Acute abdomen: spontaneous bladder rupture as an important differential diagnosis

Gomes, Carlos Augusto; Figueiredo, André Avarese de; Soares Júnior, Cleber; Bastos Netto, José Murillo; Tassi, Fabrício Rodrigues

doi:10.1590/S0100-69912009000400018

Abstract

A case of spontaneous perforation of the bladder in a diabetic female patient is reported. It is a rare clinical condition, that should be suspected in patients with a past history of radiotherapy to the pelvis, enterocystoplasty and those suspected of having a tumor in the bladder. A general surgeon should be aware of this possibility in the differential diagnosis of an acute abdomen.

Urinary Bladder; Rupture; Spontaneous; Abdomen; acute; Diagnosis; differential

CASE REPORT

Acute abdomen: spontaneous bladder rupture as an important differential diagnosis

Carlos Augusto Gomes, TCBC-MG^I; André Avarese de Figueiredo^II; Cleber Soares Júnior, TCBC-MG^III; José Murillo Bastos Netto^IV; Fabrício Rodrigues Tassi^V

^IPhD, Associate Professor, Department of Surgery, Universidade Federal de Juiz de Fora (UFJF), MG, Brazil

^IIPhD, Associate Professor, Department of Morphology, UFJF, MG, Brazil

^IIIMSc, Attending Physician, Department of Surgery, UFJF, MG, Brazil

^IVPhD, Associate Professor, Department of Morphology, UFJF, MG, Brazil

^VResident Physician, Santa Casa de Belo Horizonte, MG, Brazil

Correspondence address

ABSTRACT

A case of spontaneous perforation of the bladder in a diabetic female patient is reported. It is a rare clinical condition that should be suspected in patients with a past history of radiotherapy to the pelvis, enterocystoplasty and those suspected of having a bladder tumor. A general surgeon should be aware of this possibility in the differential diagnosis of an acute abdomen.

Key words: Urinary Bladder. Rupture, Spontaneous. Abdomen, acute. Diagnosis, differential.

INTRODUCTION

Spontaneous intraperitoneal urinary bladder rupture is a rare event whose course can be severe and even lethal if no early diagnosis and treatment are achieved¹. The aim of the present paper is to report a case of spontaneous bladder rupture with intraoperative diagnosis and poor clinical course.

CASE REPORT

A 79-year-old woman, diabetic, with a past history of repeat urinary tract infections and urinary incontinence, presented to the hospital with hypogastric pain and fever for two days. On physical examination, she had hypogastric pain with no signs of peritoneal irritation. Laboratory tests showed anemia, serum urea 54 mg/dL and serum creatinine 1.3 mg/dL, microscopic hematuria and positive urine culture for E. coli.

After 24 hours, the patient progressed to abdominal distension, oliguria and signs of sepsis, and was transferred to the Intensive Care Unit. Computed tomography of the abdomen showed no free peritoneal fluid or other significant alterations (Figure 1). Regardless of antibiotic therapy, progressive worsening of sepsis occurred; exploratory laparotomy was indicated, the chief suspicion being mesenteric ischemia. Peritonitis was found intraoperatively, with necrosis and rupture of the peritoneal bladder dome occluded by the loops of the ileum. Debridement of the perivesical necrotic tissue, cystostomy and raphy of the perforated segment of the bladder were performed. Histological examination of the bladder segment adjacent to the perforation site revealed no malignancy.

Regardless of the clinical measures taken, the patient progressed with continuing sepsis, poor clinical course, and died on the ninth postoperative day.

DISCUSSION

Spontaneous bladder rupture occurs in patients with urinary retention, reduced bladder sensitivity, urinary tract infection and vesical wall ischemia resulting from the increase in intravesical pressure. The pathophysiological mechanisms involved lead to the rupture of the bladder in its weakest portion, which, as a rule, is the peritoneal segment¹. Thus, patients with neurogenic bladder, a history of enterocystoplasty, after pelvic radiotherapy or malignant bladder tumors are most prone to develop the complication¹. In the present case, the patient was diabetic and had a history of urinary incontinence. In diabetic cystopathy, there is a decrease in bladder sensitivity and detrusor hypocontractility, leading to permanent high post-void residual urine and overflow incontinence. The chronic urinary retention and urinary tract infection could have been the inciting factors that contributed to bladder rupture in this patient. Other factors implicated in the rupture of the bladder are alcoholism, as it alters the sensitivity of the bladder, polyuria with bladder overdistension and greater susceptibility to minor traumas².

Clinically, the patients with bladder rupture present with diffuse abdominal pain, more intense in the lower abdomen, urinary ascites, abdominal distension, urinary retention and oliguria or anuria following bladder catheterization². Urea and creatinine are elevated in 45% of cases already in the first 24 hours, and in virtually 100% after 24 hours of rupture, with higher urea levels due to greater peritoneal absorption³.

The imaging test of choice is cystography, which shows intraperitoneal contrast extravasation. Accuracy is close to 100%; however, some lesions may go undetected if the perforation is blocked by loops of small bowel⁴. Computed tomography may show free intraperitoneal fluid, even though this finding alone does not warrant a definitive diagnosis.

The treatment of intraperitoneal bladder rupture is surgical, conducted through operative debridement, raphy of the bladder perforation and abdominal cavity lavage with 0.9% saline. Laparoscopy is an excellent option for diagnostic workup after the imaging tests are conducted, and should be indicated when persistent diagnostic doubt exists⁵.

Awareness of this serious condition, which has a high mortality rate (47%), as well as early surgical intervention are prerequisite to prevent the undesirable progression to abdominal sepsis and death¹.

In spite of the presence of urinary tract disease, general surgeons should be warned of the possibility of spontaneous bladder rupture. Acute abdomen with hypogastric pain, infection and urinary tract symptoms in diabetic patients, or those who suffer from neuropathy or bladder disease, are suggestive of the condition. Early diagnosis through cystography or surgical exploration could prevent poor clinical course.

REFERENCES

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