Ureterosciatic hernia treated with ureteral stent placement.

A 92-year-old female with a history of asthma and chronic heart failure presented with left lumber back pain. Physical examination revealed knocking tenderness at the left costal-vertebral angle. Laboratory test results were within normal limits. Abdominal CT showed a left hydroureteronephrosis and an obstruction in the left distal ureter with herniation into the sciatic foramen. A ureteral stent was inserted into the left ureter and was removed after 2 months. She has not complained of pain or showed symptoms since the removal. Our case suggests that doctors consider the possibility of ureterosciatic hernias when examining older patients complaining of lower back pain. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Background

Ureteral herniation is uncommon, and its location in the sciatic foramen is also rare. CT is useful for diagnosing ureterosciatic hernias. We report a case of ureterosciatic herniation with left lumber back pain and hydronephrosis, which was diagnosed with CT and treated with ureteral stent placement.

Case presentation

A 92-year-old female was referred to the Department of Urology, Kanazawa Medical University Hospital due to left lumber back pain. She had a history of asthma and chronic heart failure. She had no fever on arrival at the hospital. Physical examination revealed left costal-vertebral angle (CVA) knocking pain.

Investigations

Abdominal CT showed a left hydroureteronephrosis and obstruction of the left distal ureter with herniation into the sciatic foramen. (figure 1)

Figure 1

Abdominal CT showed a left distal ureter with herniation into the sciatic foramen. (arrow).

She underwent retrograde ureterography (RP), which showed definite tortuosity of the left ureter in the sciatic foramen. (figure 2)

Figure 2

Retrograde ureterography reveals tortuisity of the left ureter. (arrow).

Treatment

A guidewire was inserted into the left ureter and was linearized. A retro-grade placement of the 6Fr ureteral stent.

Outcome and follow-up

No recurrence of the ureterosciatic hernia was observed after the ureteral stent was removed at 12 month follow-up.

Discussion

Cases of ureterosciatic hernias are uncommon. Indeed, only 30 cases have been reported previously.1 2 Ureterosciatic hernias are more likely to develop on the left side of elderly females because of their large pelvis and subsequent increase in abdominal pressure due to constipation and pregnancy.1 Ureterosciatic hernias develop as a result of the loss of partial pelvic fascia, atrophy of the piriformis, adhesions, or congenital deformity. Radiographic studies, including intravenous urography (IVU) or RP, and CT are useful for diagnosis of ureterosciatic hernias.1 IVU and RP showed an obstruction of the distal ureter with U-shaped tortuosity, known as a curlicue sign.3 The choice of treatment includes fixation of a ureter with surgery and placement of ureteral stents.1  In this case the patient was elderly and had concurrent diseases. Therefore we selected placement of a ureteral stent. She has had no recurrence for 12 months after stent removal, and we consider this treatment to have been effective. However, there is potential for recurrence after stent removal. She needs to be monitored in the future and should be evaluated for surgical therapy at the time of recurrence.2

Radiographic studies, including IVU or RP, and CT, are useful for the diagnosis of ureterosciatic hernias.

Placement of a stent is considered a preferred choice of treatment for ureterosciatic hernias because it is less invasive.

Placement of a ureteral stent is not curative therapy; therefore, patients need to be monitored and followed up.

Although uncommon, cases of ureterosciatic hernias do exist, so it is necessary to carefully examine, diagnose and treat older patients complaining of lower back pains.