In this video, we present an anterior vaginal mass evaluation and management of extravesical incarcerated ureter seal. The patient presented with complaints of feeling a pop and noted a bulge in the vagina associated with pain. She's a 32-year-old G2P2 African-American female who presented with this one-day history of a popping sensation and bulge in the vagina. She reported history of straining to urinate for some time, as well as urgency, frequency, and nocturia. She also reported some urge incontinence. She denied any fever or chills and review of systems was negative. She had no significant past medical history, and she was a smoker. Her vital signs were stable. An upper-body physical exam was unremarkable, except for some mild suprapubic tenderness. In the pelvic exam, on retracting back the labia majora, the patient had a 5-centimeter bulge coming from the anterior vagina that appeared thrombotic in nature. Digital exam revealed this bulge to be coming from the anterior vagina and appeared to be at the right at the urethral orifice. No bulges or masses in the posterior vagina were noted. And the complete speculum exam was unable to be performed due to patient's severe discomfort. After initial assessment, our thought that this mass may be a urethral prolapse, thrombosed urethral conchal, or urethral diverticulum. We decided to take the patient to the operating room for examination under anesthesia and to develop a plan interoperatively after cystoscopy. The mass is found to be cystic in nature on palpation, and there is noted to be a hard substance inside. On cystourithroscopy, the urethra was noted to be normal. Here you can see the base of the mass. This is the anterior portion of the stalk. The stalk was traced with the cystoscope all the way around 360 degrees in a counterclockwise fashion. It was noted that the stalk was in the position of the left urethral orifice. The remainder of the bladder was found to be unremarkable. We developed a surgical operative plan. The mass was grasped with an Alice clamp and put on traction. A sharp incision with a 15 blade was used to incise the anterior portion of the mass. Immediately pus and urine appeared. This was cultured. The mass was then excised using metamban scissors, and the hard substance that was noted on exam was revealed. It was noted to be a stone. The remainder of the ureter seal was excised using cautery, and immediately a gush of urine and pus returned. This cystoscopy now reveals a patent left urethral orifice with active bleeding around the anterior edges. These edges were then cauterized using endoscopic cautery. The bleeding was adequately controlled. The bladder is drained of clot and debris, and evaluation of the bladder is performed once again. Here we note the left urethral orifice, now patent. The bleeding has now been controlled with cautery, and the remainder of the bladder is noted to be intact. The excised mass was sent to pathology and noted to be urethelium and underlying smooth muscle. There was marked acute inflammation and extravasated red blood cells. The stone that was found within the mass was calcium oxalate monohydrate 100%. The culture that was sent of the urine and pus grew out 2 plus enterococcus faecalis and 1 plus E. coli. Our final diagnosis was a prolapsed, incarcerated left ureter cell. Ureter cells are mostly observed in females and children and are a rare cause of urinary obstruction with incidence range of 1 in 5,000 to 1 in 12,000. Prolapsed ureter cells occur less than 5%. The patient is surgical, and we performed extravesical decompression, transurethral excision of the ureter cell, and endoscopic cautery to control bleeding of the cut ureteric edges. In the evaluation, management, and treatment of ureter cells, it is important to take a thorough history. Performing a complete physical exam under anesthesia is helpful and more comfortable for the patient. Cystoscopic surveillance of the bladder and urethra should be performed, and when excising the ureter cell, cautery can be used in a control and sparing fashion. Further evaluation in the form of imaging is important in order to evaluate for associated renal duplex system and vesicle uteric reflux. Patient's follow-up imaging reveals no abnormalities within her renal system. She was discharged on post-operative day number 1, and she had complete resolution of her urinary symptoms of urgency, frequency, and fatigue.

anterior vaginal mass

incarcerated ureter seal

African-American female

urinary symptoms

cystoscopic surveillance