An African Rural Doctor explores a hidden comorbid complication of fibroids on your kidneys

Author: Dr. Mark Adjetey Abban MD, MBChB

Senior Medical Director / Co-founder African Rural Doctors Association

Your fibroids can become Tombstones that drown your kidneys to death

INTRO

This is an in-depth address on how fibroids have resulted in Acute Kidney Injuries from hydronephrosis in many people of color. Leiomyoma Uteri– colloquially referred to as uterine fibroids have been with us from time indefinite, it affects 80% of women by age fifty and clinically more prevalent in people of color. As co-founder of the African Rural Doctors Association, an organization set to fill medical gaps in underserved communities of Ghana, fibroids remain among the top five surgical clinical presentations in our patient caseloads. A recent analytical cross-sectional study at the Korle-Bu Teaching Hospital in Accra, Ghana estimated 36.9% fibroids in women undergoing pelvic scans, 26.7% of all gynecological ward admissions and 40% of major gynecological surgeries (2025, Nov. National Institute of Health, pmc.ncbl.nlm.nIh.gov)

BACKGROUND

Fibroid is a benign (non-cancerous) tumor that is often confined to the uterus. The pathophysiology of growth and development of a uterine fibroid is not fully understood. However, there is a strong correlation between natural female hormone surge (estrogen and progesterone) as seen in premenopausal women and the exponential growth of the tumor when compared to the direct regression of the tumor after menopause when levels of these hormones have greatly reduced. Genetic predispositions have not only been a contributing factor but immensely supports the data of the disproportionate prevalence of the disease in black people as compared to Caucasians. Genetic mutations in uterine myocytes (muscle cells) have led to monoclonal whorl proliferation of the same cell occurring in different segments of the organ giving three distinct types of the disease based on location such as submucosal, subserosa and intramural fibroids. 

PRESENTING SYMPTOMS

Asymptomatic presentation of uterine fibroids has caused most diagnosis to be incidental, with majority presenting with late symptoms. Common presenting symptoms are pelvic pressure and discomfort, menorrhagia (excessive menstrual bleeding), dysmenorrhea (menstrual pain), inter-menstrual bleeding, frequent urination, constipation, painful intercourse and most significantly infertility. In our geographical region late presentation may be due to lack of access to basic health screening, affordability, lack of education, awareness as well as traditional beliefs and superstitions surrounding surgical management of the disease.

FIBROIDS AND HYDRONEPHROSIS

Hydronephrosis is an abnormal backup of urine into the kidneys due to a pathological blockage of urine outflow pathway into the bladder for storage and excretion. Pathologies that result in hydronephrosis may be categorized into intrinsic and extrinsic pathway obstructions. Most intrinsic obstructions occur along the renal pelvis and ureters where already made urine drains into the bladder. Conditions such as kidney stones and strictures/scars along the intrinsic pathway often prevent urine outflow causing dilated and tortuous engorgement of ureters and enlargement of the kidneys with destruction of the functional units of the kidneys (Nephrons). Both neoplastic and benign tumors outside the kidneys can apply external pressure that prevents urine drainage with consequent backups that stretch, enlarge and destroy the functional units of the kidneys.

Fibroid is the most common benign tumor in women under age fifty. Some fibroids form firm and calcified masses that exert external pressure and obstruction of urine outflow pathways causing toxic urine ammonia backup that floods the kidneys in this process called hydronephrosis. Over time, toxic urine exposure from external fibroid obstruction saturates and damages the renal architecture and parenchyma to cause renal parenchymal disease which in turn leads to acute and chronic kidney disease and eventual demise of the organ from prolonged hydronephrosis.

CASE PRESENTATION

This article is supported by a case presentation of a thirty-six-year-old woman who presented with a six-hour history of severe right flank pain that awoken her from sleep at dawn. She has had previous episodes of the pain that was suggested to be from an appendicitis that was previously managed conservatively. 

Gynecological assessment was positive for menorrhagia, intermenstrual bleeding, dysmenorrhea as well as pressure symptoms of urinary frequency, bladder fullness and also infertility. Pelvic examination revealed an irregularly shaped uterus with multiple palpable masses of different sizes in various poles of the uterus as well as severe right kidney area tenderness. Urinary catheterization for analysis yielded 600mls of urine, negative for leucocyte esterase and nitrites. Microproteins, RBCs (red blood cells) and urine culture were all negative. Bladder emptying did not subside right flank pain and kidney area tenderness. Client was managed with IV Tylenol and was scheduled for an emergency abdomino-pelvic ultrasound which revealed multiple uterine fibroids of varying sizes and bilateral hydronephrosis with significant cortical blunting and thinning of the right renal cortex.

DISEASE BURDEN AND DIAGNOSIS

A diagnosis of right renal cortical atrophy secondary to prolonged hydronephrosis due to persistent overgrowth of a leiomyoma was made. This diagnosis represents one of the severe-most complications of uterine fibroids suggesting an obstructive uropathy that prevents urine outflow into bladder through the ureters due to an obstructive overgrowth of a uterine fibroid. An emergency nephrostomy tube was passed into the renal pelvis for drainage and pain relief and definitive management for a total abdominal hysterectomy without oophorectomy (ovary sparing) was considered for this patient’s fibroid courtesy of the African Rural Doctors.

She survived the surgery with significant improvement of her kidney function. However, a major setback of this surgery is the fact that she will never be able to bare children of her own, and on the bright side sparing the ovaries helps regulate normal hypothalamo-pituitary ovarian axis hormones as well as be able to harvest ova for surrogate childbearing.

CONCLUSION

It is imperative for women of childbearing age to undergo frequent gynecological assessment for early detection and conservative management with myomectomies (uterus sparing fibroid removal) to avoid multi-organ complications, ectopic gestations and the detrimental effects on fertility. Most cases of fibroids have coexisted with growing fetuses and carried pregnancies to term with some fibroids shrinking in size due to competition between the tumor and the growing fetus for influential hormones. In other cases, fibroids such as pedunculated submucosal fibroids have interfered with placenta attachment and placental migration leading to placental abruption, insufficiency and pregnancy related bleeding.

In a nutshell, fibroids cannot be cured and there is no guarantee that another will not grow when surgically removed. However, it is clear that fibroids themselves do not kill but associated comorbid complications can seriously affect quality of life and disease outcomes. Studies have also shown that early detection and conservative management of the condition play a major role in family planning that meets reproductive needs, improving quality of life as well as avoiding complications such as infertility, anemia, chronic pain syndrome and acute kidney injury. Do not participate in erecting tombstones to drown your own kidneys.