we describe the ultrasonographic findings of an uncommon case of urethral polyp diagnosed in a young woman with gross recurrent postcoital hematuria. Case Report
In March 2010, B.S., a 31-year-old Italian eumenorrheic; para 0, woman with a stable heterosexual relationship, referred to our clinic complaining of © 2010 International Society for Sexual Medicine
Hematuria and Fibroepithelial Urethral Polyp three episodes of postcoital macrohematuria. The symptom had suddenly occurred 10–15 minutes after the intercourse. The hematuria was painless. No dyspareunia, dysuria, a distorting voiding stream, or a vaginal discharge was reported. The patient did not have a history of recurrent cystitis or of any other urological pathology. She had previously submitted, in another Department, to: urine examination, urinoculture, urine cytology for malignant cells, vaginal swab, renal and vesical ultrasonography. All the exams were normal and the urinalysis did not reveal leukocytosis or bacteruria. The vaginal swab was negative for common organisms (i.e., Escherichia coli, Gonococcus, and Chlamydia, Trichomonas vaginalis, mycetes). General and systemic examination was unremarkable. On bimanual pelvic examination, no gynecological alterations were evidenced. No vaginal or labial lesions were observed. The external urethral meatus was normal and no urethral discharge was noted. Immediately after the gynecological exam, the patient was submitted to transvaginal twodimensional (2-D) ultrasonographic evaluation of internal genitalia, bladder, and urethra, and to 3-D analysis of the urethra and paraurethral structures [8–11]. The ultrasonographic evaluation of the pelvic organs was performed by using a multifrequency vaginal transducer (Voluson 730 Expert Sonography System; GE Healthcare Ultrasound; Medex, Padua, Italy). To better analyze the bladder contour and the urethra, the bladder was not completely voided (~50 mL). The urethra and paraurethral structures were also scanned with a high resolution ultrasound transducer (RSP-16 multifrequency 4D linear array transducer; -Voluson 730 Expert-) and the power Doppler mode were used. To avoid any anatomical distortion, the ultrasonographic approach was translabial and care was taken to avoid excessive pressure on the vulva. The images were stored and analyzed offline. During the analysis and calculation, the tomographic ultrasound imaging (TUI) method was used. TUI shows the studied volumes displayed as parallel slices. This method of visualization is consistent with the way other medical systems such as computed tomography or magnetic resonance imaging present the data to the user. The 2-D transvaginal evaluation demonstrated that uterus, endometrium, ovaries, and bladder were normal. At the level of the distal part of the urethra (which normally appears as a narrow hypo/ anechoic funnel-like structure) was found a single small (7 ¥ 6 ¥ 6 mm) polypoid structure arising
613
Figure 1 (A) 2-D appearance of the polypoid mass. The urethra appears dilated. In proximity of the external meatus, a small polypoid structure is evident. (B) 3-D reconstruction of the urethral polyp. The polyp appears as a single irregular cylindrical structure (white dots) at about 5 mm from the external meatus.
from the anterior urethral wall (Figure 1A). The 3-D reconstruction confirmed the presence of a single irregular cylindrical polyp (Figure 1B). The structure was hypervascularizated and presented angiomatous features (Figure 2). A large feeding vessel of the polyp was evidenced (Figure 2). The TUI analysis allowed to exactly demonstrating the extension of the polyp (Figure 3). A cystourethroscopy, elsewhere performed 1 week later, allowed the direct visualization of the polyp (arising from the anterior wall of the urethra about 0.5–1 cm proximal to the external meatus) and its removal. No urethral catheter was required and the patient was discharged few hours after endoscopy. The pathologist made the diagnosis of fibroepithelial polyp (FEP). Seven days postoperative urinalysis was good and the patient, at the moment (about 2 months after surgical removal of the polyp), did not experience any recurrence of postcoital hematuria and the ultrasonography of the urethrovaginal space was unremarkable. J Sex Med 2011;8:612–616
614
Battaglia et al.
Figure 2 Render mode of the fibroepithelial polyp vascularization. In the sagittal view, the arrow indicates the main feeding vessels of the polyp. The white dots circumscribe the polyp. The arrowhead indicates the urethra. In the 3-D reconstruction, angiomatous features of the polyp are evident.
Discussion
FEP of the lower urinary tract is a rare benign condition. The etiology is controversial. Lam and coworkers supposed that the FEPs are congenital slow-growing lesions [12]. Other possible causative factors are: allergy, trauma, or hormonal imbalance [13]. The majority of the reported cases occurs in newborns or children, may be associated with urogenital malformations and has a marked male predominance [14]. Few cases have been reported in the second decade [10]. Its recurrence in adult women (>second decade) is exceptional [14,15]. In general, the polyps are indistinguishable from the menopausal urethral caruncles, have 1–6 cm in the maximum diameter, and exteriorize through the external urethral meatus [16]. Although FEPs may be aymptomatic and the lesion incidentally diagnosed, urinary hesitancy, diminished urinary stream, enuresis, urge incontinence, dysuria, and pyuria are the main clinical manifestations. Hematuria is another common symptom with a reported incidence of 30–60% in children [17]. In the adult females, gross hematuria has been occasionally described [14]. The optimal investigation for nonglomerular (i.e., lower urinary tract) is unclear. Voiding cystourethrography and renal/vesical ultrasonography are normally used for the diagnosis of FEPs. The increased use of spiral computerized tomography has improved the diagnosis [18]. Cystourethroscopy, and, recently, flexible urethroscopy may be considered the gold standard techniques for the J Sex Med 2011;8:612–616
Figure 3 (A) Tomographic ultrasound imaging (TUI): sagittal view of the urethra and the fibroepithelial polyp (FEP). TUI shows the studied volumes displayed as parallel slices and allows analyzing the relationship between the polyp (white dots) and the urethral wall (from the posterior to the anterior wall). The FEP does not occlude the urethral lumen. (B) TUI: coronal view of the urethra and the FEP. The FEP (white dots) does not occlude the urethral lumen.
615
Hematuria and Fibroepithelial Urethral Polyp diagnosis of urethral lesions. However, the two methods are invasive, and, especially in the small, tense, and with smooth surface polyps located in the lower part of the urethra, may fail to determine a precise source of bleeding in up 68% of the cases [1,19]. To the best of our knowledge, we present the first case of recurrent postcoital macrohematuria in an otherwise asymptomatic adult female patient. The 2-D and 3-D ultrasonography, with the auxilium of a new ultrasonographic technique (TUI), allowed a diagnosis of a small hypervasularized polypoid mass and was useful for the postoperative follow-up. The mass was not associated with low urinary tract symptoms (-LUTS- i.e., distorting voiding stream, diminished urinary stream, dysuria) [16–18]: We think that, as evidenced by TUI, the small measures of the mass (7 mm in the maximum diameter) and its distance from the urethral meatus (8 mm) did not determine the occlusion of the urethra and the correlated LUTS. Because of this, the urologist decided to just use the ultrasonographic information and of avoid further unnecessary diagnostic evaluations (i.e., uroflometry and explorative cystoscopy). We think that the translabial ultrasonographic evaluation of the urethra and the periurethral space may be a multidisciplinary, adequate, easy, cheap, fast, and noninvasive because of its first clinical manifestation in adulthood, it is unreasonable that the FEP showed no clinical manifestation for up three decades. Thus, it is unlikely that the lesion may be a congenital slow-growing anomaly [12]. The angiomatous features of the polyp, that we observed by power Doppler and 3-D reconstruction, in association with the vascular smooth muscular response to the changes in autonomic innervation and the consequent increased urethrovaginal blood flow during arousal/orgasm and the increased peniene urethral pressure during the coitus, may be responsible of this unique case of gross post-coital hematuria. Conclusions
A small FEP may be the cause of a sudden postcoital macrohematuria in adult females. The lesions may be asymptomatic for a long time. Thus, probably, FEPs are more common than the incidence reported in the clinical literature. The translabial ultrasonographic study of the urethrovaginal space [8–11] may integrate the gyne-
cological exam and may be a useful method for diagnosing the pathophysiology of this important anatomic area. Corresponding Author: Cesare Battaglia, MD, PhD, Obstetrics and Gynecology, University of Bologna, Via Massarenti, 13-40138 Bologna, Bologna 40138, Italy. Tel: 39-051-6364377; Fax: 39-051-6364377; E-mail: [email protected] Conflict of Interest: None. Statement of Authorship
Category 1 (a) Conception and Design Cesare Battaglia (b) Acquisition of Data Cesare Battaglia; Angela Ramacieri (c) Analysis and Interpretation of Data Cesare Battaglia; Bruno Battaglia
Category 2 (a) Drafting the Article Cesare Battaglia; Bruno Battaglia (b) Revising It for Intellectual Content Roberto Paradisi; Stefano Venturoli
Category 3 (a) Final Approval of the Completed Article Cesare Battaglia References 1 Grossfeld GD, Carroll PR. Evaluation of asymptomatic microscopic hematuria. Urol Clin North Am 1998;25:661–76. 2 Hosseini SR, Mohseni MG, Atharikia D. Role of sexual intercourse in hematuria and proteinuria in males and females. Urol Int 2008;81:271–4. 3 Mulhall JP, Albertsen PC. Hemospermia: Diagnosis and management. Urology 1995;46:463–7. 4 Tsui KH, Wang LJ, Chang PL, Huang ST, Hsieh ML, Lee SH. Hematuria from left internal pudendal and obturator arterial bleeding following sexual intercourse. Arch Androl 2003;49:453–5. 5 Gkougkousis EG, Khan M, Terry TR, Mellon JK, Ann R. Urethral venous malformation: An unusual cause of recurrent post-coital gross haematuria in association with haematospermia. Ann R Coll Surg Engl 2009;91:532–4. 6 Kumar R, Kesarwani P, Shrivastava DN, Hemal AK. Post coital hematuria: Presentation of an uncommon case. J Postgrad Med 2004;50:312–3. 7 Cheng YS, Lin JS, Lin YM. Isolated posterior urethral injury: An unusual complication and presentation following male coital trauma. Asian J Androl 2006;8:379–81. 8 Battaglia C, Nappi RE, Mancini F, Alvisi S, Del Forno S, Battaglia B, Venturoli S. 3-D volumetric and vascular analysis of the urethrovaginal space in young women with or without vaginal orgasm. J Sex Med 2010;7:1445–53. 9 Battaglia C, Nappi RE, Mancini F, Alvisi S, Del Forno S, Battaglia B, Venturoli S. PCOS and urethrovaginal space: 3-D Volumetric and Vascular Analysis. J Sex Med In press.
J Sex Med 2011;8:612–616
616 10 Battaglia C, Venturoli S. 3-D ultrasonographic appearance of two intermittent paraurethral cysts: A case report. J Sex Med In press. 11 Battaglia C, Nappi RE, Sisti G, Persico N, Busacchi P, Venturoli S. The role of 3-D ultrasonography in the evaluation of menstrual cycle-related vascular modifications of the clitoris. A prospective pilot study. J Sex Med 2009;6:2715–21. 12 Lam JS, Bingham JB, Gupta M. Endoscopic treatment of fibroepithelial polyps of the renal pelvis and ureter. Urology 2003;62:810–3. 13 Bhalla RS, Schulsinger DA, Wasnik RJ. Case report: Treatment of bilateral fibroepithelial polyps in a child. J Endourol 2002;16:581–2. 14 Tsuzuki T, Epstein JI. Fibroepithelial polyp of the lower urinary tract in adults. Am J Surg Pathol 2005;29:460–6.
J Sex Med 2011;8:612–616
Battaglia et al. 15 Yamashita T, Masuda H, Yano M, Kobayashi T, Kawano K, Kihara K. Female urethral fibroepithelial polyp with stricture. J Urol 2004;171:357. 16 Williams TR, Wagner BJ, Corse WR, Vestevich JC. Fibroepithelial polyps of the urinary tract. Abdom Imaging 2002;27: 217–21. 17 Demircan M, Ceran C, Karaman A, Uguralp S, Mizrac B. Urethral polyps in children: A review of the literature and report of two cases. Int J Urol 2006;13:841–3. 18 Lang EK, Macchia RJ, Thomas R, Ruiz-Deya G, Watson RA, Richter F, Irwin RR, Marberger M, Mydlo J, Lechner G, Cho KC, Gayle B. Tailored CT for assessment of microscopic hematuria. J Urol 2001;165:357. 19 Harris NM, Basketter YV, Holmes SAV. Is sexual intercourse a significant cause of hematuria? BJU Int 2002;89:344–6.