A Highly Uncommon Variation of Spontaneous Urinary Extravasation as an Unusual Presentation of Distal Ureteric Calculus

Case Presentation

Austin J Radiol. 2015;2(4): 1025.

A Highly Uncommon Variation of Spontaneous Urinary Extravasation as an Unusual Presentation of Distal Ureteric Calculus

Fouad Hajji*, Abdellatif Janane, Mohammed Ghadouane, Ahmed Ameur and Mohammed Abbar

Department of Urology, Mohammed V Military University Hospital, Rabat/Morocco

*Corresponding author: Fouad Hajji, Department of Urology, Mohammed V Military University Hospital, Ryad Street-10100, Rabat/Morocco

Received: May 05, 2015; Accepted: May 26, 2015; Published: June 03, 2015

Abstract

Urolithiasis is a leading cause of acute abdominal pain and one of the most common conditions seen in emergency departments worldwide. Spontaneous Urinary Extravasation (SUE) is a relatively uncommon manifestation of distal ureteric urolithiasis and has a wide spectrum of clinical presentations depending on the site of urine leakage. Perforation could occur at any level from the calix to the bladder but it is usually seen at the fornices or upper ureter. It is important to distinguish true rupture of the ureter from the forniceal tear with backflow extravasation because clinical presentations, outcomes and treatments are different. In this case study, a 29-year-old man was admitted to our hospital with sudden-onset of left fossa iliaca pain, fever and lower urinary tract symptoms after a short pain-free period following spontaneous cessation of an acute renal colic. He also had a microscopic haematuria and pyuria on his urinalysis. Contrast Enhanced Computed Tomography of the abdomen (CECT) showed an impacted tiny calculus (< 5mm) in the left intramural ureter and a urine extravasation from both the calyceal fornix and the upper ureter. This unique case is a highly uncommon variant of stone-induced SUE because of a special association between these two phenomena, raising both diagnostic and management challenges.

Keywords: Spontaneous urinary extravasation; Urolithiasis; Forniceal rupture; Ureteral rupture

Introduction

Urinary extravasation results from rupture of the urinary collecting system at any level from the calyx to the urethra [1]. It usually occurs after traumatic, iatrogenic, or tumor-induced tear [2,3]. However, Spontaneous Urinary Extravasation (SUE) is an uncommon condition, found in only 0.08% to 1% urograms [3,4]. It occurs in the absence of external trauma, prior ureteric manipulation, external compression, destructive kidney disease, previous surgery and stone-induced pressure necrosis [5,6]. Reviewing the literature, SUE is commonly associated with ureteral obstruction and attributed to ureteral calculus in approximately 50% of cases [3]. However, SUE is a relatively uncommon manifestation of distal ureteric calculi and has a wide spectrum of clinical presentations depending on the site of urine leakage. Perforation could occur at any level of the excretory tract but it is usually seen at the fornices and upper ureter. Spontaneous forniceal rupture is the most commonly described phenomenon leading to SUE, while spontaneous ureteral rupture is an extremely rare urological disorder; with only a few cases reported worldwide.

It is important to distinguish rupture of calyceal fornix from true ureteral rupture, as the latter can be more severe, requiring more aggressive treatment. Herein, we report a case of spontaneous rupture of both the fornix and the ureter secondary to a tiny intramural ureteral calculus and review the current literature, discussing the clinical and radiological dilemma of both phenomena.

Case Presentation

A 29-year-old previously healthy man presented to the Emergency Department complaining of a sudden onset of left iliac fossa pain, nausea, vomiting and fever, associated with increased urinary frequency and urgency of urination. He reports having experienced recurrent episodes of intractable left renal colic 10 hours before, all of which spontaneously resolved. He had an unremarkable medical history; there was no history of abdominal trauma, surgery or previous urological or kidney diseases.

On physical examination, he has a temperature of 38, 8 °C, a pulse rate of 114 beats / min, and a blood pressure of 110/56 mm Hg. His abdomen was nondistended and the bowel sounds were normal. However, he had left costovertebral angle tenderness and painful left hemi-abdomen without any signs of peritoneal irritation. The rest of physical exam was unremarkable.

Urine dipstick testing was positive for both microscopic haematuria and leukocyte esterase activity. Laboratory investigations showed moderate leukocytosis (13300/μl) with predominant neutrophils (96%), elevated C-reactive protein 34 mg/l and normal serum creatinine. Urinalysis revealed pyuria with microscopic heamaturia and urine culture was sterile.

Unenhanced computed tomography of the abdomen showed a left intramural ureteric calculus that was less than 5mm in diameter with ipsilateral perirenal, peripelvic and retroperitoneal fluid collections, extending down to the left iliac fossa along with the ipsilateral psoas muscle (Figure 1A, 1B and 1C).