Rectus sheath hematoma in an elderly male with anticoagulation therapy—a diagnostic challenge

Rectus sheath hematoma (RSH) is a rare but potentially life-threatening condition, often underdiagnosed due to its non-specific presentation. We report a case of a 71-year-old male admitted for pneumonia, who developed hypotension, urinary retention, and a palpable pelvic mass after receiving low molecular weight heparin (LMWH) for new-onset atrial fibrillation. Ultrasound suggested a pelvic abnormality, and computed tomography angiography (CTA) confirmed a large rectus sheath hematoma with active venous bleeding. The patient underwent successful embolization of the right inferior epigastric artery, resulting in hemodynamic stabilization. This case highlights the importance of maintaining high clinical suspicion for RSH in anticoagulated patients and emphasizes the need for early imaging and multidisciplinary management to prevent complications.