an 84-year - old man presented to our department with a 12-hour history of painless gross hematuria . his past medical history included anemia , benign prostatic hyperplasia , appendicectomy , duodenal ulcer ( treated surgically 40 years ago ) , and an abdominal aortic aneurysm . laboratory investigations on admission showed the following : hemoglobin 10 g / dl , hematocrit 31.5% , platelets 16210/l , urea 77 mg / dl , and creatinine 1.5 mg / dl . midstream urine ( msu ) sample investigations revealed the following : specific weight 1,030 , ph 5.5 , white cells 2 - 4 , and red cells > 200 per optic field . cystoscopy showed decreased expansion suggesting compression from outside the bladder . at the point of compression , increased vascularization was noted in the bladder mucosa with no evidence of active bleeding . no trace of blood was identified coming from the ureteric orifices , the bladder neck , or the prostate . the abdominal computed tomography ( ct ) scan with intravenous contrast revealed left - sided hydronephrosis and dilation of the upper third of the left ureter with no evidence of stones or related peri - ureteric mass . there was an abdominal aortic aneurysm starting 3 cm below the origin of the renal vessels and involving the aortic bifurcation and both internal iliac arteries ( fig . 1 , 2 ) . the greatest diameter of the aortic aneurysm was 8.0 cm , and the left internal iliac artery 's diameter was 11.5 cm ( fig . the iliac artery aneurysm contained a peripheral thrombus , whereas the aortic aneurysm was partly calcified ( fig . aneurysm of the iliac artery usually coexists with aortic aneurysm and occurs more frequently in men . the diagnosis is difficult not only because of its rare occurrence but also because of its atypical presentation and the deep anatomical position of the artery in the pelvis . for these reasons , an aneurysm of the iliac artery is often not considered in the differential diagnosis of macroscopic hematuria . when an aneurysm of the iliac artery increases in size , symptoms appear as the result of compression or rupture into adjacent organs causing urological , gastroenterological , and neurological symptoms . direct compression by the aneurysm and the desmoplastic reaction that surrounds and fixes the bladder and the ureter can result in obstructive urological symptoms . direct rupture of an iliac aneurysm into the bladder associated with hematuria is rare , and only few cases have been reported . it is important to note that hematuria secondary to a large aneurysm of the internal iliac artery does not necessarily suggest an arterio - vesical or arterio - ureteral fistula . the hematuria may be due to bladder mucosal bleeding as a result of congested peri - vesical vessels resulting from aneurysm compression . this explains the hematuria in our patient , because no other cause of bleeding was identified by the series of investigations . the cystoscopic findings excluded a diagnosis of congenital arteriovenous malformation , because no trace of blood was found coming from the ureteric orifices . this finding was also reported by bhasin et al , who reported two cases of lower limb edema due to venous and lymphatic compression with subsequent cellulitis in one case and deep venous thrombosis in the other . the mortality rate due to rupture of an iliac artery aneurysm is over 50% , with survival rates following treatment of over 90% . surgical intervention is indicated in patients in reasonable clinical condition and whose aneurysms are greater than 3 cm in diameter . two methods of treatment are currently available : open surgery and endovascular aneurysm repair ( evar ) . surgical resection and reconstruction other open surgical techniques include exclusion , aneurysmorrhaphy , and resection . however , surgery for aneurysms of the internal iliac artery is technically challenging because of the depth of the operative field . aneurysm exclusion is the simplest procedure but carries a risk of long - term complications because the aneurysm is still supplied by collaterals and thus continues to expand and may even rupture . for a unilateral aneurysm of the internal iliac artery with the contralateral internal iliac artery free of disease , aneurysmorrhaphy with over - sawing of the proximal neck and distal branches , different minimally invasive techniques for the exclusion of the internal iliac artery aneurysm from the flow can be used . a combination of embolization of the distal branches of the internal iliac artery and stent - graft placement at the orifice of the internal iliac artery is usually advocated as the primary endovascular treatment option . these include thrombosis of the graft , endoleaks , kinking , rupture or distal migration of the graft , or even rupture of the aneurysm due to endotension . small coil or glue embolization of the distal branches of the internal iliac artery , packing of the aneurysmal sac with wires or coils of various sizes , and percutaneous ct - guided embolization of the aneurysmal sac can also be preformed , but the long - term outcomes of these techniques have not been studied . in our case , the patient was reviewed by vascular surgeons , who offered surgery , but the patient declined surgery because of his age . an aneurysm of the internal iliac artery is a rare cause of macroscopic hematuria that can be fatal . awareness of this as a possible cause of hematuria can assist in immediate diagnosis and appropriate treatment .
we report a case of macroscopic hematuria secondary to an aneurysm of the internal iliac artery . 
 an 84-year - old male presented to our department with a 12-hour history of painless gross hematuria . 
 cystoscopy showed decreased expansion suggesting compression from outside the bladder . at the point of compression , increased vascularization was noted in the bladder mucosa without evidence of active bleeding . 
 no trace of blood was identified coming from the ureteric orifices , the bladder neck , or the prostate . 
 there was no evidence of intra - vesicular masses or other inflammatory changes . 
 the abdominal computed tomography scan revealed left - sided hydronephrosis and an abdominal aortic aneurysm involving the aortic bifurcation and both internal iliac arteries . 
 there was no evidence of rupture . 
 an aneurysm of the internal iliac artery is a rare cause of macroscopic hematuria that can be fatal . 
 awareness of this as a possible cause of hematuria may assist in immediate diagnosis and appropriate treatment .