ureteral sciatic hernia: a case report - koreamed synapse€¦ · ureteral herniation occurring...

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Ureteral herniation occurring through the sciatic fora- men is rare, and its etiology is varied. It is difficult to identify ureteral sciatic herniation with a physical exam- ination, and the condition can cause variable degrees of urinary obstruction. Thus, diagnosis and treatment of the disorder are important. We present a case of ureteral sciatic herniation with hydronephrosis, which was treat- ed by double J catheter placement. Intravenous urogra- phy (IVU) showed a curved, laterally displaced ureter and CT images clearly depicted a herniated ureter through the sciatic foramen. The patient was treated transiently with a double J catheter. Case Report A 74-year-old woman was admitted to our hospital in 2005 with a voiding difficulty. The patient had diabetes mellitus, hypertension, and a history of myocardiac in- J Korean Radiol Soc 2008;59:201-204 201 Ureteral Sciatic Hernia: A Case Report 1 So Young Choi, M.D., Hyun Young Han, M.D., Suk Jin Park, M.D., Hyoung Shim Choe, M.D., Eun Tak Kim, M.D. 2 1 Department of Radiology, Eulji University Hospital 2 Department of Urology, Eulji University Hospital Received May 9, 2008 ; Accepted July 17, 2008 Address reprint requests to : Hyun Young Han, M.D., Department of Radiology, Eulji University Hospital, 1306 Dunsan-dong, Seo-gu, Daejeon 302-799, South Korea Tel. 82-42-611-3563 Fax. 82-42-611-3590 E-mail: [email protected] A ureteral hernia that occurs through the sciatic foramen is very rare. We present a case of a ureteral sciatic hernia with hydronephrosis. Intravenous urography (IVU) showed the presence of a curved, laterally displaced ureter, and computed tomogra- phy (CT) clearly depicted the herniated ureter through the sciatic foramen. The patient was treated transiently with a double J catheter. Index words : Ureter Hernia Hydronephrosis Tomography, X-Ray Computed Fig. 1. Intravenous urography shows a loop of the left distal ureter coursing laterally and then medially (arrow). This is known as a “curlicue” ureter, a characteristic finding of ureter- al sacral herniation.

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Ureteral herniation occurring through the sciatic fora-men is rare, and its etiology is varied. It is difficult toidentify ureteral sciatic herniation with a physical exam-ination, and the condition can cause variable degrees ofurinary obstruction. Thus, diagnosis and treatment ofthe disorder are important. We present a case of ureteralsciatic herniation with hydronephrosis, which was treat-ed by double J catheter placement. Intravenous urogra-phy (IVU) showed a curved, laterally displaced ureterand CT images clearly depicted a herniated ureterthrough the sciatic foramen. The patient was treatedtransiently with a double J catheter.

Case Report

A 74-year-old woman was admitted to our hospital in2005 with a voiding difficulty. The patient had diabetesmellitus, hypertension, and a history of myocardiac in-

J Korean Radiol Soc 2008;59:201-204

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Ureteral Sciatic Hernia: A Case Report1

So Young Choi, M.D., Hyun Young Han, M.D., Suk Jin Park, M.D., Hyoung Shim Choe, M.D., Eun Tak Kim, M.D.2

1Department of Radiology, Eulji University Hospital2Department of Urology, Eulji University HospitalReceived May 9, 2008 ; Accepted July 17, 2008Address reprint requests to : Hyun Young Han, M.D., Department ofRadiology, Eulji University Hospital, 1306 Dunsan-dong, Seo-gu, Daejeon302-799, South KoreaTel. 82-42-611-3563 Fax. 82-42-611-3590 E-mail: [email protected]

A ureteral hernia that occurs through the sciatic foramen is very rare. We present acase of a ureteral sciatic hernia with hydronephrosis. Intravenous urography (IVU)showed the presence of a curved, laterally displaced ureter, and computed tomogra-phy (CT) clearly depicted the herniated ureter through the sciatic foramen. The patientwas treated transiently with a double J catheter.

Index words : Ureter HerniaHydronephrosisTomography, X-Ray Computed

Fig. 1. Intravenous urography shows a loop of the left distalureter coursing laterally and then medially (arrow). This isknown as a “curlicue” ureter, a characteristic finding of ureter-al sacral herniation.

farction. The patient also had a compression fracture ofthe L2 vertebra, which was treated by percutaneousvertebroplasty. In addition, the patient had a hysterecto-my due to uterine prolapse. A plain supine radiographof the abdomen (KUB) showed round radiopacity nearthe left sacroiliac joint; thus, a double dose IVU was per-formed. The left distal ureter was seen with a loop,coursing laterally and then medially, that is a character-istic finding of a ureteral sacral hernia (Fig. 1). However,the physician failed to notice any IVU abnormality, andthe patient was diagnosed as having a neurogenic blad-der or overflow incontinence.

Two years later, the patient was readmitted due tofever, voiding difficulty, nausea and vomiting.

Urinalysis showed microscopic pyuria and hematuria,and a contrast-enhanced CT scan showed a dilated andlaterally displaced left ureter (Fig. 2A). The left ureterwas obstructed and had herniated through the sciaticforamen (Fig. 2B, C), and the left kidney showed hy-dronephrosis, mild atrophy and reduced parenchymalenhancement. However, the ureteral segment distal tothe sciatic foramen was collapsed and entered the blad-der in the normal location (Fig. 2D). The urologistplaced a 6-French double J catheter under endoscopicguidance and the herniated left ureter was reducted(Fig. 3). Subsequently, the patient experienced symptomrelief. The patient was being treated transiently with adouble J catheter.

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A B

C D

Fig. 2. A, B. Axial contrast-enhancedCT images show a dilated, laterallycoursing left ureter (A, arrow) and aherniated left ureter though the sciaticforamen (B, arrow). C, D. Coronal reconstructed imagesshow an obstructed left ureter withherniation into the sciatic foramen (C,arrow). The distal ureter is not dilatedand enters the bladder in the normallocation (D, arrow).

Discussion

The sacrospinous ligament divides the sciatic notch in-to the greater and lesser sciatic foramen. The greater sci-atic foramen is bounded by the ilium laterally, by thesacrum and sacrotuberous ligament medially and by thesacrospinous ligament inferiorly (1-3).

A ureterosciatic hernia is very uncommon, and only25 cases of a ureterosciatic hernia have been reported inthe clinical literature since 1947 (4). There have been noreported cases so far in Korea.

A sciatic hernia describes the protrusion of the peri-toneal sac through the sciatic foramen, and most herniasoccur through the greater sciatic foramen (3). Sciatic her-nial sacs have been reported to contain the small intes-tine, Meckel’s diverticulum, omentum, colon, ovaryand ureter (2, 5). Predisposing factors include neuro-muscular disease and cachexia that can cause pyri-formis muscle atrophy (6). A congenital pelvic fascia de-fect can also cause ureteral sciatic herniation, whichseems to occur more frequently in women due to a larg-er sciatic foramen and a wider pelvis (7).

It is difficult to identity ureteral sciatic herniation with

a physical examination as the gluteal muscles overly thesciatic foramen (2, 7, 8). Moreover, as the disorder cancause urinary obstruction, diagnosis is important. Ourcase was revealed by hydronephrosis, because the diag-nosis was not made after the initial IVU examination.Diagnoses can be made by the use of IVU, retrogradeurography or CT imaging. In particular, CT imaging canclearly depict herniated ureters through the sciatic fora-men. The characteristic finding of a ureteral sciatic her-nia is a curled ureter seen on IVU, which shows ureterdisplacement laterally, inferiorly, and posteriorly (3). Infact, a ureteral sciatic hernia was referred to as a“curlicue” ureter by Beck in 1952.

The patient was being treated with retrograde double Jcatheter insertion under endoscopic guidance. Double Jcatheter placement can provide rigidity to the ureter, re-ducing the hernia. Whether this could be considered afundamental treatment is questionable. After removal ofthe catheter, surgical repair might be necessary. Surgicaloptions include reduction of the hernia, excision of thelength of the redundant ureter and reimplantation (2, 9).

In summary, ureteral herniation through the sciaticforamen is very rare, and it can be diagnosed by IVUand CT imaging based on the characteristic findings andlocation.

References

1. Pollack HM, Popky GL, Blumerg ML. Hernias of the ureter. Ananatomic roentgenographic study. Radiology 1975;117:275-281

2. Lebowitz RL. Ureteral sciatic hernia. Pediatr Radiol 1973;1:178-1823. Weintraub JL, Pappas GM, Romano WJ, Kirsch MJ, Spencer W.

Percutaneous reduction of ureterosciatic hernia. AJR Am JRoentgenol 2000;175:181-182

4. Loffroy R, Bry J, Guiu B, Dubruille T, Michel F, Cercueil JP, et al.Ureterosciatic hernia: a rare cause of ureteral obstruction visual-ized by multislice helical computed tomography. Urology2007;69:385. e1-e3

5. Arat A, Haliloglu M. Ureteral-sciatic hernia in a child demonstrat-ed by voiding cystography. J Urol 1998;160:157-158

6. Stockle M, Muller SC, Riedmiller H. Ureterosciatic hernia. A rarecause of pyonephrosis. Eur Urol 1989;16:463-465

7. Noller MW, Noller DW. Ureteral sciatic hernia demonstrated onretrograde urography and surgically repaired with Boari flap tech-nique. J Urol 2000;164:776-777

8. Spring DB, Vandeman F, Watson RA. Computed tomographicdemonstration of ureterosciatic hernia. AJR Am J Roentgenol1983;141:579-580

9. Rommel FM, Boline GB, Huffnagle HW. Ureterosciatic hernia: ananatomical radiographic correlation. J Urol 1993;150:1232-1234

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Fig. 3. KUB after 6-Fr double J catheter placement in the leftureter. After catheter placement, the herniated left ureter is re-ducted, but it shows slightly lateral coursing.

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대한영상의학회지 2008;59:201-204

요관좌골공탈장: 증례 보고1

1을지대학병원 영상의학과교실2을지대학병원 비뇨기과학교실

최소영·한현영·박숙진·최형심·김은탁2

요관좌골공 탈장은 매우 드문 질환이다. 저자들은 수신증을 동반한 요관 좌골공 탈장 1예를 경험하였기에 이를

보고하고자 한다. 경정맥 요로정맥술과 컴퓨터 단층 촬영에서 하부 요관이 좌골공을 통해 탈출 되어 있는 것을 확

인할 수 있었다. 환자는 현재 double J catheter 삽입으로 일시적인 치료를 받고 있다.