Iliac artery aneurysm mistaken for distended bladder
Journal
Journal of the American Geriatrics Society
Journal Volume
57
Journal Issue
12
Pages
2350-2351
Date Issued
2009
Author(s)
Abstract
To the Editor: Lower urinary tract symptoms (LUTS) are common in elderly men, and various causes can be differentiated. Benign prostatic hyperplasia (BPH) is a common cause of LUTSs, and effective medical therapy includes alpha-blockers, 5-alpha-reductase inhibitors, and phytotherapy. Intractable symptoms require further studies (imaging, cystoscopy, or urodynamic). Abdominal aneurysm is a rare cause of LUTS. The current case was an iliac artery aneurysm (IAA) mistaken for a distended bladder. If an aneurysm is mistaken for a distended bladder according to ultrasonography, and urethral bladder catheterization is not possible, to resolve urine retention, emergent real-time ultrasound-guided suprapubic cystostomy might be performed, which will cause the aneurysm to rupture and may cause massive internal bleeding. IAA often occurs in elderly men with atherosclerotic vascular disease and other comorbidities. Repair is suggested when the size is greater than 3 cm in diameter; mortality decreases if management takes place early. A 73-year-old man presented with frequent urination and lower abdominal discomfort. He had past histories of hypertension for 20 years and LUTSs for 1 year. LUTSs had progressed recently, especially urinary frequency and the sensation of incomplete bladder emptying. Abdominal ultrasonography revealed a fully distended bladder with a tumor mass protruding from the right lateral wall (Figure 1A), right hydronephrosis, and left renal cyst, but computed tomography (CT) (Figure 1C) showed a huge IAA, 9 cm in diameter, with thrombosis (Figure 1C, white arrow) and a compressed urinary bladder (Figure 1C, black arrow). The aneurysm also resulted in right hydronephrosis and hydroureter, with obstruction of the right distal ureter. Doppler ultrasonography revealed a pulsatile cyst with high flow (Figure 1B). He underwent a common iliac to right femoral artery bypass with endarterectomy and returned home 2 weeks later without complications. (A) Abdominal ultrasonography reveals right hydronephrosis, left renal cyst, and a cyst-like lesion with soft tissue content. The cyst-like lesion was mistaken for a fully distended bladder with a tumor mass protruding from the right lateral bladder wall. (B) Doppler ultrasonography reveals a pulsatile cyst with high flow. (C) Computed tomography shows a huge iliac artery aneurysm, 9 cm in diameter, with thrombosis (white arrow) and a compressed urinary bladder (black arrow). In elderly men, LUTSs are common in urological outpatient clinics and can have many causes, including urethral stricture, BPH, prostate cancer, bladder tumor, urinary tract infection, and urolithiasis. Bladder cancer is the second most common cancer of the genitourinary tract and accounts for 7% of new cases in men. In this case, the patient presented with intractable LUTSs; further ultrasonography revealed a fully distended bladder with a tumor mass protruding from the right lateral wall that resulted in acute urine retention. The current case was an iliac artery aneurysm (IAA) mistaken for a distended bladder. If an aneurysm is mistaken for a distended bladder according to ultrasonography, and urethral bladder catheterization is not possible, to resolve urine retention, emergent real-time ultrasound-guided suprapubic cystostomy might be performed, which will cause the aneurysm to rupture and may cause massive internal bleeding. Isolated IAAs are rare and account for approximately 2% to 7% of all abdominal aneurysms.1,2 Atherosclerotic vascular disease is the most common cause of aneurysm; other causes, such as pregnancy or infection, are infrequent. Most IAAs occur in elderly men; the mean age at diagnosis is 74, and the male:female ratio is 5:1.1 Another study reported similar results in the past 12 years and showed the mean age to be 72, with 96% of IAAs occurring in men.3 Because of their pelvic location, symptoms of solitary IAAs are variable and nonspecific and include lower abdominal, flank, and groin pain. They are usually found incidentally using CT or ultrasonography; IAAs are silent or asymptomatic in 45% to 73% of patients and are diagnosed using imaging studies or when they rupture or enlarge enough to compress adjacent organs, such as the bladder, ureter, colon, and rectum.1,3 In the current case, the IAA was large enough to compress the bladder, resulting in LUTSs. The average size of isolated IAAs at diagnosis is 5.5 cm, with a rupture rate of 33%. The operative mortality rate is as high as 40% if IAAs rupture.1 Therapeutic management depends on size. IAAs smaller than 3 cm in diameter can be closely observed using ultrasound or CT; IAAs larger than 3 cm in diameter are managed using open surgical or endovascular repair.3 The previous study reported that endovascular repair of isolated IAA is a safe and effective alternative in appropriately selected patients and is associated with a significantly shorter hospital stay, less need for transfusion, and less mortality than with open repair.3 LUTSs are common in elderly men with BPH. Imaging is warranted for persistent, intractable symptoms. IAAs are rare but lethal if diagnosed after rupture. They occur in elderly men with atherosclerotic vascular disease and other comorbidities, such as coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus, chronic obstructive pulmonary disease, smoking history, prior abdominal aorta aneurysm, and prior myocardial infarction. Early diagnosis and elective surgery can decrease the mortality rate. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Concept and design : Shun-Fa Hung, Shiu-Dong Chung. Acquisition of subjects and/or data: Shun-Fa Hung, I-Hui Wu. Analysis and interpretation of data: Shun-Fa Hung, Shuo-Meng Wang, Hong-Jeng Yu. Preparation of manuscript: Shun-Fa Hung, Hong-Chiang Chang. Sponsor's Role: None.
SDGs
Other Subjects
abdominal discomfort; abdominal radiography; aged; aneurysm; bladder emptying; bypass surgery; case report; computer assisted tomography; Doppler echography; endarterectomy; femoral artery; human; hydronephrosis; hydroureter; iliac artery aneurysm; kidney cyst; letter; lower urinary tract symptom; male; micturition; prostate hypertrophy; thrombosis; urinary frequency; Aged; Diagnosis, Differential; Humans; Iliac Aneurysm; Male; Urinary Bladder Diseases
Type
letter