A 65-year-old Iranian man slipped backward to the ground. He immediately felt left flank and groin pain but was able to continue walking. Approximately 4 h after falling, the pain severely increased, and the patient complaint of gross hematuria and difficulty in walking. He presented to the emergency department of Shahid Beheshti hospital affiliated to Yasuj University of Medical Sciences on the very same day because of gross hematuria. The pain was sharp, non-radiating, and worse with attempting ambulation, and better at rest. He reported no significant medical history, such as hypertension, diabetes mellitus, vascular disease or peripheral neuropathy and clotting or hemorrhagic disorders, and taking antiplatelet or anticoagulant agents. Surgical and genitourinary evaluation revealed no evidence of a hernia or any other disorder.
On physical examination, he was alert, and his vital signs were stable: temperature was 37.60C (afebrile), with a regular pulse of 72 bpm, and blood pressure of 135/70 mmHg. There was skin bruising and ecchymosis in left flank area, but abdomen was soft without tenderness. No pulsatile mass was detected and both femoral pulses were equal. There was no hernia and the scrotal contents were normal, and there was no blood at the urethral meatus. No perineal and scrotal hematoma was seen. The anal tone was good, rectal examination was normal and there was no occult blood, prostate was in normal place on examination and there was no saddle anesthesia. There was severe left CVA tenderness and mild groin tenderness, the lower back area was painful, he had some pain with the flexion of the vertebral column, and there was tenderness on the lumbar spine, but there was no tingling, paresthesia, and weakness in left lower extremity. Hip flexion was 3/5 in the left lower extremity and 5/5 in the right lower extremity. He also had pain on adduction or abduction of the left leg. The straight leg raise (SLR) and FABER tests of left leg were impaired. He was unable to bear weight on the left leg when the patient attempted ambulation. Sensory and motor examinations of the left lower extremity were normal. Ankle jerk reflex (Achilles reflex) was normal in both side, but knee-jerk reflex (patellar reflex) was 1+ in the left side, and 4+ (normal) in the right side.
At the Emergency Department (ED), initial trauma management was done according to the Advanced Trauma Life Support (ATLS) protocol and two IV accesses in the bilateral antecubital fossae were obtained, and urethral catheterization was performed in order to monitor the patient’s urine output, and patient was hydrated with 500 cc of lactated ringer at the initial stage. Focused Assessment with Sonography for Trauma (FAST) scan was done and there was no free fluid in abdomen and pelvic cavity and no solid organ damage.
Hematology revealed normal complete blood count and electrolytes. Coagulation time, prothrombin time (PT) and platelet count did not show any abnormalities. Blood urea nitrogen (BUN) and creatinine (Cr) were 19 and 8 mg/dl retrospectively. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) was 7 mm/h, and 12 mg/dl retrospectively. The result of urinalysis showed 2+ protein, 3+ blood and many red blood cells (RBCs).
Radiographs of the pelvis and the lumbo-sacral spine revealed no abnormalities (Figs. 1 and 2). An ultrasound scan obtained on the day of admission revealed a hyperechoic heterogeneous area measuring 48 × 30 mm in the left psoas muscle. Left kidney was enlarged (142 mm) with multiple cortical cyst with the maximum diameter of 46 mm. The intra-abdominal solid organs and adjacent soft tissues were intact, and there was no finding indicative of vascular disorders.
The ultrasound scan was compatible with a diagnosis of organizing acute psoas hematoma. A subsequent CT scan was done and revealed multiple large cortical cysts in both kidneys, an enlarged left-sided psoas muscle, and fracture of transverse process of third vertebral spine adjacent to the psoas muscle. CT scan confirmed the presence of psoas hematoma (Figs. 3 and 4).
In order to evaluate bladder for suspected bladder rupture, a CT cystography was done (contrast was instilled retrograde into the patient's bladder, and then the pelvis is imaged with CT) and this revealed no extravasation of contrast or other abnormal pathological findings (Figs. 5, 6, and 7). To evaluate kidneys, ureters, and bladder for gross hematuria, an intravenous pyelogram (IVP) was done next, and it demonstrated no abnormal findings (Figs. 8, 9, 10, 11, 12, 13, and 14).
Hemoglobin levels remained stable for 3 days, thereby excluding active bleeding. Treatment was initialized after confirmation of the diagnosis. Treatment consisted of strict bed rest, conditioning activities, physiotherapy and mobilization, and IV non-steroidal anti-inflammatory drugs (NSAIDs) (Pethidine 50 mg IV every 6 h PRN, and Apotel 1000 mg by IV infusion; it is usually dissolved in 100 ml Sodium Chloride 0.9% Sterile Solution), and they all were started in the hospital, and all of them except the IV NSAIDs were continued on an out-patient basis after discharge 3 days from the injury. A 14-day course of oral analgesic tablets (naproxen sodium; 250 mg every 6 to 8 h) was prescribed. Gradually, the pain eased, and on the first and the second out-patient follow-up visit 7, and 14 days from the discharge the pain was much decreased, and the patient was able to walk without aid. On the 28 days from discharge, the patient was relatively symptom free and returned to his daily routine activities.