The case is unusual because the patient had no preceding trauma, pelvic surgery, radiation treatment, urinary instrumentation or other identified intervention associated with the arterial abnormalities. She also reported no previous hematuria and had no significant medical, surgical or obstetric history. At admission, she was pale, with a heart rate of 112 beats per minute and a blood pressure of 110/70 mmHg, although she was not hemodynamically unstable. Mild suprapubic tenderness and a palpable, markedly distended bladder were present without signs of peritonitis. Her menstrual history was unremarkable, with regular cycles.

Initial testing revealed severe normocytic normochromic anemia, with hemoglobin of 5.3 g/dL, and thrombocytopenia, with a platelet count of 92 × 10³/μL. She also had severe kidney dysfunction associated with urinary outflow obstruction: serum creatinine was 6.8 mg/dL, blood urea nitrogen was 84 mg/dL and estimated glomerular filtration rate was 7.4 mL/min/1.73 m². Mild coagulopathy was present, with a prothrombin time of 14.2 seconds and an international normalized ratio of 1.25. These abnormalities could contribute to the extent or persistence of bleeding, but the case report notes that they did not explain the localized formation of bilateral arterial pseudoaneurysms.

Renal and pelvic ultrasonography showed bilateral normal-sized kidneys without hydronephrosis, while the urinary bladder was markedly distended and contained a heterogeneous, non-shadowing intravesical mass measuring 9.4 × 7.2 cm that corresponded to extensive clot retention. Because kidney function continued to deteriorate despite treatment directed at a suspected urinary tract infection, the patient underwent two urgent hemodialysis sessions for progressive renal failure and metabolic acidosis through a temporary right internal jugular venous catheter. Emergency rigid cystoscopy after metabolic stabilization confirmed extensive intravesical blood clots. An Ellik evacuator was used to remove them, but diffuse mucosal oozing obscured both the bleeding source and any discrete structural lesion.

A 22-Fr three-way Foley catheter was then inserted, and continuous irrigation with normal saline cleared the blood from the bladder. Serum creatinine initially declined from 4.0 to 1.4 mg/dL, and the patient was discharged after 48 hours. The apparent improvement was temporary: within 48 hours of discharge, she again developed severe gross hematuria, passed large clots and became profoundly lethargic. Recurrent severe anemia prompted transfusion of three units of packed red blood cells. Intravenous ceftriaxone was started empirically because of concern about a secondary urinary tract infection or post-procedural bacteremia. Urine cytology and repeated cystoscopic biopsies had shown acute and chronic inflammation with localized hemorrhages but no dysplastic or malignant changes, making bladder urothelial carcinoma an unlikely explanation for the bleeding.

Urgent multiphasic CT urography with contrast demonstrated two areas of arterial hyperenhancement corresponding to vesical artery pseudoaneurysms. One lesion measured 1.8 × 1.4 cm in the left superior vesical artery, while the other measured 1.1 × 0.9 cm in the right inferior vesical artery. Synchronous arterial enhancement with persistent delayed contrast filling supported the diagnosis of bilateral urinary bladder pseudoaneurysms. CT angiography also showed saccular pseudoaneurysms without a vascular nidus or early venous filling, findings that excluded a congenital arteriovenous malformation and an arteriovesical fistula. Selective pelvic angiography subsequently confirmed the two pseudoaneurysms and their distinct feeding arteries.

The patient had been diagnosed three months earlier with chronic hepatitis B virus infection and hepatitis delta coinfection and was receiving weekly 180-microgram subcutaneous injections of pegylated interferon alpha-2a under gastroenterology follow-up. Her coagulation parameters had been normal before this treatment, but laboratory tests one week before admission showed thrombocytopenia and moderate prolongation of prothrombin time and international normalized ratio, attributed in the case report to myelosuppression associated with interferon therapy. The investigators could not establish a causal link between interferon, the infection and development of the pseudoaneurysms. Tests for systemic vasculitis markers, including p-ANCA, c-ANCA, ANA, anti-dsDNA, cryoglobulins and complement levels, did not support an obvious interferon-associated systemic vasculitis. The authors therefore considered spontaneous development the most defensible interpretation, while treating infection and interferon therapy only as possible contributing factors.

After multidisciplinary discussion, emergency endovascular embolization was performed under local anesthesia through right common femoral arterial access. Both internal iliac arteries were selectively catheterized with a 5-Fr Roberts uterine catheter, and the left superior vesical and right inferior vesical arteries were superselectively catheterized with a 2.8-Fr Progreat microcatheter. The left pseudoaneurysm was supplied by a single, short and relatively straight feeding branch, allowing the microcatheter tip to advance safely close to the aneurysm neck. That anatomy favored precise mechanical occlusion with two pushable microcoils, each measuring 3 mm × 4 cm, deployed across the neck and within the feeding vessel. The immediate angiographic result was stasis within the left pseudoaneurysm.

The right inferior vesical artery pseudoaneurysm had a different anatomical pattern. Its feeding vessel was more distal, narrower in caliber and more tortuous, limiting how close the microcatheter could safely be advanced to the aneurysm neck. Because this position carried a greater risk of coil migration or reflux, 300–500-micrometer polyvinyl alcohol particles were used to occlude the small terminal feeding branches supplying the lesion. The choice of embolic agents therefore reflected the different vessel anatomy and catheter positions that could be achieved safely. Completion angiography showed complete exclusion of both pseudoaneurysms while preserving flow in the major pelvic arterial circulation and adjacent pelvic structures, allowing the vascular sources to be treated without open surgery.

Gross hematuria resolved completely within 12 hours after embolization. The urinary catheter was removed on the second postoperative day, and the patient voided without difficulty. Hemoglobin was stable at 10.1 g/dL before discharge, while serum creatinine had fallen to 0.8 mg/dL. At the six-week follow-up visit, she was asymptomatic and had no recurrence of hematuria or lower urinary tract symptoms. Pelvic ultrasonography and CT angiography demonstrated complete thrombosis and regression of both pseudoaneurysms, unremarkable renal morphology and function, and no residual intravesical clot. Because this was a single-patient report with a six-week follow-up, it cannot establish the frequency of spontaneous vesical pseudoaneurysms, identify a definitive cause or determine the long-term recurrence risk of the procedure.

The clinical course illustrates how arterial bleeding and urinary obstruction can reinforce one another. Blood from the pseudoaneurysms produced severe hematuria and large clots; those clots obstructed urinary outflow, increased pressure in the bladder and renal collecting systems and reduced the filtration gradient, contributing to postrenal acute kidney injury. Clot evacuation and continuous irrigation temporarily restored drainage and improved kidney function but did not remove the arterial sources, allowing bleeding to recur. Published reports describe a similar pattern in which pulsatile hematuria may appear to improve with irrigation, electrocautery or clot removal before returning. Because electrocautery does not correct the underlying vascular abnormality and may aggravate it, the case authors emphasized timely cross-sectional imaging or catheter angiography when bleeding recurs despite apparently satisfactory endoscopic control.

Vesical and pelvic pseudoaneurysms are rare abnormalities that usually follow disruption of an arterial wall through trauma, pelvic surgery, radiation therapy or urological procedures. Spontaneous cases arising without a preceding precipitating event are exceptionally uncommon and have appeared mainly as isolated reports. Selective angiographic embolization is described in the source as the standard minimally invasive approach for vascular causes of hematuria such as vesical pseudoaneurysm and arteriovesical fistula. Larger case series, mainly involving pelvic bleeding associated with malignancy rather than pseudoaneurysm, have reported technical success rates above 90% for superselective particulate or coil-and-glue embolization of vesical arteries and durable control of hematuria. The present case documents a bilateral spontaneous presentation in which anatomy-specific use of coils and particles stopped the bleeding, allowed renal recovery and produced no evident recurrence at six weeks, while remaining insufficient to establish comparative long-term effectiveness.

Subject of Research: A single-patient case report of bilateral spontaneous vesical artery pseudoaneurysms causing recurrent hematuria and obstructive acute kidney injury.

Article Title: Spontaneous Bilateral Vesical Artery Pseudoaneurysms Presenting With Massive Recurrent Hematuria and Obstructive Acute Kidney Injury: A Case Report

Article References: Sailish, D. K. A., Kumari, A., Jamil, H., Singh, S. R., Javaid, M. H., Khalid, M., & Segawa, F. (2026). Spontaneous Bilateral Vesical Artery Pseudoaneurysms Presenting With Massive Recurrent Hematuria and Obstructive Acute Kidney Injury: A Case Report. Clinical Case Reports, 14(10), Article e73739. https://doi.org/10.1002/ccr3.73739

Image Credits: AI Generated

DOI: 10.1002/ccr3.73739

Keywords: vesical pseudoaneurysms, spontaneous hematuria, acute kidney injury, urinary clot retention, endovascular embolization, pelvic angiography, vesical arteries, case report, interferon alpha, hepatitis delta, Spontaneous, Bilateral