Varied Radiographic Manifestations of Urinary Tract Bleeding

Vol. JOO, Sept. Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright © 1968 by The Williams & Wilkins Co.

VARIED RADIOGRAPHIC MANIFESTATIONS OF URINARY TRACT BLEEDING SHIV NAVANI, MORTON A. BOSNIAK, JEROME H. SHAPIRO AND SEYMOUR KAUFMAN From the Departments of Radiology, Boston City Hospital and Boston University Medical Center, Boston, Massachusetts

Hematuria occurs in one-fifth of all urologic admissions.1 Causes of hematuria essentially fall into 3 broad groups: diseases of the urinary tract, diseases of adjacent organs that secondarily involve the urinary tract and finally systemic diseases. Hemorrhage in the perirenal space or into the renal parenchyma leads to pseudotumor formation while bleeding within the lumen or wall of portions of the collecting system can, at times, present with a confusing radiographic picture. We have studied a number of cases of urinary tract bleeding with a wide and unusual spectrum of radiological findings. Presentation of these cases is the purpose of our report. CASE REPORTS

Case 1.Perirenal hematoma. A. C., B.C.H. No. 2010944, a 41-year-old woman, had left flank pain, nausea and vomiting. Excretory urography revealed an enlarged, non-hydronephrotic left renal silhouette (fig. 1, A). Renal angiography disclosed two small aneurysms involving intrarenal branches of the left kidney (fig. 1, B) and a large, avascular circumrenal mass compressing and surrounding the kidney (fig. 1, C). In view of the presence of renal artery aneurysms and an avascular perirenal mass, a diagnosis of perirenal hematoma was made which was subsequently confirmed by operation and histological examination. The left kidney showed massive hemorrhage in the subcapsular and perinephric adipose tissue which was histologically reported as perirenal organizing hematoma. There was no evidence of periarteritis nodosa. Comments. Since the first description of spontaneous (non-traumatic) circumrenal hematoma by Wunderlich, in 1856, 2 more than 300 cases have been reported. 3 The etiology of this

condition includes hydronephrosis, nephritis, renal neoplasms, hemorrhagic infarcts, vascular lesions (e.g. renal artery aneurysm, arteriovenous malformation), underlying systemic disease such as periarteritis nodosa and blood dyscrasia (including anticoagulant therapy) and trauma. Only a small percentage of these cases are caused by rupture of a renal artery aneurysm. Hemorrhage in case 1 was felt to be due to rupture of a small, uncalcified aneurysm. More than 180 cases of renal artery aneurysm have been described of which only 24 were reported to have ruptured. 4 Mathe described 2 cases of pea-sized renal artery aneurysms which ruptured. He emphasized the need for prompt surgical treatment. 5 Horner and associates have recently described a case of perirenal hematoma secondary to intrarenal microaneurysms of periarteritis nodosa and demonstrated it radiographically. 6 Gas 2. lntrarenal hematoma. * A 55-year-old man entered the hospital with right upper abdominal and flank pain, gradually increasing in severity over a 12-hour period. He was on anticoagulant therapy. A pyelogram revealed a large mass in the lower pole of the right kidney (fig. 2, A) which was less opacified than the remainder of the kidney. It was felt that this mass might represent an intrarenal hematoma. The anticoagulant therapy was discontinued and the patient was treated symptomatically. In 4 days, the symptoms had abated and 11 days later the mass had almost disappeared (fig. 2, B). Melicow, M. M.: Non traumatic perirenal hematomas: a report based on 7 cases. J. Urol., 81: 388-394, 1959. 4 Harrow, B. R. and Sloane, J. A.: Aneurysm of renal artery: report of five cases. J. Urol., 81: 35, 1959. 5 Mathe, C. P.: Aneurysm of the renal artery. J. Urol., 27: 607, 1932. 6 Horner, B. A., Hunt, J. C., Kincaid, 0. W. and DeWeerd, J. H.: Perirenal hematoma secondary to intrarenal microaneurysms of periarteritis nodosa demonstrated radiographically. Mayo Clin. Proc., 41: 169-178, 1966. * Reported by courtesy of Dr. P. Mc Lellan, Boston, Massachusetts

Accepted for publication September 29, 1967. 1 Robbins, S. L.: A Textbook of Pathology With Clinical Application. Philadelphia: W. B. Saunders Co., 2nd edit., 1962. 2 Wunderlich, C. R. A.: Handbuch der Pathologie und Therapie. Stuttgart: Ebner & Seubert, 2nd edit., 1856. 3 Uson, A. C., Knappenberger, S. T. and 339

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Fw. 1. Case 1. A, excretory urogram. Large perirenal mass associated with poor filling of left kidney is noted. B, selective left renal arteriogram, arterial phase. Renal artery and its major branches are normal except for 2 small intrarenal aneurysms (arrows). Note renal vessels do not extend to surface of perirenal shadow. C, selective left renal arteriogram, nephrogram phase. Nephrogram reveals small kidney and demonstrates extent of perirenal hematoma (arrows).

Comments. Widespread use of anticoagulants has given rise to an increased incidence of bleeding, which occurs in 5 to 6 per cent of patients during a short course of anticoagulant therapy. 7 The bleeding can occur from any orifice and in any tissue. Hematuria is the most common complication. 8 Case 2 is a good example of intrarenal pseudotumor due to interstitial

hemorrhage. It may be difficult to differentiate a kidney neoplasm that has begun to bleed from a pseudotumor due to bleeding within the renal parenchyma. 9 The clue to the diagnosis is disappearance of the mass following discontinuation of anticoagulant therapy. Sukthomya and Levin reported two such

7 Douglas, A. S.: Anticoagulant Therapy. Springfield, Illinois: Charles C. Thomas, 1961. 8 Salzman, E. W. and Britten, A.: Hemorrhage and Thrombosis: A Practical Clinical Guide. Boston: Little, Brown & Company, 1965.

9 Kaufman, S. A. and Mc Lellan, P.: Urinary tract complications during prolonged anticoagulation therapy. In: XI International Congress of Radiology. New York: Excerpta Medica Foundation, pp. 477-478, 1965.

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Frn. 2. Case 2. A, excretory urogram. Note mass in midportion of kidney displacing middle and lower pole calyces. B, excretory urogram performed 11 days later. Calyceal pattern has returned to normal.

Frn. 3. Case 3. A, excretory urogram. Left hydronephrosis is demonstrated. Bulbous upper pole can also be seen. B, retrograde pyelogram. Worm-like filling defect representing displaced ureteral blood clot is noted in renal pelvis. Note distortion of upper pole calyx caused by renal cell carcinoma.

cases.1° In one, a peripelvic hematoma was noted at operation while in the other case, followup excretory urogram 10 weeks later showed disappearance of the pseudotumor. The radiologist 10 Sukthomya, C. and Levin, B.: Pseudotumors of kidney secondary to anticoagulant therapy. Radiology, 88: 701-703, 1967.

and the urologist should be aware of the possibility of pseudotumor formation by intrarenal hematoma in order to avoid unnecessary diagnostic procedures and operations. Case 3. Intraluminal blood clots. W. B., B.C.H. No. 2030581, a 57-year-old man, presented with gross hematuria and left flank pain. Excretory

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urography revealed evidence of acute urinary tract obstruction with a left nephrogram. The left kidney was enlarged and on delayed films showed hydronephrosis (fig. 3, A). On left retrograde pyelography an unusual cylindrical and worm-like filling defect was seen in the pelvis (fig. 3, B). This filling defect was caused by displacement of an elongated blood clot that had formed in the left ureter and obstructed the kidney. By the pressure of the injection, the blood clot was dislodged from the left ureter and was pushed up into the pelvis. At this point, the

Frn. 4. Excretory urogram in an 81-year-old woman. Note tubular filling defect (elongated blood clot in distal left ureter) causing obstruction of left upper collecting system (arrow).

Frn. 5. Excretory urogram in a 62-year-old man. Note large irregular filling defect in left side of bladder displacing Foley catheter to right. Filling defect proved to be large blood clot from bleeding prostatic varices.

patient noticed disappearance of the left flank pain following relief of the obstruction. A subsequent angiogram disclosed a large upper pole carcinoma, which was confirmed by operation and histological examination. Comments. Case 3 is a rare radiographic observation by means of retrograde pyelography of displacement of a worm-like ureteral blood clot into the pelvis. Relief of the renal obstruction by the procedure coincided with alleviation of the patient's symptoms. It is not uncommon to find blood clot formation in the ureter or in the bladder during profuse hematuria resulting from any underlying cause (figs. 4 and 5). In the latter case, it is noteworthy that the blood clot within the lumen of bladder caused displacement of the indwelling Foley catheter to the right, thus mimicking a mass in the bladder rather than a soft blood clot. There is a tendency toward blood clot formation in the renal pelvis and bladder due to r2lative stasis. In the differential diagnosis, negative shadows on pyelographic examination caused by tumors, roentgenolucent stones and air bubbles should be considered. Radiologic and clinical observations usually establish the diagnosis but at times it can be perplexing. Case 4. Intramural hlmatoma. F. P., B.C.H. 2042105, a 62-year-old woman entered the hospital with bloody urine and pain in abdomen and back, 3 days following an automobile accident. Increasing abdominal girth and a soft-tissue, tender mass in the pelvis were noted. There was a fracture at L4. An excretory urogram revealed grade 1 bilateral hydronephrosis and a large filling defect in the superior wall of the bladder, consistent with bleeding in and above the bladder wall (fig. 6). Exploration of the perivesical space revealed intramural bleeding which was subsequently evacuated. The followup cystogram was normal. Comments. Case 4 represents dissection of the superior bladder wall due to intranrnral hemorrhage following blunt trauma. This is a somewhat unusual area for bleeding to occur as it usually develops intraluminally or in the perivesical space. Case 5. Perivesical hematoma. n. F ., U. H. No. 445812, a 60-year-old woman was on anticoagulant treatment (intravenous and subcutaneous heparin) for thrombophlebitis. During her hospitalization she suddenly became diaphoretic and looked pale. The blood pressure fell

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F_w. G. Case 4. A, cystogram. l\!Iass displacing and stretching dome of bladder can be seen. Dissect10n of bladder mass is better seen on oblique film. B, at operation huge intramural hematoma was evacuated.

diagnosis ,ms blood clot formation within the lumen and bleeding in prevesical ancl perivcsical tissues. The intravcsical bleeding was confirmed by cystoscopic exami11ation and the blood clots were removed. The anticoagulant treatrn.cnt wa~ cfacontinued and the patient was treated with constant drainage and antibiotics. The outline of the bladder rnbsequently regained its normal cystographic appearance, indicating absorption of perivesical hematoma. Recovery ,Yas unevent-

ful. Comments. In case 5 there was bleedingi11to the

Fw. 7. Case 5. Film of bladder from excretory urogram. Note large filling defect within bladder as well as evidence of extrinsic lateral pressure on bladder. Patient was on anticoagulant therapy and suffered intravesical, flB well as perivesical, bleeding.

from the usual level of 180 /100 mm. Hg to 100 /50 mm. Hg. The pulse was thready with the rate of 140 per minute. A urinalysis revealed gross hematuria. A tender suprapubic mass could be palpated to the level of umbilicus. On excretory urography there was right calyceal dilatation and a large intravesical radiolucent mass. The bladder was deformed by extrinsic compression caused by extravesical hematoma, and had a "tear-drop" configuration. The soft tissue density rising upwards and anteriorly was thought to be due to bleeding into the perivesical space (fig. 7). The

lumen of bladder which resulted in clot formation while bleeding into the space of Retzius and in the tissues surrounding the bladder resulted in prevesical and peri,·esical hematoma accounting for vertically elongated and narrowed bladder "Tear-drop" configuration of the bladder j,, primarily caused by perivesica,l extraYasation of blood and/or urine frequently seen following trauma to the lower abdomen, although it rna,y also be observed in pelvic periYesical abseess.11 SUMMARY

Cases demonstrating various radiographic manifestations of bleeding in and around the urinary tract are presented. These cases include perirenal and intrarenal hematoma, as well as intramural, intraluminal and perivesical bleeding. The etiology included trauma, tumor, aneurysm and anticoagulant therapy. These conditions arc briefly discussed and illustrate 1. 11 Prather, G. C. and Kaiser, T. F.: The bladde1 in fracture of the bony pelvis: the significance of a "tear drop bladder" as shown by cystogram. Urol., 63: 1019-1030, 1950.