Presentation
A patient with a history of obesity (BMI of 30), hyperlipidemia, osteoporosis, GERD, smoking, and COPD is presenting with abdominal pain. There is no history of surgery or trauma.
Patient Data
Multiphase CT images demonstrate a right ureterosciatic hernia with looping consistent with the curlicue sign. In particular, the right ureter curves into the greater sciatic foramen posterior to the right acetabulum. This abuts the right sciatic nerve. The left ureter has a slightly posterior course near the sciatic notch, but subsequently courses anteriorly towards the bladder.
There is a right inguinal hernia containing the appendix. No evidence of appendicitis is seen. Oral contrast is present in the bowel and appendix.
There is also a fat-containing umbilical hernia.
A right-sided bladder hernia is seen extending through the pudendal canal.
Chronic compression fractures of the T12 and L1 vertebrae are present.
Sludge/stones are noted in the gallbladder. Colonic diverticula are seen without acute diverticulitis.
Case Discussion
The CT shows a case of ureterosciatic hernia and multiple other hernias. A ureterosciatic hernia, also known as a Lindbom hernia, can follow three different paths 1: the ureter can enter either through the greater sciatic foramen or the lesser sciatic foramen, and within the greater sciatic foramen, the ureter can be suprapiriformis or infrapiriformis in location. Identifying the anatomy is pertinent if surgical management is indicated. In this patient, the right ureter extends through the greater sciatic foramen in the infrapiriformis region, with a pathognomonic curlicue sign best shown on the final reconstructed coronal images.
The ureterosciatic hernia was asymptomatic in this patient. Symptoms that can occur with a ureterosciatic hernia include focal pain, changes in bowel habits, flank pain or urinary symptoms due to urinary obstruction, paresthesia, or a unilateral bulge of the buttocks 2,3.
Management, like most common hernias, includes determining if the hernia is reducible or symptomatic 2. Surgical management can include open reduction or stent placement if urinary obstruction is present 3. For this patient, clinical follow-up was advised, and no surgical intervention was indicated.
In addition to the ureterosciatic hernia in this case, the appendix is visualized almost entirely in a right inguinal hernia, consistent with an Amyand hernia. A fat-containing umbilical hernia is also present. Finally, part of the bladder is seen herniating into the right pudendal canal. Similar to the ureterosciatic hernia, the bladder hernia is best seen on post-contrast delayed images 4.
The patient's abdominal pain was attributed to biliary colic in this case and subsequently resolved.
Case co-author: Emma Sechrist, MD (Loyola University Medical Center)
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