Radiological Case: Spontaneous Ureteral Injury

Kristy L. Ratkowski, MD; Michael Lin, MD; Sanjeev Bhalla, MD

Disclosures

Appl Radiol. 2018;47(7):38-39. 

In This Article

Discussion

Spontaneous ureteral injury, defined as injury in the absence of interventional procedure, surgery, or trauma, is a rarely reported cause of acute abdominal pain.[2–4] Most commonly due to ureteral stones, they typically occur in the proximal ureter.[2–4] Ureteral rupture during pregnancy is thought to result from increased pressure secondary to ureteral compression.[2,5] Vaginal delivery is an even more rarely documented cause of spontaneous ureteral injury. In our case, it was presumably due to the downward pressure placed on the bladder during active labor, placing the ureter in traction. Spontaneous ureteral injury can present with symptoms similar to other entities found during pregnancy and/or immediately postpartum, such as appendicitis, pyelonephritis, renal calculi, and uterine rupture.[2,3,5] A CT scan using split bolus technique that captures information both in the normal portal venous and excretory phases may be valuable in narrowing the differential diagnosis.

In a postpartum patient with a history of uncomplicated vaginal delivery, the presence of a large amount of simple free fluid immediately places the urinary tract injury as the most probable source. In our case, the presence of bladder gas and gas adjacent to an abnormal right ureter deepened suspicion of a ureteral injury. When appropriately performed, a contrast-enhanced CT containing information in the excretory phase can easily confirm this diagnosis and potentially delineate the level of injury for treatment planning. The key is to recognize large-volume, simple free fluid in this rare clinical scenario as a trigger for repeat, delayed scanning in the excretory phase. The patient could then proceed to surgery, urgent cystoscopy for stent placement, or be treated with conservative management.[3]

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