Wunderlich syndrome (WS), defined as spontaneous, non-traumatic renal, or perirenal hemorrhage, is a rare but potentially life-threatening condition often presenting with flank pain and hypovolemic shock. Although it can arise from benign or malignant renal lesions, its changing etiologies and management strategies over time have not been well characterized.

We retrospectively analyzed patients diagnosed with WS at a single tertiary center from 2011 to 2024. Inclusion required non-traumatic perirenal hemorrhage confirmed by emergency computed tomography. Clinical data (demographics, comorbidities, symptoms, hemodynamic status), interventions (surgery, radiologic embolization), and outcomes were collected. Final diagnoses were determined by pathology when surgery was performed or by imaging in conservatively managed cases.

A total of 46 hemorrhagic events occurred in 38 patients (mean age 47.5 ± 16.6 years). Flank pain was the most common symptom (95.7%). Thirteen cases (28.3%) required surgical exploration and nephrectomy, while seven (15.2%) underwent embolization; one of these required delayed nephrectomy. Hemodynamic instability (systolic blood pressure <90 mmHg) occurred in seven patients, leading to emergency embolization in one and emergency surgery in four. Final diagnoses showed a broad etiological range. Renal cell carcinoma accounted for eight hemorrhagic events in six patients, while angiomyolipoma accounted for 11 events in six patients. Four events were linked to chronic pyelonephritis, and six had no identifiable underlying disease. Over time, the use of conservative or interventional radiologic management increased, leading to fewer nephrectomies. During follow-up (mean 44.0 ± 44.9 months), six patients died, with four deaths directly related to WS or its underlying disease.

WS remains a rare but life-threatening entity from diverse renal pathologies. Rapid recognition and intervention are critical, especially for unstable patients. Our data illustrate a notable shift toward conservative and interventional approaches, reducing surgical rates. Further multi-center studies are needed to establish optimal management strategies for this uncommon but serious condition.