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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2011  |  Volume : 22  |  Issue : 6  |  Page : 1259-1260
Groin urinoma: A delayed complication of bladder injury


1 Department of Urology, Christian Medical College and Hospital, Ludhiana, Punjab - 141 008, India
2 Department of Surgery, Christian Medical College and Hospital, Ludhiana, Punjab - 141 008, India

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Date of Web Publication8-Nov-2011
 

How to cite this article:
Ahmed S, John GM, Mammen KJ. Groin urinoma: A delayed complication of bladder injury. Saudi J Kidney Dis Transpl 2011;22:1259-60

How to cite this URL:
Ahmed S, John GM, Mammen KJ. Groin urinoma: A delayed complication of bladder injury. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Dec 9];22:1259-60. Available from: http://www.sjkdt.org/text.asp?2011/22/6/1259/87250
To the Editor,

A urinoma is a cyst formed by extravasation of urine from any part of the urinary tract; i.e., via the kidney, ureter, urinary bladder or the urethra. It may vary in its presentation according to its etiology, the point of the extravasation, its duration and time of diagnosis.

We report on a 35-year-old male patient who presented with a swelling in the right groin extending up to the medial aspect of the right thigh of ten days duration. He had a road traffic accident two months prior to admission, when an exploratory laparotomy and repair of the extra-peritoneal bladder injury was performed. He was on an indwelling catheter for two weeks and, after removal of the catheter, he was voiding normally for six weeks. On clinical examination, a soft fluctuant swelling was found extending from the right inguinal region to the medial aspect of the right thigh [Figure 1].
Figure 1: Photograph showing swelling in the right groin extending to the medial aspect of the thigh.

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Baseline investigations were normal except for the serum sodium, which was 116 meq/L. Ultrasonogram (USG) of the pelvis showed normal bladder with fluid collection in the right groin extending up to the medial aspect of the right thigh. Doppler USG showed normal vascular flow in the lower limbs and an X-ray pelvis revealed wide pubic diastasis with disruption of the right sacroiliac joint (Type II anteroposterior injury-Young-Burgess classification).

Contrast-enhanced computerized tomography (CT) scan showed normal bladder contour with delayed films demonstrating extravasation of the contrast into the groin swelling [Figure 2].
Figure 2: CECT image showing contrast extravasation into the groin and thigh.

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The patient was catheterized with a 16F Foley's catheter and approximately 300 mL of clear urine was aspirated from the groin swelling. It was observed during the hospital stay that the urinoma did not recur. The patient was discharged and followed-up after two weeks with a cystogram, which was normal. Foley's catheter was removed subsequently and the patient voided successfully.

He was followed-up on a weekly basis for a month during which period no recurrence of the urinoma was seen.

Urine leaks from the kidney, ureter, bladder and urethra most commonly result from trauma. Urinomas may be occult initially and may lead to complications such as abscess formation and electrolyte imbalance if not promptly diagnosed and appropriately managed. [1] In our case, the patient had hyponatremia (Na + 116 meq/L). Foley's catheter drainage alone has become routine management of extra-peritoneal bladder rupture in many medical centers, with few reports showing treatment failures with this approach. Of those patients managed non-operatively, 74% had spontaneous healing within 10-14 days, with 26% patients having significant complications, including delayed healing, vesicocutaneous fistula, septic events, bladder calculi or death, especially in patients with multiple pelvic fractures. [2] Bladder rupture resulting from blunt trauma was caused by compression (burst) type of injury in all patients with intra-peritoneal rupture and in 24% of those with extra-peritoneal rupture. In the remaining instances of extra-peritoneal rupture, pelvic bone fragments corresponded to the site of the injury. Our patient had compression type fracture with pubic diastasis. Although surgical repair has been the commonly followed method of management of bladder ruptures, conservative (catheter) management of extra-peritoneal rupture was found to be successful in most cases. [3] The umbilicovesical fascia divides the anterior extra-peritoneal fat into a perivesical and prevesical space. Auh et al [4] have characterized extra-peritoneal pelvic fluid collections as assuming a "molar-tooth" configuration, with the "crown" lying anterior to the bladder and the "root" lying posteriorly between the fascia and either the peritoneum superiorly or the pelvic fascia inferiorly. The prevesical extra-peritoneal compartment is also continuous with the rectus sheath, pre-sacral space and the femoral sheath. [4] In our case, a possible unrecognized rupture of the pelvic fascia because of wide pubic diastasis and bone fragments from the resultant fracture site could have formed a tract for urine to reach the groin and medial aspect of the thigh.

This case is reported because of its rarity and unusual presentation. Patients with pelvic fracture having wide pubic diastasis, who are candidates for surgical repair, should have the pelvic fascia inspected intra-operatively for any tear and, if detected, warrants repair along with the bladder injury. Foley's catheter in such cases should be kept for a minimum period of three weeks, even if the cystogram does not show any contrast extravasation.

 
   References Top

1.McAninch JW, Santucci RA. Genitourinary trauma. In: Walsh PC, Eds. Campbell's Urology. Philadelphia, PA: Saunders, 2002; 3721-7.  Back to cited text no. 1
    
2.Kotkin L, Koch MO. Morbidity associated with nonoperative management of extra peritoneal bladder injuries. J Trauma 1995;38(6):895-8.  Back to cited text no. 2
    
3.Cass AS, Luxenberg M. Features of 164 bladder ruptures. J Urol 1987;138(4):743-5.  Back to cited text no. 3
    
4.Auh Y, Rubenstein WA, Reckler J, Whalen JP, Kazam E. Extarperitoneal Paravesical spaces: CT delineation with US correlation. Radiology 1986;159:319-28.  Back to cited text no. 4
    

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Correspondence Address:
Kim J Mammen
Department of Urology, Christian Medical College and Hospital, Ludhiana, Punjab - 141 008
India
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PMID: 22089799

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