Obstructive Uropathy because of a Large Rectus Sheath Haematoma: A Case Report of Combined Interventional Radiology and Surgical Approach

Abstract

IntroductionRectus sheath haematomas associated with anticoagulation are often self limiting. When large, however, they can even extend into the pelvis and cause compression of adjacent organs such as the bladder. A combined endovascular and surgical approach can decrease the operative exposure necessary to treat this occurrence.ReportA 42 year old morbidly obese African American female on warfarin treatment for pulmonary embolism presented outside the hospital with pneumonia. During her hospitalisation, she developed a spontaneous right rectus abdominis haematoma below the level of the umbilicus with active bleeding in the extraperitoneal space causing mass compression of the bladder. She developed acute renal failure and became anuric. Following endovascular embolisation of the inferior epigastric artery, surgical exploration was successfully performed to remove the haematoma and relieve the urinary obstruction. Diuresis resumed and renal function normalised without any further evidence of bleeding.DiscussionA large rectus sheath haematoma that extends into the bladder causing renal obstruction can be treated by endovascular embolisation and surgical exploration to limit operative risks and exposure in morbidly obese patients.

Rectus Sheath Hematoma Causing Bladder Outlet Obstruction

“…Type 2 hematomas are intramuscular with blood between the muscle and the transversalis fascia, can be unilateral but are usually bilateral, and no blood is found in the prevesical space. With type 3 hematomas, as discussed in this case, blood is seen between the transversalis fascia and the muscle, in the peritoneum, which can dissect into prevesical space [2][3][4][5][6][7][8][9][10][11]. Unlike types 1 and 2, type 3 has a higher prevalence of a hematocrit effect, requiring blood transfusion as there is no sheath below the arcuate line to contain the hematoma and this reduces the compressive force of the sheath [6][7][8][9][10][11].…”

“…The rupture may be caused by external trauma to the abdominal wall, iatrogenic trauma from surgery, or the rectus muscle vigorously contracting from coughing, vomiting, or straining at the stool [1][2][3][4][5][6]. Hematomas originating below the arcuate line are caused by damage to the inferior epigastric artery and its branches [7][8][9][10]. These hematomas are more prone to bleed, and are more likely to shift across the midline descending into prevesicular space [9][10][11].…”

“…Hematomas originating below the arcuate line are caused by damage to the inferior epigastric artery and its branches [7][8][9][10]. These hematomas are more prone to bleed, and are more likely to shift across the midline descending into prevesicular space [9][10][11].…”

“…There are three types of RSH based on CT scan findings [9][10][11]. If the hematoma is intramuscular as well as unilateral and does not dissect along the fascial planes, it is classified as type 1.…”

“…If RSH is small and present, it usually is accompanied by an abdominal bulge which can be painful [3][4][5]. Some can dissect into the pelvis, and if large enough, can cause pressure symptoms [5][6][7][8][9][10][11]. It is unusual for them to cause bladder outlet obstruction.…”