When hematuria becomes life-threatening

Ruptured abdominal aortic aneurysm (AAA) is a life-threatening condition requiring rapid diagnosis and urgent management.

In rare cases, it may present with atypical symptoms such as gross hematuria, particularly when complicated by an aortorenal fistula.

This case highlights the diagnostic challenge of an unusual presentation of hemorrhagic shock and emphasises the importance of prompt imaging and decision-making in the emergency setting.

Jaroen Cheewinmethasiri

Lampang hospital, Thailand

Part I - Case presentation

Clinical presentation

A 72-year-old man presented with syncope while watching television. Shortly beforehand, he noticed that his underwear had become wet and realised he had experienced an episode of urinary incontinence. The urine was grossly bloody, prompting immediate transfer to the emergency department.

On arrival, he was hemodynamically unstable, with a blood pressure of 40/20 mmHg and a heart rate of 140 bpm. Physical examination revealed a palpable pulsatile abdominal mass measuring approximately 5 cm.

Bedside ultrasound demonstrated a 6 cm abdominal aortic aneurysm (AAA) and a large hematoma within the urinary bladder.

After initial resuscitation, the patient was transferred urgently to the CT suite. A whole-aorta CT angiography (CTA) was then performed.