Bladder septum: an unexpected finding on cystoscopy in a patient with mixed urinary incontinence

A 58-year-old G3, P0 woman presented for management of severe urinary incontinence. She reported urgency as well as stress-provoked symptoms. She voided hourly during the day and had bothersome nocturia. She used adult diapers lined with pads which she changed several times daily. Past surgical history included what the patient called a Bbladder tie^ in 2002 and MarshallMarchetti-Krantz urethropexy in 2004. She reported no relief after either of these procedures. Subsequent urethral bulking procedures were ineffective. She had not benefited from several anticholinergic agents. Pelvic examination revealed no prolapse and a fixed, immobile urethra. Office cystoscopy revealed a 2-cmwide bandlike structure vertically spanning the bladder from the anterior to the posterior wall (Fig. 1). The band appeared epithelialized and vascular, but was without calcification or evidence of exposed mesh. Urodynamics revealed stress urinary incontinence with a Valsalva leak point pressure of 30 cm of water, severe detrusor overactivity, and a reduced cystometric capacity of only 160 ml. The patient underwent cystoscopic resection of the bladder septum using electrocautery with simultaneous rectus fascia pubovaginal sling. Pathologic analysis of the bladder septum revealed fibrosis, without evidence of foreign bodies. Five months postoperatively the stress incontinence symptoms had entirely resolved. Her urgency incontinence, frequency, and nocturia had dramatically improved, and were now responsive to fesoterodine. Though the etiology of the bladder septum was not entirely clear, it was presumably related to Bscarring^ from prior surgical intervention. As pathologic review Fig. 1 Cystoscopic view of bladder septum. The septum vertically spans the bladder from the 12 o’clock to the 6 o’clock position. It is approximately 2 cm in thickness and 5 cm in depth, and is adherent to the anterior and posterior walls of the bladder but not to the dome. An air bubble is seen at the 8 o’clock position in the figure; the trigone is not in view