March/April - West Virginia State Medical Association

Scientific Article |
Obstructive Uropathy Secondary to Rectus
Sheath Hematoma
Pankaj P. Dangle, MD
Saint Louis University School of Medicine, Department
of Surgery, Division of Urology
Mitesh B. Patel, MS III
Saint Louis University School of Medicine
Marcos Terán, MS, MS III
Saint Louis University School of Medicine
Micheal J. Chehval, MD
Saint Louis University School of Medicine, Department
of Surgery, Division of Urology
Corresponding Author: Pankaj P. Dangle MD, Mch, 3517
South Hoyne Ave Unit 6, Chicago Il 60609 pankajdangle@
gmail.com
Abbreviations: RSH – Rectus
sheath hematoma, DVT – Deep
vein thrombosis, PE – Pulmonary
embolus, OSH – Outside
hospital, INR – International
normalized ratio, BUN – Blood
urea nitrogen, Cr - Creatinine,
CT – Computed tomography
Abstract
Rectus sheath hematoma (RSH) is
uncommon and is often reported in the
setting of anticoagulation or trauma.
Typically RSH presents with localized or
diffuse abdominal pain and a fixed
abdominal wall mass, however, various
presentations and complications have
been reported depending on the setting
and extent of the hematoma. We report a
case of a rapidly expanding RSH causing
obstructive anuria and hydronephrosis in
addition to a review of literature on this
rare presentation of RSH.
Introduction
Rectus sheath hematoma is
a collection of blood within the
abdominal wall musculature or
fascia. RSH frequently presents
with acute abdomen in the setting
of anticoagulation or trauma, but
various presentations have been
reported. Symptoms can range from
slight abdominal pain to hypovolemic
shock. Although uncommon, RSH
is important to consider in the
differential for acute abdomen as
a patient may clinically deteriorate
and become hemodynamically
unstable if bleeding persists. We
report a case of a rapidly expanding
RSH causing obstructive anuria
and hydronephrosis in addition
to a review of literature on this
rare presentation of RSH.
Case Report
An obese 58-year-old woman on
day ten of Coumadin therapy for
deep vein thrombosis (DVT) and
pulmonary embolus (PE) presented
with an acute-onset of severe lower
abdominal pain, nausea, and urge to
void hours after a bout of coughing.
Prior to transfer, exam at an outside
hospital (OSH) demonstrated
elevated blood pressure, tachycardia,
diffuse abdominal tenderness,
distension, and negative for a
palpable mass. Laboratory evaluation
showed an International Normalized
ratio (INR) of 3.3, low hematocrit,
and a blood urea nitrogen (BUN)
and creatinine (Cr) of 25 and 2.1,
respectively. She had minimal urine
output with moderate blood and
protein. CT scan with contrast of
the abdomen and pelvis revealed
a Grade 3 left rectus muscle
hematoma contiguous into the pelvis,
displacing the bladder superiorly
and posteriorly to the right.
On hospital day 2, the patient
abruptly stopped producing urine
per her Foley catheter. Repeat CT
scan showed an enlarging RSH
compressing the urinary bladder
and left ureter as well as increased
hydronephrosis and concern for
intravesicular hematoma (Fig 1a-1c).
Bladder irrigation removed minimal
blood and urine mix. In view of
persistent anuria and compressive
hematoma, INR was optimized for
laparotomy, yielding 1300 mL of
clot from preperitoneal space and
leading to subsequent improvement
of symptoms. Immediately after
evacuation, roughly 200 mL of
concentrated urine was put out.
Urine output returned to normal
following surgery and foley catheter
was removed with normal voiding
pattern. Follow up images prior
to discharge revealed a resolved
hydronephrosis on renal ultrasound.
Discussion
RSH is rare and does not typically
require intervention, however, it
remains an important diagnosis in
patients with acute abdomen and
recent history of anticoagulation,
pregnancy, trauma, or severe
coughing 1,2 . An expanding RSH can
lead to hemodynamic instability or
compression of surrounding tissues
and significant consequences as
in the case reported here. In this
patient, sudden expansion was
significant enough to cause ureteral
obstruction and hydronephrosis.
Similar reports of urinary
complications with RSH are few.
A thorough literature search of
RSH with oliguria, anuria, or
hydronephrosis yielded only
five cases from 1961 and 2011. 3-7
Excluded from our discussion are
the report written in French and
cases of retroperitoneal hematomas
causing urine obstruction that did
not describe the rectus sheath as the
source of bleed. Of the four remaining
reports three of the patients had
been anticoagulated. These three
32 West Virginia Medical Journal