Ultrasound Obstet Gynecol 2008; 32: 959–960 Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.6269 Picture of the Month The use of transvaginal ultrasonography to diagnose bladder carcinoma in women presenting with postmenopausal bleeding G. BETSAS, T. VAN DEN BOSCH, J. DEPREST, T. BOURNE and D. TIMMERMAN Department of Obstetrics and Gynecology, University Hospitals, K.U.Leuven, Leuven, Belgium The aim of a gynecological ‘one-stop bleeding clinic’ is to identify the cause of the bleeding and, if possible, to exclude endometrial carcinoma. Most of these outpatient clinics are based on the use of transvaginal sonography (TVS) with endometrial biopsy if indicated and/or a diagnostic hysteroscopy. One additional advantage of TVS is that it enables the examiner to investigate the entire pelvis 1 . If no endometrial pathology is detected, a detailed examination of the bladder during TVS scanning may be indicated, certainly when the patient is postmenopausal. Bladder carcinoma is a rather rare finding in patients presenting at a gynecological clinic for abnormal vaginal bleeding. In a series of 673 consecutive patients evaluated at our department’s one-stop bleeding clinic, only two patients (0.3%) were diagnosed with primary bladder cancer. In our first case, a 75-year-old white female, gravida 3 para 3, was referred to the clinic with postmenopausal bleeding. She had been postmenopausal for 23 years. She reported irregular vaginal bleeding (spotting) during the previous 36 months, which occurred during, as well as after, passing urine. Clinical examination was unremarkable. On ultrasonography (Voluson E8, GE Medical Systems, Zipf, Austria) the uterus and ovaries were normal for her age. Ultrasound examination and gel infusion sonography revealed a normal endometrial cavity and a thin endometrium. No free fluid was identified in the pouch of Douglas. The bladder was incompletely emptied, which allowed the identification of several irregular solid lesions of up to 29 mm in diameter (Figure 1). On color Doppler imaging, these were found to be highly vascular, with a ‘color score’ of 4 2 . She subsequently underwent further urological investigation and a papillary transitional cell carcinoma (TCC), with stromal invasion but an intact muscularis, was revealed (stage T1N0M0). In the second case, a 75-year-old white female, gravida 1 para 1, who had been postmenopausal for 25 years, was referred with a 3-month history of irregular minimal vaginal bleeding which became obvious during and after micturition. Again, gynecological ultrasound examination was normal, but in the bladder several irregular, highly perfused (color score of 4) lesions of up to 30 mm in diameter were visualized (Figure 2). Cystoscopy revealed a papillary TCC carcinoma, with stromal invasion not affecting the muscularis (stage T1N0M0). Both these patients were postmenopausal, indicating that in our series we found bladder malignancy in 0.8% of postmenopausal women attending the bleeding clinic, which is in accordance with a previous series 3 . However, it is possible that we have a selected population at our bleeding clinic, including those women with persistent bleeding after initial negative investigation. Therefore our data may not reflect the true incidence of bladder cancer in women with abnormal bleeding. Although most cases of abnormal bleeding in women are of gynecological origin (principally the endometrium, but also the cervix, vagina or hormone-producing ovarian tumors), other non-gynecological causes (e.g. pathologies of the rectum, anus, urethra or bladder) must also be considered. Particularly when endometrial pathology cannot be identified as the cause for the bleeding, there should be a high index of suspicion for other gynecological 1,4 and non-gynecological causes 3 . A detailed examination of the bladder during TVS of the pelvis could be part of the standard examination pro- cedure, especially in postmenopausal women. In order to achieve adequate visualization of its wall, the blad- der should be filled with at least a moderate amount of urine – about 50 mL – to act as a negative contrast agent. Filling of the bladder facilitates identification of focal intravesical pathology, and is analogous to hydrosonog- raphy for the endometrial cavity. The contrast between tissue and fluid means that tissue interfaces in the bladder are relatively easy to visualize on ultrasound. Previous studies have described the use of TVS to diagnose several causes of intravesical pathology, such as bladder endomet- rosis, stones and carcinoma 3,5,6 . However, underfilling of the bladder and trabeculation due to bladder wall thick- ening associated with detrusor overactivity could lead to false-positive results 6 when mucosal folds are present. Correspondence to: Dr T. Van Den Bosch, Department of Obstetrics and Gynecology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium (e-mail: thierry.van.den.bosch@skynet.be) Copyright  2008 ISUOG. Published by John Wiley & Sons, Ltd. PICTURE OF THE MONTH