Acute Obstructive Uropathy Complicated by Spontaneous Fornix Rupture and Hemorrhagic Urinoma

Acute ureteric obstruction is a common urological presentation, but complications such as spontaneous calyceal rupture leading to a urinoma and hemorrhage are rare. This report details the case of a 43-year-old male who presented with acute right flank pain and chills due to severe right hydroureteronephrosis caused by two large obstructive ureteric stones. Initial computed tomography (CT) of the kidneys, ureters, and bladder (KUB) revealed a large peri-renal fluid collection (approximately 6.9 cm) with heterogeneous hyperdense components (measuring approximately 47 Hounsfield units), consistent with a hemorrhagic urinoma secondary to renal fornix rupture. The patient's clinical course was complicated by a significant drop in hemoglobin requiring transfusion. Immediate intervention via retrograde ureteral stent (6/26 double-J (DJ) stent) insertion successfully decompressed the system, resulting in clinical stabilization and a rapid reduction in urinoma size on follow-up imaging. Although the acute crisis was resolved, persistent cortical thinning of the right kidney and residual calculi necessitate a multi-stage management plan, including a dimercaptosuccinic acid (DMSA) scan to assess differential renal function and subsequent ureteroscopy laser lithotripsy for definitive stone removal. This case highlights the complexity of managing complicated obstructive uropathy and emphasizes the critical importance of prompt decompression to prevent irreversible renal damage.