Unusual presentation of more common disease/injury


Spontaneous bladder rupture of a urinary bladder with non-muscle invasive bladder cancer Marios Hadjipavlou, Tharu Tharakan, Shahid A A Khan, Michael Swinn Department of Urology, East Surrey Hospital, Redhill, Surrey, UK Correspondence to Marios Hadjipavlou, [email protected] Accepted 10 December 2013

SUMMARY We describe the case of a 65-year-old man who developed spontaneous bladder rupture after picking up his suitcase from a squatting position. He was known to have non-muscle invasive bladder cancer (NMIBC), managed previously with transurethral resections and intravesical chemotherapy. CT scan showed a large amount of free intraperitoneal fluid anterior to the bladder, suggestive of a urinoma. Management was initially conservative, with insertion of urethral catheter, intravenous antibiotics and fluid resuscitation. Follow-up CT scan showed resolution of the urinoma with the patient making a full recovery after 3 weeks.

BACKGROUND Spontaneous bladder rupture has been previously described in trauma and rarely in patients with bladder diverticulae, malignant infiltration or previous pelvic radiotherapy. The case illustrates that bladder tumour resection may result in long-term loss of bladder elasticity and thinning, which can predispose to spontaneous rupture. In addition, in cases of non-traumatic bladder rupture, nonoperative supportive management with urethral catheterisation, intravenous fluids and antibiotics may be safe and effective.

However, the vital signs recorded at admission were within normal range. Metabolic acidosis ( pH 7.23) and a raised lactate of 2.0 mmol/L were noted on his blood tests. The patient was catheterised immediately and administered intravenous morphine, fluids and antibiotics.

INVESTIGATIONS A CT scan demonstrated free fluid within the peritoneal cavity, in particular anterior to the bladder and adjacent to the liver, with pockets of air within the bladder (figures 1 and 2). Laboratory tests showed an acute kidney injury (creatinine 185 μmol/L, urea 8.7 mmol/L and estimated glomerular filtration rate 32) and the inflammatory markers were marginally raised (white cell count 14.7×109/L and C reactive protein 2 mg/L).

OUTCOME AND FOLLOW-UP The renal function normalised after 2 days and a repeat CT scan 3 days later showed a marked reduction in the amount of free intraperitoneal fluid. The patient was discharged with a catheter in situ and oral antibiotics. A flexible cystoscopy was performed as part of his bladder cancer surveillance 3 weeks following the bladder rupture, which


To cite: Hadjipavlou M, Tharakan T, Khan SAA, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201972

A 65-year-old man presented with sudden onset of lower abdominal pain at our emergency department. The patient had just returned from holiday and while picking up a suitcase from the squatting position experienced severe acute suprapubic pain radiating to the epigastrium. Prior to this, he felt that his bladder was full and wanted to void, however, he was unable to do so following the onset of pain. He was wearing a moderately tight trouser belt at the time. He denied any history of lower urinary tract symptoms. The patient was diagnosed with a solitary 2 cm bladder transitional cell tumour (G3pT1) in the bladder dome 9 years ago and was originally treated with transurethral resection. The patient had five recurrences involving several locations in the bladder, including the bladder dome, which were managed with biopsy and diathermy. The last recurrence was 2 years ago following which he received single-dose intravesical mitomycin chemotherapy. Flexible cystoscopy checked 5 months ago did not show any evidence of tumour recurrence. On arrival to the emergency department, the patient was in significant distress, with severe lower abdominal tenderness and signs of peritonism.

Hadjipavlou M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201972

Figure 1 Coronal (1) and saggital (2) reconstructions of the CT scan on admission showing free fluid in the pelvis superior to the bladder and around the liver. 1

Unusual presentation of more common disease/injury Spontaneous intraperitoneal bladder rupture has been previously described in patients with muscle-invasive disease.10 In these cases, malignant infiltration of the lamina propria and detrusor muscle could contribute to loss of tissue tensile strength and elasticity, making the bladder prone to rupture. Our case is unique as it occurred in a patient with non-muscle invasive bladder cancer (NMIBC). The probable cause may be attributed to his previous bladder resection, biopsies and cystodiathermy, which may have compromised the structural integrity of the bladder wall thereby making it susceptible to injury. There are currently no specific guidelines for the management of spontaneous bladder rupture due to the rarity of this condition. The European Association of Urology guidelines recommend that intraperitoneal bladder rupture as a result of blunt trauma should always be managed by formal surgical repair due to the risk of peritonitis and abdominal sepsis.7 However, given our patients’ rapid improvement and with close clinical observation, conservative management proved successful.

Learning points Figure 2 Coronal (1) and saggital (2) reconstructions of the CT scan on admission showing free fluid in the pelvis superior to the bladder and around the liver. showed no abnormality except for catheter-related cystitis and no evidence of chronic obstruction. The catheter was then removed successfully. Subsequent uroflowmetry and postmicturition residual volume were normal, suggesting that there was no evidence of bladder outflow obstruction.

▸ Bladder rupture should always be considered as a differential diagnosis of sudden onset lower abdominal pain in patients with a history of bladder cancer. ▸ Urgent CT scan (CT abdomen/pelvis or CT urogram/ cystogram) is important to establish the diagnosis. ▸ Non-operative management of spontaneous intraperitoneal bladder rupture with early fluid resuscitation, antibiotic therapy and urinary catheterisation can be a safe and effective option in selected cases.

DISCUSSION Rupture of the bladder is usually precipitated by blunt or penetrating injury. The bladder is most vulnerable to trauma when distended, with the weakest area being the peritoneal surface of the dome. Conditions that impair the normal elasticity of the bladder may predispose to bladder rupture. The commonest cause is overdistension, but this is unusual in the absence of a pre-existing bladder abnormality such as bladder inflammation, ulceration or fibrosis (caused by tuberculosis/radiotherapy) or secondary to malignant infiltration.1 Case reports have highlighted that spontaneous atraumatic bladder rupture can occur also in the context of alcohol intoxication whereby diuresis, the dampening effect of alcohol and the reduction in the urge to micturate can contribute to a sudden rise in intravesical pressure therefore increasing the risk of rupture.2 3 Other risk factors cited include previous pelvic radiotherapy,4 bladder diverticulum5 and a neurogenic bladder.6 The investigation of choice for a suspected bladder injury is CT cystography.7 8 Non-iatrogenic bladder rupture can be classified into intraperitoneal or extraperitoneal. Intraperitoneal ruptures are usually caused by a sharp rise in the intravesicular pressure, most commonly due to blunt trauma to the pelvis or lower abdomen. The bladder dome, being the weakest, is most commonly affected, resulting in intraperitoneal urinary extravasation. Reabsorption of urea and creatinine through the peritoneum causes elevated serum levels of these metabolites, which may falsely lead the clinician to diagnose acute kidney injury. Extraperitoneal bladder rupture occurs secondary to pelvic fractures. Distortion of the pelvic ring and tearing of the anterolateral bladder wall at the bladder base causes the injury. It can also occur via counter-coup bursting opposite the fracture site or by penetration of bony fragments.7–9 2

Contributors MH and TT contributed equally in the data collection and manuscript write-up. SK and MS assisted in the write-up and editing of the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.


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Hadjipavlou M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201972

Unusual presentation of more common disease/injury

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Hadjipavlou M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-201972


Spontaneous bladder rupture of a urinary bladder with non-muscle invasive bladder cancer.

We describe the case of a 65-year-old man who developed spontaneous bladder rupture after picking up his suitcase from a squatting position. He was kn...
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