Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 5  |  Page : 667-669  

An unusual consequence of an usual condition: Spontaneous psoas urinoma in a case of urinary tract obstruction


1 Department of Radiology, Shri Harilal Bhagwati Hospital, Borivali, Mumbai, Maharashtra, India
2 Department of Radiology, BDBA Hospital, Kandivali, Mumbai, Maharashtra, India

Date of Web Publication10-Sep-2015

Correspondence Address:
Hardik Uresh Shah
Department of Radiology, Shri Harilal Bhagwati Hospital, Borivali, Mumbai - 400 103, Maharashtra
India
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Source of Support: Nil., Conflict of Interest: None declared.


DOI: 10.4103/0975-2870.164964

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  Abstract 

Urinoma and urine leaks can occur at any level from the calyx to the urethra. An urinoma is an encapsulated collection of urine in any confined space or may present as ascites. Urinoma can occur due to multiple causes involving two broad categories-nonobstructive and obstructive. We present a rare case of urinoma in the iliopsoas compartment in a case of urinary tract obstruction due to ureteric calculus. Though, urinomas in various compartments including the iliopsoas are a relatively common occurrence due to iatrogenic trauma like pelvic, gynecological, retroperitoneal and gynecologic surgeries; obstructive causes including ureteric calculi are rare and even rarely reported. Timely recognition and treatment of this uncommon condition is important to avoid complications like abscess formation and electrolyte imbalances.

Keywords: Psoas urinoma, spontaneous, urinary tract obstruction


How to cite this article:
Shah HU, Sannananja B, Laxman V, Nagesh C. An unusual consequence of an usual condition: Spontaneous psoas urinoma in a case of urinary tract obstruction. Med J DY Patil Univ 2015;8:667-9

How to cite this URL:
Shah HU, Sannananja B, Laxman V, Nagesh C. An unusual consequence of an usual condition: Spontaneous psoas urinoma in a case of urinary tract obstruction. Med J DY Patil Univ [serial online] 2015 [cited 2024 Mar 29];8:667-9. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2015/8/5/667/164964


  Introduction Top


Urinoma is an encapsulated collection of urine in a confined space or may present as free fluid mimicking ascites. It can be unilateral or bilateral and may be symptomatic or asymptomatic.[1] It results from the disruption of the urinary system at any level from the calyx to the urethra. Computed tomography (CT) imaging is the investigation of choice in the diagnosis and finding out the underlying cause of urinary leaks and urinomas.[2] CT imaging involves a plain study followed by administration of contrast and delayed imaging to delineate the urinoma and site of the leak as iodine in the contrast increases the attenuation of the urinoma. We present an unusual case of an urinoma in the iliopsoas compartment secondary to obstruction by a ureteric calculus.


  Case Report Top


A 17-year-old boy presented with a complaint of pain in the right flank and right lumbar region since 2 months. There was a recent exacerbation of pain in the last 2 days. There were 2 episodes of vomiting on the day of the presentation. There was no antecedent history of trauma or surgery. On physical examination, the temperature was 37.8°C, pulse: 96/min, blood pressure: 120/56 mmHg, and respiratory rate: 15/min. There was mild tenderness in the right iliac fossa and right lumbar region. The remainder of the physical examination was normal. A provisional clinical diagnosis of acute on chronic appendicitis was made. Laboratory studies upon admission: Hemoglobin 12.8 g/dL, leukocytes 15500/uL with 88% polymorphonuclear leukocytes, platelets 242,000/uL; sodium 139 mEq/L, potassium 5.2 mEq/L, chloride 102 mEq/L, bicarbonate 27 mEq/L, blood urea nitrogen 56 mg/dL, serum creatinine 2.8 mg/dL. The urine analysis showed: White blood cell 5-10, red blood cell 0-3, bacteria 2+, leukocyte esterase moderate, nitrite negative. Extended spectrum beta-lactamase-producing  Escherichia More Details coli grew in the urine. A diagnosis of pyelonephritis was made, and patient started on appropriate antibiotics.

Ultrasonography was performed as a part of diagnostic work up. It revealed a clear collection with a few septae in the right iliopsoas muscle. There was moderate hydronephrosis of the right kidney. Multiple tiny calculi were identified in both the kidneys [Figure 1]a, [Figure 1]b, [Figure 1]c. Hence, a CT scan was ordered for further evaluation of the psoas collection. The plain study showed tiny calculi in both kidneys along with a calculus at the right vesicoureteric junction (VUJ) [Figure 2]b. A hypodense collection was seen in the right psoas muscle on plain study [Figure 2]a. Delayed imaging performed at 15 min and 1 h showed progressive filling of the right pelvicalyceal system and right ureter and minimal increase in attenuation of the iliopsoas collection [Figure 2]c and [Figure 2]d. Subsequent imaging at 2.5 h revealed conspicuous increase in attenuation of the iliopsoas collection [Figure 2]e. A diagnosis of urinoma in the right iliopsoas muscle with communication at the level of right mid ureter with hydronephrois and hydroureter secondary to right VUJ calculus was made. The patient was treated with percutaneous nephrostomy and pigtail catheter insertion in the psoas urinoma. The pelvicalyceal system took 12 days to decompress while psoas urinoma was drained in approximately 3 weeks. This was followed by ureteroscopy with lithotripsy. Ureteroscopy revealed a full thickness rent in the posterior wall of midureter. A double J stent was inserted to allow the rent to heal. The stent was removed after 6 weeks.
Figure 1: Hydronephrosis with hydroureter and psoas collection. (a and b) Ultrasound images showing dilated pelvicalyceal system (open arrow) of right kidney with dilated upper ureter (curved arrow). A calculus is also noted in one of the dilated calyces (arrow) (c) Ultrasound image showing a clear hypoechoic collection within thin the right psoas muscle (asterisk), posteromedial to the kidney (open arrow)

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Figure 2: Hydronephrosis, hydroureter with a psoas urinoma. (a and b) Plain computed tomography (CT) scan showing a hypodense collection in the right psoas muscle (P) and a calculus at the right vesicoureteric junction (arrow). (c and d) 1 h delayed CT images showing contrast collection in dilated pelvicalyceal system (open arrow) and dilated ureter (U) of the right kidney. The hypodense psoas collection (P) is seen posterior to the dilated right ureter. (e) 2 h delayed CT scan showing extravasation of contrast in the right psoas muscle, indicating communication with the dilated ureter

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  Discussion Top


Urinoma in the iliopsoas compartment due to ureteral calculus is a rare entity, with only a few reports in the literature.[3] In general, urinomas result from nonobstructive and obstructive causes. The nonobstructive causes include iatrogenic trauma to the urinary tract including pelvic, gynecological, retroperitoneal, or genitourinary surgeries and so also accidental trauma. The obstructive causes include a list, more common of which are calculi, pelvic tumors, congenital obstructive causes, prostatic enlargement, postradiation scarring. Although all causes are rare, iatrogenic trauma is the most common cause.[2]

Obstruction of the urinary tract leads to increased intrapelvic pressures, pyelosinus backflow with resultant rupture of the collecting system. The most common site of the urinoma formation is the subcapsular or perirenal space, due to rupture of the fornices and resultant urinary extravasation. In our patient, the site of the leak was the dilated ureter. This is a common site of urinary leak in cases of iatrogenic trauma, but a rare site in cases of spontaneous urinary leak. The cause of this in our patient is unclear. The patients with urinary tract obstruction and urinoma formation due to ureteric calculus present with symptoms typical of ureteric calculus. The key to the diagnosis in our patient were the delayed scans at 1 and 2 h after the administration of contrast. This helped in locating the site of the leak, which was the dilated ureter. The increased attenuation of the collection in the psoas muscle confirmed the diagnosis.

Urinomas are initially managed conservatively. Interventional management including catheter placement for drainage is done as the first step. This is followed by antegrade nephrostomy or ureteronephrostomy and/or stent placement to relieve the increased pressure within the collecting system. This results in healing of the site of urinary leak.[4]

Through this case, we want to illustrate a rare cause of urinoma formation in a rare site. We also want to emphasize the importance of delayed contrast-enhanced CT scan in any case of urinary tract obstruction with an adjacent psoas collection. It is very crucial to confirm the diagnosis, differentiate urinoma from any other psoas muscle collection and locate the site of the leak.[5] This can guide appropriate management of this unusual condition because inadvertent delay can lead to complications like abscess formation, electrolyte imbalance, and sepsis.

 
  References Top

1.
Puri A, Bajpai M, Gupta AK. Bilateral spontaneous perinephric urinomas: Case report and review of the literature. Urology 2004;64:590-1.  Back to cited text no. 1
    
2.
Titton RL, Gervais DA, Hahn PF, Harisinghani MG, Arellano RS, Mueller PR. Urine leaks and urinomas: Diagnosis and imaging-guided intervention. Radiographics 2003;23:1133-47.  Back to cited text no. 2
    
3.
Gayer G, Zissin R, Apter S, Garniek A, Ramon J, Kots E, et al. Urinomas caused by ureteral injuries: CT appearance. Abdom Imaging 2002;27:88-92.  Back to cited text no. 3
    
4.
Pereira BM, Ogilvie MP, Gomez-Rodriguez JC, Ryan ML, Peña D, Marttos AC, et al. A review of ureteral injuries after external trauma. Scand J Trauma Resusc Emerg Med 2010;18:6.  Back to cited text no. 4
    
5.
Tonolini M, Campari A, Bianco R. Common and unusual diseases involving the iliopsoas muscle compartment: Spectrum of cross-sectional imaging findings. Abdom Imaging 2012;37:118-39.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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Case Report
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Case Report
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