Misdiagnosis of hematuria after catheterization: A case report and literature review of posterior urethral hemangioma in a pediatric male

Abstract

Hemangioma is a common benign skin tumor, but it is relatively rare in the bladder, prostate, and urethra. We report a case of a 12-year-old male child who was misdiagnosed in the early stage due to hematuria after catheterization. Due to severe gross hematuria, he was re-admitted for further examination, which confirmed the diagnosis of urethral hemangioma. Successful treatment was achieved through local cauterization and pingyangmycin injection under cystoscopy. This case highlights the importance of considering urethral hemangioma in similar scenarios, providing valuable insights for doctors and urging further research on this underdiagnosed condition.

1 Introduction

Hemangioma is a prevalent vascular tumor, affecting both infants and adults. It can manifest in various tissues and organs, predominantly in the skin and subcutaneous tissue, with rare occurrences in deeper organs. Literature predominantly reports hemangiomas outside the skin in cases involving the digestive system, such as the liver, stomach, and intestine. Hemangiomas in the bladder, prostate, and urethra are exceedingly rare.

Urethral hemangioma, a rare benign tumor, can develop at any age but is relatively more common in adult males. Due to its rarity, there is no established incidence rate. Clinical presentations of urethral hemangioma include lower urinary tract symptoms, hematuria, dysuria, and urinary retention. We report the case of a 12-year-old male with misdiagnosis of hematuria after catheterization.

2 Case report

A 12-year-old male patient was diagnosed with concealed penis in August 2022, primarily due to underdeveloped penis and excessive foreskin. He underwent surgical correction under general anesthesia in the operating room. Following anesthesia, a catheter was inserted through the urinary tract, revealing significant bleeding at the urethral opening, estimated at 100 ml. Catheter removal resulted in decreased bleeding, attributed to a posterior urethral injury caused by catheter insertion. Consequently, the catheter was retracted and secured to stop the bleeding. The patient was discharged one week post-surgery with favorable wound healing, no urethral blood leakage, and no hematuria. A week after discharge, he underwent outpatient follow-up, during which the urinary catheter was removed. Two days later, he presented to the emergency department with substantial gross hematuria emanating from the urethral opening post-physical activity. He was readmitted and treated with indwelling catheters and intravenous hemostatic drugs. Subsequently, a transurethral cystoscopy revealed numerous blood clots in the bladder, which were cleared, uncovering no bleeding points or urethral tears. However, a fresh, strawberry-shaped protrusion with a diameter of 0.8 cm was identified on the left urethral wall, 12 cm from the urethral opening, oozing blood, with a total estimated bleeding volume of 400 ml. A posterior urethral hemangioma was suspected. A portion of the protrusion tissue was excised for pathological examination, and electrocoagulation and cauterization were performed to control bleeding. Pathological examination confirmed hemangioma ( Fig. 1 ). Four months post-operation, the patient underwent a follow-up MR examination, revealing a nodular abnormal signal on the lower left side of the urethral bulb, approximately 10 × 10 × 8.4 mm in size, with local enhancement ( Figs. 2 and 3 ). A 4 mg Pingyangmycin solution was injected into the hemangioma base under cystoscopy, with an indwelling catheter for 3 days. Post-surgery, there was no bleeding or gross hematuria at the urethral opening. Three days post-catheter removal, no bleeding or gross hematuria persisted. A one-month follow-up showed no hematuria or vascular tumor-like tissue at the initial lesion site on endoscopy. A 6-month post-surgery MR scan indicated reduced nodule size and no hematuria ( Fig. 4 ). Subsequent 12- and 18-month follow-ups showed no hematuria and normal urination.