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CMI JOURNAL 393 

 

 
 

Clinical Medicine Insights 
 

DOI:https://doi.org/10.52845/CMI/2023-4-3-1 

    CMI 04 (03), 393-395 (2023)                                                                                                                                                   
ISSN (O) 2694-4626

 

SHORT COMMUNICATION                                             

Spontaneous Hematoma of the Renal Pelvis: Diagnostic and Therapeutic 

Difficulties 

Nizar Cherni
1
, Abdallah Chaachou

1
, Wael Ferjaoui

2
* , Samir Ghozzi

1
, Mohamed 

Dridi
1
,
 

1
Department of Urology, Military Hospital of Tunis 

2
Department of General surgery, Military Hospital of Tunis 

*Corresponding Author: Wael Ferjaoui 

  

Introduction

Spontaneous haematomas of the kidney are rare. 

They pose two problems: the first is their 

aetiology, in which tumour pathology is dominant, 

and the second is their management. Through a 

series of 7 cases of spontaneous hematoma of the 

kidney, we discuss the role of imaging in the 

etiological diagnosis and the management of this 

condition. 

Material and Methods: 

Seven cases of spontaneous kidney haematoma 

were managed between December 2020 and 

January 2023. These were 5 women and 2 men, 

with a mean age of 61 years. 

Discussion:  

The first case of HSR was described in 1856 by 

Wunderlich, since when hundreds of cases have 

been reported in the literature. The clinical 

symptomatology varies according to the duration 

and extent of the bleeding. The typical clinical 

picture is represented by the Lenk triad: back pain, 

signs of bleeding and a retroperitoneal mass [3, 4, 

7]. 

Ultrasound shows a peri-renal fluid collection, 

sometimes septated, without being able to make 

an accurate diagnosis of peri-renal haemorrhage. 

Indeed, the peri-renal haematoma may be 

interpreted as a tumour or a renal abscess. The 

etiology of the haematoma is even more difficult 

to detect on ultrasound [2, 3, 5]. 

CT is the gold standard for diagnosis and our 

observations confirm these data [2-5, 7]. On 

images without injection, the haematoma has the 

same density as the renal parenchyma and merges 

with the shadow of the latter, which is more or 

less enlarged and deformed, surrounded by peri-

renal fat. After injection of contrast medium, the 

density of the renal parenchyma is enhanced and 

the haematoma, which does not change, appears 

well delimited [2, 3, 5]. The CT scan can also be 

used to study the renal parenchyma in contact with 

the haematoma in search of a possible tumour 

lesion or vascular malformation. However, the 

tumour may go unnoticed when its volume is 

small and aneurysms are only visible when they 

are large [2, 3, 5, 7]. 

Because of its richness in contrast and its multi-

planar approach, MRI is more effective than CT in 

confirming the haemorrhagic nature of the 

collection and in visualising small tumours [3]. 

The role of arteriography in retroperitoneal 

haematomas is still debated in the literature [2, 7]. 

When the bleeding is active, arteriography can be 

used for embolisation. 

Copyright : © 2021 The Authors. Published by Medical Editor and Educational Research Publishers Ltd. 

This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/lic enses/by-

nc-nd/4.0/). 

https://orcid.org/0000-0002-4279-9370
https://creativecommons.org/lic%20enses/by-nc-nd/4.0/
https://creativecommons.org/lic%20enses/by-nc-nd/4.0/


CMI 04 (03), 393−395 
CMI JOURNAL 394 

CMI JOURNAL                                                                                                      Wael Ferjaoui et al. 

 

 
 

There are many different causes of spontaneous 

haematomas of the renal pelvis. Kidney tumours 

are responsible in 61.2% of cases. These tumours 

are most often benign (31.5% of cases), 

dominated by angiomyolipomas. Malignant 

tumours represent 29.7% of cases and are 

dominated by clear cell cancers. The other 

aetiologies are represented by the following 

vascular diseases causes in 17% of cases, 

dominated by periarteritis nodosa, infectious 

causes in 2.4% of cases, spontaneous rupture of a 

cyst, nephrosclerosis, pre-eclampsia. Sometimes 

no cause is found (6.7% of cases) [5, 6]. 

The treatment is conditioned by the patient's 

clinical condition and the results of imaging and in 

particular the CT scan. In the case of a patient in 

shock, surgical exploration or arteriography with 

arterial embolisation is urgently required. 

In other cases, treatment should be considered at a 

distance from the haemorrhagic episode, at best 

the second week after the haematoma occurred, as 

spontaneous haemostasis has taken place and the 

clots are not yet organised. 

When the haematoma is secondary to a kidney 

tumour, extended nephrectomy is required. If the 

haematoma is secondary to a benign cause, simple 

monitoring of haematoma resorption can be 

considered. However, in the absence of an 

obvious cause, the choice between radical surgery 

or conservative treatment is not well defined [2, 3, 

5, 7, 8]. Some authors believe that simple 

surveillance may be sufficient. In this case, a 

repeat imaging study (CT +/- MRI) should be 

carried out at a distance. After 6 to 8 weeks, the 

haematoma has reabsorbed so that a tissue lesion 

can be found. Appropriate surgical treatment will 

then be considered. Evacuation of a large 

haematoma avoids the transition to abscessation 

and compressive phenomena leading to the 

progressive destruction of the kidney. Other 

authors prefer nephrectomy because of the risk of 

underlying cancer [2, 4, 7]. 

 

 
Figure 1: MRI: upper polar renal mass with peri-tumoral haemorrhage 

 

 
Figure 2: MRI: perirenal haematoma with mass effect on the rest of the renal parenchyma. 



CMI 04 (03), 393−395 
CMI JOURNAL 395 

CMI JOURNAL                                                                                                      Wael Ferjaoui et al. 

 

 
 

 
Figure 3.  Uroscanner: right perirenal haematoma, and mid-renal tissue mass. 

 

Conclusion: 

Spontaneous hematoma of the renal pelvis poses 

problems in etiological diagnosis and 

management. The CT scan is the best examination 

to confirm the diagnosis but it can sometimes be 

misleading. Arteriography should be performed 

whenever the CT scan is not conclusive, in cases 

of vascular pathology and in cases of 

angiomyolipoma with active bleeding. The 

treatment of choice remains nephrectomy if the 

tumour is malignant in appearance or if there is 

any doubt about the nature of the lesion.  

For benign lesions and in the absence of causes 

found after surgery, treatment is conservative. The 

fear of an undetected tumour requires close and 

prolonged surveillance. 

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235-238.

 


