0022-534 7 /90/1432-0349$02.00 /0 THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 143, February Printed in U.S.A.
SPONTANEOUS RUPTURE OF A BLADDER DIVERTICULUM LOUIS L. KEELER
AND
GRANNUM R. SANT*
From the Departments of Urology, New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
ABSTRACT
A case of spontaneous rupture of an acquired bladder diverticulum is presented. Diagnosis was made preoperatively and full recovery followed surgical treatment. A review of the literature revealed 9 other cases of spontaneous rupture. Bladder outlet obstruction and urinary tract infection were present in the majority of cases. In the past misdiagnosis and delayed treatment led to significant mortality. However, the prognosis currently is better due to the use of broad-spectrum antibiotics, better radiological imaging studies, and earlier diagnosis and treatment. (J. Ural., 143: 349-351, 1990) Spontaneous rupture of acquired bladder diverticulum is extremely rare. A review of the literature has yielded 9 reported cases and we add case 10. Before 1971 the mortality rate associated with spontaneous rupture of bladder diverticula was 100% (4 of 4 patients). 1 Mitchell and Hamilton added 1 patient in 1971 1 and since then 4 more have been reported, all of whom survived due to better preoperative diagnosis, earlier surgical intervention and improved postoperative care. 2- 4 We present a case and review the literature on this rare condition. CASE REPORT
I. G., 140-89-95, a 77-year-old man, presented to the emergency room with urinary retention. Urinary catheterization yielded 750 cc purulent, bloody urine. The patient also had right lower quadrant tenderness, fever (101F), leukocytosis (white blood count 26,000, normal 4,500 to 10,000/JLL) and a serum creatinine of 2.0 mg./dl. (normal 0.6 to 1.2). A further 2,000 cc urine subsequently drained in the emergency room. The patient was hospitalized and treated with parenteral antibiotics for an enterococcal urinary tract infection. The lower abdominal discomfort resolved, and an excretory urogram (IVP) showed dilated upper tracts and a severely trabeculated bladder with multiple diverticula (fig. 1). The patient was discharged from the hospital 10 days later with the indwelling catheter and plans for rehospitalization 1 month later for elective transurethral prostatic resection. A prominent bladder diverticulum was noted on a computerized tomography (CT) scan obtained as part of the evaluation of the lower abdominal tenderness (fig. 2). The patient was rehospitalizated 2 weeks later with complaints of urinary retention, suprapubic and abdominal pain, and vomiting. He had removed the Foley catheter at home earlier that day. Physical examination again revealed moderate tenderness in the right lower abdomen as well as abdominal distension and hypoactive bowel sounds. The white blood count was 22,000 and creatinine was 2.5 mg./dl. Catheterization yielded 800 cc and urinalysis revealed pyuria (greater than 100 white blood cells per high power field, normal Oto 5), bacteriuria and microscopic hematuria (5 to 8 red blood cells per high power field, normal Oto 2). Later that day the clinical condition deteriorated with increasing abdominal tenderness, tachycardia and hypoxemia. A cystogram revealed intraperitoneal extravasation of contrast medium consistent with bladder rupture and multiple diverticula, including a large diverticulum at the dome (fig. 3). At exploratory laparotomy a large volume of purulent material was discovered throughout the abdomen, along with a phlegmon in the right paracolic gutter extending down to the Accepted for publication September 15, 1989. * Requests for reprints: New England Medical Center, 750 Washington St., Box 142, Boston, Massachusetts 02111.
FIG. 1. IVP shows hydroureteronephrosis, severe trabeculation and multiple bladder diverticula.
FIG. 2. CT scan demonstrates thickened bladder wall with large diverticulum in dome.
dome of the bladder. A 6 cm. area on the dome of the bladder, including a 2 cm. ruptured diverticulum, was resected. Convalescence was uneventful and the patient returned 2 months later for elective transurethral resection of the prostate. DISCUSSION
The reported cases of spontaneous rupture of bladder diverticula are listed in the table. 1- 5 Bladder outlet obstruction is
350
KEELER AND SANT Clinical features of spontaneous rupture of bladder diuerticula in 10 patients Diagnosis
Reference Mitchell and Hamilton 1
Pt. Sex-Age M-48 M-? M-69 M-? M-72
Creekmur and associates 5
M-50
Smith and Kettlewell'
F-48
Saeki and associates'
F-52
Miyake and associates 8
M-81
Present case
M-72
Clinical
Outcome
Urethral stricture, probably infected Status after transurethral prostatectomy, infected Outlet obstruction, peritonitis, infected Outlet obstruction, peritonitis, infected Retention, benign prostatic hyperplasia, infected Bladder neck obstruction, infected Multiple sclerosis, bladder neck obstruction, ? infected Status after radical hysterectomy, radiotherapy, retention Benign prostatic hyperplasia Benign prostatic hyperplasia, infected
FIG. 3. Cystogram shows intraperitoneal extravasation and multiple bladder diverticula.
present in the majority of patients and most also have coexistent urinary tract infection. Among the 10 reported cases, including ours, there were 8 men with benign prostatic hypertrophy or urethral stricture and 2 women with urinary retention. One woman had bladder neck obstruction secondary to previously undiagnosed multiple sclerosis, and 1 had undergone radical hysterectomy and external beam radiation therapy 16 years before presentation. Burns suggested that infection coupled with a sudden increase in bladder wall tension creates the proper milieu for perforation of a diverticulum. 6 Alternatively,
Complications
Delayed (hrs.)
Preop.
Died
>24
No
Died
Died
?
?
Died
Died
?
?
Died
Died
?
?
Died
Recovered
>24
Yes Yes
Recovered
Vol. 143, February Printed in U.S.A.
SPONTANEOUS RUPTURE OF A BLADDER DIVERTICULUM LOUIS L. KEELER
AND
GRANNUM R. SANT*
From the Departments of Urology, New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
ABSTRACT
A case of spontaneous rupture of an acquired bladder diverticulum is presented. Diagnosis was made preoperatively and full recovery followed surgical treatment. A review of the literature revealed 9 other cases of spontaneous rupture. Bladder outlet obstruction and urinary tract infection were present in the majority of cases. In the past misdiagnosis and delayed treatment led to significant mortality. However, the prognosis currently is better due to the use of broad-spectrum antibiotics, better radiological imaging studies, and earlier diagnosis and treatment. (J. Ural., 143: 349-351, 1990) Spontaneous rupture of acquired bladder diverticulum is extremely rare. A review of the literature has yielded 9 reported cases and we add case 10. Before 1971 the mortality rate associated with spontaneous rupture of bladder diverticula was 100% (4 of 4 patients). 1 Mitchell and Hamilton added 1 patient in 1971 1 and since then 4 more have been reported, all of whom survived due to better preoperative diagnosis, earlier surgical intervention and improved postoperative care. 2- 4 We present a case and review the literature on this rare condition. CASE REPORT
I. G., 140-89-95, a 77-year-old man, presented to the emergency room with urinary retention. Urinary catheterization yielded 750 cc purulent, bloody urine. The patient also had right lower quadrant tenderness, fever (101F), leukocytosis (white blood count 26,000, normal 4,500 to 10,000/JLL) and a serum creatinine of 2.0 mg./dl. (normal 0.6 to 1.2). A further 2,000 cc urine subsequently drained in the emergency room. The patient was hospitalized and treated with parenteral antibiotics for an enterococcal urinary tract infection. The lower abdominal discomfort resolved, and an excretory urogram (IVP) showed dilated upper tracts and a severely trabeculated bladder with multiple diverticula (fig. 1). The patient was discharged from the hospital 10 days later with the indwelling catheter and plans for rehospitalization 1 month later for elective transurethral prostatic resection. A prominent bladder diverticulum was noted on a computerized tomography (CT) scan obtained as part of the evaluation of the lower abdominal tenderness (fig. 2). The patient was rehospitalizated 2 weeks later with complaints of urinary retention, suprapubic and abdominal pain, and vomiting. He had removed the Foley catheter at home earlier that day. Physical examination again revealed moderate tenderness in the right lower abdomen as well as abdominal distension and hypoactive bowel sounds. The white blood count was 22,000 and creatinine was 2.5 mg./dl. Catheterization yielded 800 cc and urinalysis revealed pyuria (greater than 100 white blood cells per high power field, normal Oto 5), bacteriuria and microscopic hematuria (5 to 8 red blood cells per high power field, normal Oto 2). Later that day the clinical condition deteriorated with increasing abdominal tenderness, tachycardia and hypoxemia. A cystogram revealed intraperitoneal extravasation of contrast medium consistent with bladder rupture and multiple diverticula, including a large diverticulum at the dome (fig. 3). At exploratory laparotomy a large volume of purulent material was discovered throughout the abdomen, along with a phlegmon in the right paracolic gutter extending down to the Accepted for publication September 15, 1989. * Requests for reprints: New England Medical Center, 750 Washington St., Box 142, Boston, Massachusetts 02111.
FIG. 1. IVP shows hydroureteronephrosis, severe trabeculation and multiple bladder diverticula.
FIG. 2. CT scan demonstrates thickened bladder wall with large diverticulum in dome.
dome of the bladder. A 6 cm. area on the dome of the bladder, including a 2 cm. ruptured diverticulum, was resected. Convalescence was uneventful and the patient returned 2 months later for elective transurethral resection of the prostate. DISCUSSION
The reported cases of spontaneous rupture of bladder diverticula are listed in the table. 1- 5 Bladder outlet obstruction is
350
KEELER AND SANT Clinical features of spontaneous rupture of bladder diuerticula in 10 patients Diagnosis
Reference Mitchell and Hamilton 1
Pt. Sex-Age M-48 M-? M-69 M-? M-72
Creekmur and associates 5
M-50
Smith and Kettlewell'
F-48
Saeki and associates'
F-52
Miyake and associates 8
M-81
Present case
M-72
Clinical
Outcome
Urethral stricture, probably infected Status after transurethral prostatectomy, infected Outlet obstruction, peritonitis, infected Outlet obstruction, peritonitis, infected Retention, benign prostatic hyperplasia, infected Bladder neck obstruction, infected Multiple sclerosis, bladder neck obstruction, ? infected Status after radical hysterectomy, radiotherapy, retention Benign prostatic hyperplasia Benign prostatic hyperplasia, infected
FIG. 3. Cystogram shows intraperitoneal extravasation and multiple bladder diverticula.
present in the majority of patients and most also have coexistent urinary tract infection. Among the 10 reported cases, including ours, there were 8 men with benign prostatic hypertrophy or urethral stricture and 2 women with urinary retention. One woman had bladder neck obstruction secondary to previously undiagnosed multiple sclerosis, and 1 had undergone radical hysterectomy and external beam radiation therapy 16 years before presentation. Burns suggested that infection coupled with a sudden increase in bladder wall tension creates the proper milieu for perforation of a diverticulum. 6 Alternatively,
Complications
Delayed (hrs.)
Preop.
Died
>24
No
Died
Died
?
?
Died
Died
?
?
Died
Died
?
?
Died
Recovered
>24
Yes Yes
Recovered
