Medical Mystery: A painless lump, blood in urine

A 76-year-old woman who discovered a lump in the left side of left groin while toweling off after a shower went to see her family doctor. The lump didn't hurt, she told him, but she had noticed blood in her urine occasionally in the last few days, so she thought she should get it checked out.

She is an active woman who has been in fair health since she quit smoking in her 50s after needing a bypass operation for blocked pelvic arteries that had been affecting her legs. Over the last 10 years, she had been dealing with recurrent kidney stones.

Given her history, her family doctor appropriately sent her to the hospital for further evaluation.

The list of conditions that might account for her symptoms is long - kidney stones, urinary tract infection, bladder cancer, lupus, hernia, lymphadenopathy, appendicitis, and diverticulitis, to name a few.

Clinicians begin testing her blood and urine immediately. The blood tests revealed a slightly elevated white blood cell count, suggesting infection or inflammation. The urine tests were positive for red blood cells, indicating bleeding in the urinary tract. In medicine, the principle of Occam's razor is often invoked when dealing with complicated diagnoses. It essentially means the simplest answer is usually correct.

But in this case, the simple answer was not at all obvious.

An ultrasound of the lump revealed a false aneurysm, which occurs when a blood vessel wall is injured and surrounding tissues contain the blood.

It was exactly where her bypass graft had been sewn to her common femoral artery 20 years before, suggesting the graft had become infected.

We told our patient we thought she had developed a very rare condition hardly ever reported in the medical literature. It appeared an opening, or fistula, had developed between her bypass graft and left ureter, accounting for the blood. A CT scan later that day confirmed that to be the case.

We knew the fistula had to be closed before the light bleeding she had experienced turned into a catastrophic hemorrhage.

Treatment of a fistula between an aortofemoral bypass graft and a ureter is risky business. It involves removing the infected graft, addressing the hole in the ureter, and restoring blood flow to the limb through an alternative pathway. Complications include hemorrhage, infection, limb loss, heart attack, stroke, and death, but may be reduced by staging the procedures when possible.

In the first stage, a long synthetic tube was used to route blood flow from her axillary artery under her collar bone down the side of her body and into blood vessels in her mid-thigh to feed her leg. This is a "clean" operation where no infected tissues are encountered, minimizing the risk of surgical-site infection. Plus, there would be no interruption of blood flow to the limb when the infected graft was removed 24 hours later.

The graft removal revealed mineral deposits on the graft where it was opening up to the ureter - which proved to be the source of her recurrent kidney stones. Finally, the hole in the ureter was closed. She left the hospital in a week.

It is now six months since surgery, and this inspiring patient is back to enjoying her active life.

Joseph L. Grisafi, M.D. is a vascular surgeon in East Norriton and Sellersville, and founder of the Artery & Vein Institute.

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