INTRAPERITONEAL
RUPTURE
PSEUDODIVERTICULUM
DAVID CUMES, ROBERT
OF
OF BLADDER
M.D.
KESSLER,
M.D.
From the Division of Urology, Department of Surgery, Stanford University School of Medicine, Stanford, Caliibmia
ABSTRACT -A case is presented of a pseudodiverticulum of the bladder which developed afier a bladder rupture nine years previously. In this case, rupture of the pseudodiverticulum occurred intraperitoneally. The pseudodiverticulum communicated with the bladder via a small fish-mouthed opening surrounded by attenuated fibrotic bladder wall.
We describe a patient with a pseudodiverticulum of the bladder which developed after an automobile accident nine years prior to diagnosis. Review of the English literature shows only one similar case reported.’
A thirty-six-year-old woman with a history of difficult voiding associated with lower abdominal pain, especially on attempted voiding, was admitted via the emergency room at Stanford Medical Center. The history of her main complaint included the following: The patient had been involved in a motor vehicle accident in 1968 and sustained multiple fractures. A tracheotomy had been done, and she was hospitalized for a threemonth period with an indwelling Foley catheter in place for most of that period. She noted that from the time the Foley catheter was removed, her voiding had not been normal and was assoand the ciated with hesitancy, intermittency, need for Valsalva and Crede maneuvers to empty her bladder. After discharge from the hospital, she continued to have this difficulty, and she had required approximately six bladder catheterizations over the previous years and two urethral dilations for “urethral stenosis” in 1969 and 1970. In December, 1976, she had had an “attack’ similar to her current one, with lower abdomi-
nal pain associated with severe difficulty in voiding. She was sure that prior to 1968 she had voided normally, but since her automobile accident she had constant difficulty, with a feeling of incomplete emptying. Her previous history included an appendectomy, a cholecystectomy and, more importantly, a partial hysterectomy followed by a total abdominal hysterectomy and bilateral salpingooophorectomy in 1969. The latter had been done for the same complaint of lower abdominal pain, without relief. Physical examination showed a woman in moderate distress and febrile (38.3” C.). The rest of the physical examination was unremarkable, except for lower abdominal and pelvic tenderness. Laboratory data: urinalysis showed 3 to 5 red and 2 to 6 white blood cells. Urine culture was sterile. White cell count (WCC) was elevated at 16,900. An abdominal x-ray film series revealed a few dilated loops of small bowel but was otherwise unremarkable. Findings on intravenous pyelogram (IVP) were normal. without The patient was catheterized difficulty for 300 cc. of clear urine. After the IVP, she again could not urinate and was recatheterized with a 22 F Foley catheter for another 300 cc. She was treated conservatively as a probable case of diverticulitis with intravenous antibiotics, Foley catheter drainage, and close
UROLOGY
5
Case Report
/ NOVEMBER
1979 / VOLUME
XIV, NUMBER
515
Surgical exploration confirmed the presence of urine intraperitoneally. It was apparent that the area visualized at cystoscopy on the bladder dome communicated with a urinomatous collection well walled off by surrounding adhesions and loops of bowel. Moreover, gross inspection showed a rim of attenuated fibrotic bladder through which the communication had occurred. The patient had, in fact, an intraperitoneal rupture of a pseudodiverticulum of the bladder. The pseudodiverticulum was connected to the bladder via the abnormal fish-mouthed opening seen previously at cystoscopy. Pathologic examination confirmed the fact that the rim of bladder around the fish-mouth opening was fibrotic and associated with chronic inflammation (Fig. 2).
FIGURE 1. (A) Contrast material in bladder diver-tic&m after bladder emptying. (B) Intraperitoneal extravasation of contrast material during cystogram after patient tried to empty bladder by Valsalva and Cre& maneuvers.
observation. At no time did her abdominal signs increase, and within twenty-four hours her pain was gone, she was afebrile, and her WCC was 8,000. At this point, a cystoscopic examination revealed a fish-mouthed diverticular opening in the dome of the bladder - approximately in the position of the air bubble. Attempts to look inside the fish mouth were unsuccessful. A cystogram was performed at the time the patient was on the cystoscopy table. The filling phase showed no apparent abnormality. The emptying x-ray films, in the oblique and lateral positions, however, outlined a collection of contrast material in the superior part of the bladder dome in the area where the fish-mouth opening was noted at cystoscopic examination (Fig. 1A). The patient subsequently underwent another x-ray examination in the Radiology Department, where a voiding cystourethrogram was attempted to demonstrate better what was thought at that time to be a bladder diverticulum. The bladder was filled with 500 cc. sodium diatrizoate (Hypaque), the catheter was withdrawn, and the patient was asked to void. She claimed she could not void and would do better in the toilet where she could sit down and the Valsalva and Crede maneuvers would be more effective. On return from the toilet, the patient claimed to have severe abdominal pain which was generalized and associated with some shoulder tip pain. She stated that this was identical to the most severe pain she had experienced in the past. Abdominal x-ray examination done immediately showed intraperitoneal extravasation of contrast material (Fig. 1B).
516
Comment We believe that this patient probably had ruptured her bladder at the time of the automobile accident in 1968. This was treated (unknowingly) conservatively by two months of continuous Foley catheter drainage, leaving a weakened area of fibrotic bladder through which a pseudodiverticulum could develop. This has been shown to be a successful way of treating l bladder rupture, even when intraperitoneal. Alternatively, this could have occurred after the gynecologic procedure in 1969, although the patient’s symptoms of difficult voiding preceded this. Her bizarre symptoms can be ascribed to the fact that when attempting to void, the patient
FIGURE 2. Pathologic confirmation of chronic injlammation and fibrosis around fish-mouthed opening in bladder.
UROLOGY
/ NOVEMBER1979
/ VOLUMEXIV,
NUMBER5
was filling the pseudodiverticulum rather than emptying her bladder. No doubt her periodic catheterizations and urethral dilations were helpful in relieving her symptoms. After the bladder repair, the patient was well and voided normally “for the first time since 1968.” Postoperatively, after filling her bladder, the patient voided the entire volume without the Valsalva or Crede maneuver. Follow-up at a year confirmed that she continued to be well. We were able to find only one other reported case in the English literature of a pseudodiverticulum of the bladder, which developed two and one-half years after repair of a traumatic
UROLOGY
/ NOVEMBER
1979 / VOLUME
XIV, NUMBER
bladder laceration.’ This patient also presented with abdominal pain and difficult voiding. Unlike our patient, who was symptomatic most of the other patient remained the time, asymptomatic for two and one-half years. Divison of Urology, S-287 Stanford, California 94305 (DR. KESSLER)
References 1. Robards VL, Jr, Haglund RV, Lubin AN, and Leach JR: Treatment of rupture of the bladder, 1. Urol. 116: 178 (1976). 2. Smith TW, Madden J, and Gillenwater 1: Gigantic traumatic vesical pseudodiverticulum. Urology 1: 464 (1973).
5
517
RUPTURE
PSEUDODIVERTICULUM
DAVID CUMES, ROBERT
OF
OF BLADDER
M.D.
KESSLER,
M.D.
From the Division of Urology, Department of Surgery, Stanford University School of Medicine, Stanford, Caliibmia
ABSTRACT -A case is presented of a pseudodiverticulum of the bladder which developed afier a bladder rupture nine years previously. In this case, rupture of the pseudodiverticulum occurred intraperitoneally. The pseudodiverticulum communicated with the bladder via a small fish-mouthed opening surrounded by attenuated fibrotic bladder wall.
We describe a patient with a pseudodiverticulum of the bladder which developed after an automobile accident nine years prior to diagnosis. Review of the English literature shows only one similar case reported.’
A thirty-six-year-old woman with a history of difficult voiding associated with lower abdominal pain, especially on attempted voiding, was admitted via the emergency room at Stanford Medical Center. The history of her main complaint included the following: The patient had been involved in a motor vehicle accident in 1968 and sustained multiple fractures. A tracheotomy had been done, and she was hospitalized for a threemonth period with an indwelling Foley catheter in place for most of that period. She noted that from the time the Foley catheter was removed, her voiding had not been normal and was assoand the ciated with hesitancy, intermittency, need for Valsalva and Crede maneuvers to empty her bladder. After discharge from the hospital, she continued to have this difficulty, and she had required approximately six bladder catheterizations over the previous years and two urethral dilations for “urethral stenosis” in 1969 and 1970. In December, 1976, she had had an “attack’ similar to her current one, with lower abdomi-
nal pain associated with severe difficulty in voiding. She was sure that prior to 1968 she had voided normally, but since her automobile accident she had constant difficulty, with a feeling of incomplete emptying. Her previous history included an appendectomy, a cholecystectomy and, more importantly, a partial hysterectomy followed by a total abdominal hysterectomy and bilateral salpingooophorectomy in 1969. The latter had been done for the same complaint of lower abdominal pain, without relief. Physical examination showed a woman in moderate distress and febrile (38.3” C.). The rest of the physical examination was unremarkable, except for lower abdominal and pelvic tenderness. Laboratory data: urinalysis showed 3 to 5 red and 2 to 6 white blood cells. Urine culture was sterile. White cell count (WCC) was elevated at 16,900. An abdominal x-ray film series revealed a few dilated loops of small bowel but was otherwise unremarkable. Findings on intravenous pyelogram (IVP) were normal. without The patient was catheterized difficulty for 300 cc. of clear urine. After the IVP, she again could not urinate and was recatheterized with a 22 F Foley catheter for another 300 cc. She was treated conservatively as a probable case of diverticulitis with intravenous antibiotics, Foley catheter drainage, and close
UROLOGY
5
Case Report
/ NOVEMBER
1979 / VOLUME
XIV, NUMBER
515
Surgical exploration confirmed the presence of urine intraperitoneally. It was apparent that the area visualized at cystoscopy on the bladder dome communicated with a urinomatous collection well walled off by surrounding adhesions and loops of bowel. Moreover, gross inspection showed a rim of attenuated fibrotic bladder through which the communication had occurred. The patient had, in fact, an intraperitoneal rupture of a pseudodiverticulum of the bladder. The pseudodiverticulum was connected to the bladder via the abnormal fish-mouthed opening seen previously at cystoscopy. Pathologic examination confirmed the fact that the rim of bladder around the fish-mouth opening was fibrotic and associated with chronic inflammation (Fig. 2).
FIGURE 1. (A) Contrast material in bladder diver-tic&m after bladder emptying. (B) Intraperitoneal extravasation of contrast material during cystogram after patient tried to empty bladder by Valsalva and Cre& maneuvers.
observation. At no time did her abdominal signs increase, and within twenty-four hours her pain was gone, she was afebrile, and her WCC was 8,000. At this point, a cystoscopic examination revealed a fish-mouthed diverticular opening in the dome of the bladder - approximately in the position of the air bubble. Attempts to look inside the fish mouth were unsuccessful. A cystogram was performed at the time the patient was on the cystoscopy table. The filling phase showed no apparent abnormality. The emptying x-ray films, in the oblique and lateral positions, however, outlined a collection of contrast material in the superior part of the bladder dome in the area where the fish-mouth opening was noted at cystoscopic examination (Fig. 1A). The patient subsequently underwent another x-ray examination in the Radiology Department, where a voiding cystourethrogram was attempted to demonstrate better what was thought at that time to be a bladder diverticulum. The bladder was filled with 500 cc. sodium diatrizoate (Hypaque), the catheter was withdrawn, and the patient was asked to void. She claimed she could not void and would do better in the toilet where she could sit down and the Valsalva and Crede maneuvers would be more effective. On return from the toilet, the patient claimed to have severe abdominal pain which was generalized and associated with some shoulder tip pain. She stated that this was identical to the most severe pain she had experienced in the past. Abdominal x-ray examination done immediately showed intraperitoneal extravasation of contrast material (Fig. 1B).
516
Comment We believe that this patient probably had ruptured her bladder at the time of the automobile accident in 1968. This was treated (unknowingly) conservatively by two months of continuous Foley catheter drainage, leaving a weakened area of fibrotic bladder through which a pseudodiverticulum could develop. This has been shown to be a successful way of treating l bladder rupture, even when intraperitoneal. Alternatively, this could have occurred after the gynecologic procedure in 1969, although the patient’s symptoms of difficult voiding preceded this. Her bizarre symptoms can be ascribed to the fact that when attempting to void, the patient
FIGURE 2. Pathologic confirmation of chronic injlammation and fibrosis around fish-mouthed opening in bladder.
UROLOGY
/ NOVEMBER1979
/ VOLUMEXIV,
NUMBER5
was filling the pseudodiverticulum rather than emptying her bladder. No doubt her periodic catheterizations and urethral dilations were helpful in relieving her symptoms. After the bladder repair, the patient was well and voided normally “for the first time since 1968.” Postoperatively, after filling her bladder, the patient voided the entire volume without the Valsalva or Crede maneuver. Follow-up at a year confirmed that she continued to be well. We were able to find only one other reported case in the English literature of a pseudodiverticulum of the bladder, which developed two and one-half years after repair of a traumatic
UROLOGY
/ NOVEMBER
1979 / VOLUME
XIV, NUMBER
bladder laceration.’ This patient also presented with abdominal pain and difficult voiding. Unlike our patient, who was symptomatic most of the other patient remained the time, asymptomatic for two and one-half years. Divison of Urology, S-287 Stanford, California 94305 (DR. KESSLER)
References 1. Robards VL, Jr, Haglund RV, Lubin AN, and Leach JR: Treatment of rupture of the bladder, 1. Urol. 116: 178 (1976). 2. Smith TW, Madden J, and Gillenwater 1: Gigantic traumatic vesical pseudodiverticulum. Urology 1: 464 (1973).
5
517
