Voiding dysfunction in pelvic organ prolapse mimicking obstruction: an unusual presentation of sacral chordoma - A...

Pelvic organ prolapse (POP) is commonly associated with voiding dysfunction, often presumed to result from bladder outlet obstruction. However, neurological or structural lesions may mimic or coexist with prolapse-related dysfunction. Sacral chordoma is a rare malignant tumor that can compress sacral nerves and present with lower urinary tract symptoms.

We describe a 71-year-old multiparous Thai woman with stage II POP and mild lower urinary tract symptoms, including occasional stress incontinence, rare urgency, and mild voiding difficulty, initially not affecting her quality of life. She also reported constipation, which improved with dietary changes. Pessary use was discontinued due to discomfort, and surgical management for POP was subsequently considered. Five months later, she developed progressive urinary retention requiring Foley catheterization. Urodynamics revealed normal bladder sensation and compliance but absent detrusor contractions, with residual volume of ~ 550 mL, consistent with acontractile detrusor. Initial pelvic MRI demonstrated a 10.0 × 6.7 × 9.4 cm sacral/presacral mass involving S1-S3 vertebrae and sacral foramina. Biopsy confirmed conventional chordoma. Planned colpocleisis was cancelled, and the patient was referred for multidisciplinary care. En bloc resection was not feasible; proton beam radiotherapy was initiated. Bladder management required chronic catheterization, while constipation was treated conservatively. At follow-up, POP remained but was less distressing compared with tumor-related symptoms.

This case highlights an unusual neurourological presentation of sacral chordoma in a woman with POP. It emphasizes that not all voiding dysfunction in prolapse results from obstruction. Atypical findings, especially detrusor underactivity, should prompt further imaging to exclude neurological or structural causes. Comprehensive preoperative evaluation, including urodynamic studies, is essential in patients with pelvic organ prolapse and suspected detrusor underactivity to ensure accurate diagnosis and to avoid inappropriate surgical intervention, in line with current clinical guidelines. Early recognition prevents misdiagnosis and inappropriate surgery.