Case Report: Deep vein thrombosis and pulmonary embolism secondary to urinary retention in a neurogenic bladder

Our patient is a 36-year-old man with a past medical history significant for the SCN-95 mutation associated with Brugada syndrome, two provoked episodes of DVT, and Hinman syndrome, also known as non-neurogenic neurogenic bladder, which is a voiding dysfunction of the urinary bladder of neuropsychological origin. Despite negative hypercoagulability workups in the past, the patient had experienced two provoked episodes of DVT, thirteen and nine years ago, respectively, leading to previous anticoagulant therapy with warfarin and Eliquis. However, he discontinued anticoagulation on the advice of his hematologist four years ago and currently manages his Hinman syndrome with intermittent straight catheterization, which poses challenges to adherence. The patient presented to the emergency department with right lower extremity pain, initially yielding a negative DVT workup. Subsequent presentation with exertional dyspnea led to the discovery of an acute non-occlusive thrombus in the right saphenofemoral junction and a chronic occlusive thrombus in the right femoral vein, with pulmonary emboli noted on imaging. Given his history of urinary retention secondary to Hinman syndrome, non-compliance by the patient to self-catheterize five times a day, and absence of any recent provoking factor, the thromboembolic events were attributed to right iliac vein obstruction caused by an enormously distended bladder compressing the anatomical structures in the vicinity and leading to DVT and pulmonary embolism. Hospitalization ensued, with the initiation of urethral catheterization and anticoagulant therapy, resulting in clinical improvement and the subsequent decision for lifelong anticoagulation. This case underscores the importance of recognizing rare etiologies of DVT/PE, particularly in patients with underlying urinary dysfunction, and highlights the need for timely intervention to prevent potentially fatal complications. • In the US, DVT/PE occurs in 600 thousand people every year, and about 100 thousand Americans die every year due to DVT/PE. • Hinman syndrome is a voiding dysfunction of the urinary bladder of neuropsychological origin. • Urinary retention can lead to an enormously distended bladder, which can lead to compression of the iliac veins draining the lower limbs. • Imaging findings indicated that the cause of DVT may have been venous return failure caused by compression of the iliac vein by an extremely distended bladder.