Spontaneous Ureteric Rupture Secondary to Ureteric Calculus: A Case Report

Abstract

Spontaneous ureteric rupture is a rare clinical entity defined by the extravasation of urine from the ureter in the absence of external trauma or instrumentation. It is most frequently associated with obstructive urolithiasis.

We report the case of a 37-year-old male presenting with acute, severe abdominal pain secondary to spontaneous proximal ureteric rupture from an obstructing calculus. Despite the absence of advanced imaging like CT, a definitive diagnosis was achieved using Intravenous Urogram (IVU). The patient was managed conservatively and achieved full recovery without surgical intervention. This case demonstrates that in resource-constrained environments, clinical judgment paired with traditional imaging provides a viable framework for the successful diagnosis and non-surgical management of spontaneous ureteric rupture.

Introduction

Spontaneous rupture of the ureter is an uncommon urological emergency defined as non-traumatic leakage of urine from the ureter. ^{1, 2} It is usually secondary to obstruction from ureteric calculi and is frequently associated with severe symptoms requiring drainage or surgical intervention. ³ Though this is a rare condition, clinical documentation is very important to raise awareness among clinicians that even in the absence of more advanced imaging diagnosis, patients can still be managed conservatively, especially in a low-income society.

Case Report

A 37-year-old civil servant presented to the emergency department of our institution with a four-hour history of sudden-onset of colicky abdominal pain. The pain started from the left lumbar region and radiated to the left groin. It had no identifiable aggravating or relieving factors. There was no history of trauma to the abdomen, recent urinary instrumentation, or previous urological surgery. There was no prior history of fever or associated vomiting, but reported passage of bloody urine. He had experienced a similar episode of flank pain 6 months earlier, which resolved with analgesics and was not accompanied by haematuria. Clinical evaluation revealed a young man who was in painful distress with mild pallor. The patient was afebrile with an axillary temperature of 36.7 ^°C and ^a stable cardiovascular and respiratory examination. There was left costovertebral angle and mild suprapubic tenderness. There was moderate anaemia with haematocrit of 28%, while the blood film revealed a normocytic-normochromic anaemia. Urinalysis showed numerous red blood cells with no organism cultured. The renal function test, which included electrolytes, urea and creatinine, was not remarkable. Abdominopelvic ultrasound (Fig. 1) revealed mild left hydronephrosis secondary to a focal calculus at the region of the left vesicoureteric junction (VUJ). There was no evidence of ascites. Findings are consistent with ureteric lithiasis.

Figure 1.

Axial pelvic ultrasound showing a focal stone in the region of the left vesico-ureteric junction (arrow)

Plain abdominal radiograph was not remarkable as no radio-opaque calculus was visualised in the regions of the kidney, ureter and urinary bladder (KUB), Fig 2. Intravenous urography (IVU), Fig. 3 demonstrated a delayed and persistent nephrogram of about 5 minutes on the left. The delayed film showed mild left hydronephrosis and columnization of the left ureter with moderate contrast extravasation at the proximal ureter near the pelvi-ureteric junction. A tapered termination of the distal ureteric contrast column was also observed. A diagnosis of spontaneous rupture of the left ureter secondary to a ureteric calculus was made. The patient was treated conservatively with analgesics (intravenous diclofenac 75mg b.d for 48 hours, followed by 50mg oral tablet b.d for 5 days). Patient was commenced on antibiotics on the same day, immediately after the IVU, which included intravenous ciprofloxacin 500mg 12 hourly and 500mg metronidazole 8 hourly for 48 hours. These were later converted to oral ciprofloxacin 500mg b.d for ten days and metronidazole 400mg tds for five days. The patient was also catheterised in order to monitor the urinary output and to assess the clearance of the haematuria. In addition, he was placed on intravenous fluids and muscle relaxants. He improved significantly and was discharged home on day four. A follow-up IVU after 6 months demonstrated complete resolution.

Figure 2.

Plain abdominal X-ray showing no calcification in the region of the KUB.

Figure 3.

Delayed IVU showing contrast extravasation at the proximal left ureter (A) and a tapered termination of contrast column at the distal ureter (B)

Discussion

Ureteric rupture may be traumatic or spontaneous in origin. ² Spontaneous rupture remains a rare clinical entity, typically precipitated by obstructive urolithiasis. ⁴ Less frequent aetiologies include ureteric malignancies, inflammatory processes, or adjacent gastrointestinal pathology. Since its initial description by Schwartz et al. ⁵, several pathophysiological mechanisms have been proposed, including pressure-induced ischaemic necrosis at the impaction site or mechanical tearing during stone migration. Diagnosis of this condition is made in the absence of traumatic injury to the ureters. Our patient had no preceding history of injury to the ureter before the presentation. Clinical presentation is often nonspecific. Sudden flank or abdominal pain is typical, similar to how our reported patient presented. Haematuria may account for the patient's low PCV of 28%. While a reticulocyte count was unavailable, the normocytic-normochromic blood film suggests an acute rather than chronic blood loss.

Physical findings may mimic other acute abdominal conditions or chemical peritonitis from urine leakage.

Plain radiographs may miss radiolucent stones, as occurred in our patient. Ultrasonography may detect hydronephrosis or distal calculi, while a superior diagnostic IVU can demonstrate delayed nephrograms and contrast extravasation in such a patient. A delayed and persistent nephrogram of about 5 min was demonstrated in this patient as a result of the distal obstruction and ureteric rupture. However, IVU has poor sensitivity in detecting stones and ureteric tumours.

Contrast-enhanced CT scan (CT urography) is currently considered the most sensitive diagnostic modality for identifying the site and extent of urinary leakage. CT urography is also able to detect the majority of ureteric calculi and to exclude differential diagnosis. ^{6, 7} In this patient, a CT was not performed due to financial constraints, but an IVU provided adequate diagnostic information.

Spontaneous ureteric rupture requires prompt intervention to prevent complications such as urinoma, perinephric abscess and urosepsis. ^8-10 Management of this condition is individualised and depends on the clinical state of the patient, degree of ureteric rupture and underlying cause. ⁹ Surgical interventions, including minimally invasive techniques, such as insertion of double-J stenting or percutaneous drainage, depending on the severity are favoured as documented by several reports. This case highlights that minimally invasive procedures are not always necessary, as emerging evidence indicates that conservative management consisting of analgesia, prophylactic antibiotics, and careful clinical monitoring can be a safe and effective alternative for selected stable patients. ^{11, 12} Akpinar et al. demonstrated that supportive measures alone can be curative. In their case series, three out of four patients recovered fully without surgical or endoscopic intervention, with follow-up imaging confirming the reabsorption of extravasated fluid within days. ¹¹ Similarly, Chen et al reported that while the majority of their 18 patients received stents, approximately 28% were successfully managed with antibiotics and observation alone, achieving excellent outcomes. ¹² Eken et al. concluded that while endourological procedures offer high success rates, conservative management remains a viable alternative to surgery, particularly when the patient remains clinically stable. ⁶

This case demonstrates that conservative management can lead to a successful outcome. Despite the presence of a proximal ureteric rupture and associated haematuria, the patient’s improvement on intravenous and oral analgesia precluded the need for more invasive drainage or stenting. This outcome corroborates the existing literature that, in the absence of evidence of extensive infected urinoma or systemic sepsis, the ureteric wall can heal spontaneously once the high-pressure system is relieved or the patient is stabilised. As demonstrated in this report, this approach is particularly valuable in resource-limited settings where specialised endourological equipment may be unavailable, provided that vigilant clinical monitoring is maintained. The index patient responded well to conservative management and was discharged home.

Conclusion

Spontaneous rupture of the ureter is a rare but important differential diagnosis in acute flank or abdominal pain. Contrast imaging, preferably a CT urography, is essential for diagnosis. Although surgical or endourological interventions may be necessary in some cases, conservative treatment remains an effective option in selected stable patients.

Ethical Considerations

This case does not require institutional ethical approval. However, written informed consent of the patient was obtained to have the case details and accompanying images published.

Disclosure

The authors report no conflicts of interest in this work.