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Ureteral injury should be suspected when a patient develops flank tenderness and fever after a hysterectomy or oophorectomy.

Meticulous ureteral dissection can lead to devascularization injury to the ureter.

A fistula should be considered when there is constant leakage of drainage from the vagina.

Intravenous pyelogram is the imaging test of choice to assess a postoperative patient with a suspected ureteral injury.

REFERENCES

Broder MS, Gambone JC. Gynecologic procedures. In: Hacker NF, Moore JG. Ganibone JC, eds. Essentials of obstetrics and gynecology, 4th ed. Philadelphia: Saunders. 2004:372-384. Montz FJ. Operative injuries to the ureter: prevention, recognition, and management. In: Rock JA. Jones III HW. eds. TeLinde's operative gynecology, 9th ed. Philadelphia: Lippincott. 2003:1081-1097.

A 66-year-old nulliparous woman who underwent menopause at age 55 years complains of a 2-week history of vaginal bleeding. Prior to menopause, she had irregular menses. She denies use of estrogen replacement therapy. Her medical history is significant for diabetes mellitus controlled with an oral hypoglycemic agent. On examination, she weighs 190 lb and is 5 feet 3 inches tall. Her blood pressure is 150/90 and temperature 99°F. Heart and lung examinations are normal. The abdomen is obese, and no masses are palpated. The external genitalia appear normal, and the uterus seems to be of normal size without adnexal masses.

^ What is your concern?

ANSWERS TO CASE 13: Postmenopausal Bleeding

Summary: A 66-year-old diabetic, nulliparous woman complains of postmenopausal vaginal bleeding. Prior to menopause, which occurred at age 55 years, she had irregular menses. She denies use of estrogen replacement therapy. Her examination is significant for obesity and hypertension.

^ Next step: Perform an endometrial biopsy.

^ Your concern: Endometrial cancer.

Analysis

Objectives

1. Understand that postmenopausal bleeding requires endometrial sampling to assess for endometrial cancer.

2. Know the risk factors for endometrial cancer.

3. Know that endometrial cancer is staged surgically.

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