Open Journal of Urology, 2011, 1, 1-3
doi:10.4236/oju.2011.11001 Published Online February 2011 (http://www.SciRP.org/journal/oju)
An Unusual Case of Urinary Incontinence
Eric R. Anderson, Darius J. Unwala
Departments of 1General Surgery and Urology, Marshfield Clinic, Marsh field, Wisconsin
Received January 18, 2011; revised February 16, 2011; accepted February 24, 2011
Abstract
Urinary incontinence and hematuria are frequent complaints evaluated by urologists often with readily iden-
tifiable etiologies. Occasionally, an unlikely source is found. We present an unusual case of urinary inconti-
nence and hematuria in an elderly female. Evaluation revealed that the complaints were due to a large cyst
emanating from her right hip which was the result of a previous right hip arthroplasty in 1970 with three
subsequent revisions. Her symptoms resolved spontaneously and the cyst has remained unchanged.
Keywords: Hematuria, Hip Arthroplasty, Particle Disease, Synovial Cysts, Urinary Incontinence
1. Introduction
Urinary incontinence and hematuria are frequent com-
plaints evaluated by urologists. In the majority of cases,
the etiologies are readily identifiable. Occasionally these
complaints arise from an unlikely source. We present an
unusual case of sudden onset of urinary incontinence and
hematuria in an elderly female.
2. Case Report
An 81-year-old female presented to her primary care
provider in January 2009 with an acute onset of urinary
incontinence, hematuria, and suprapubic pain. She had
urinary frequency, hesitancy, urgency, and urge inconti-
nence. On physical examination, a right-sided abdominal
mass was palpated. A computed tomography (CT) scan
of the abdomen an d pelvis was obtained. This revealed a
large cystic fluid collection emanatin g from the right hip
and extending into the right hemipelvis (Figures 1 & 2).
The mass was large enough to displace the right ureter
and bladder, resulting in mild hydroureter, borderline
hydronephrosis, and thickening of the bladder wall
(Figure 3). A urinalysis showed 11-20 red blood cells
per high-powered field. A urine culture was negative.
The urinary cytology was negative for malignant cells.
Further evaluation consisted of a cystoscopy and right-
sided retrograde pyelogram. The cystoscopy revealed
roughened bladder mucosa on the right side of the blad-
der wall and no bladder tumors. A bladder biopsy was
negative for malignancy. The retrograde pyelogram was
significant for a medially displaced, but normal caliber,
right-sided ureter with no signi fi cant hy dr o nephrosis.
In reviewing the patient’s past medical history, it was
noted that she had a right hip arthroplasty performed in
1970. She had three subsequent revisions, the most re-
cent of which was thirteen years prior to her recent pres-
entation. The cyst was thought to be the sequelae of
long-standing particle disease, resulting in inflammatory
changes within the join t and erosion of the medial aspect
of the right acetabulum. The collection was felt to be
benign, and no operative intervention was recommended
by the patient’s orthopedic surgeon.
Interestingly, her symptoms resolved within a few
months after her urologic evaluation. As she was as-
ymptomatic with no signs of systemic infection and her
urinary complaints had resolved, a conservative approach
of simple observation of the mass was chosen. On fol-
low-up pelvic ultrasound six months later, the mass re-
mained stable.
3. Discussion
Urinary tract complaints are not unusual after total hip
arthroplasty, with the most common problem being uri-
nary retention [1]. These urinary complaints are often
acute complications related to perioperative and postop-
erative management. However, urinary symptoms may
occur at any time after hip arthroplasty. While uncom-
mon, synovial cysts arising from prosthetic hip replace-
ments can cause urinary complaints years after the initial
operation [2-4]. These cysts may be the result of in-
creased friction and particle debris within the joint. The
friction and debris result in the release of inflammatory

E. R. ANDERSON ET AL. 2
Figure 1 and Figure 2. CT scan images of the abdomen and pe lvis revealing a large cystic fluid collection emanating from the
right hip and extending into the right hemipelvis.
Figure 3. CT scan reveals a large mass displacing the right
ureter and bladder, resulting in mild hydroureter, border-
line hydronephrosis, and thickening of the bladder w all.
mediators which can cause osteolysis, resulting in an
increased release of synovial fluid. Defects in the
acetabulum allow fluid to escape from the joint space,
thus forming a cyst [2-5]. Extrusion of cement into the
pelvis may allow particles of polyethylene wear to mi-
grate into the pelvis and cause cyst formation [4]. Cysts
may form in the groin, pelvis, or retroperitoneum. These
cysts can potentially cause compression of the colon,
ureters, bladder, uterus, vagina, and neurovascular struc-
tures [2, 4-6]. Treatment options include observation,
aspiration, excision, and revision of the total hip arthro-
plasty.
Although acute urinary tract complaints such as uri-
nary retention after hip arthroplasty are common [1],
those patients presenting with symptoms years after hip
arthroplasty warrant a thorough evaluation. The physical
exam was instrumental in this case, as it identified the
abdominal mass which, through imaging resulted in the
correct diagnosis. This case also demonstrates that in the
absence of symptoms successful non-operative treatment
of synovial cysts arising from a prosthetic hip is possible.
4. Acknowledgement
The authors thank the Marshfield Clinic Research Foun-
dation’s Office of Scientific Writing and Publication for
editorial assistance with this manuscript.
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