THEJOURNAL O F UROLOGY Copyright 5 1991 by
Vol. 145, 135-137, January 1991 Pri~ltsdin C S . A .
AMERICAX CROLOGIC.AL ASSOCIATION, INC.
SUBSTANCE ABUSE-RELATED SPONTANEOUS BLADDER RUPTURE: REPORT OF 2 CASES AND REVIEW OF THE LITERATURE G R E G O R Y A. MARSHALL, C H R I S T O P H E R
M. D I X O N
W. M c A N I N C H *
From the Department of Urology, University of California School of Medicine and Sun Francisco General Hospital, Sun Francisco, California
Spontaneous rupture of the normal bladder associated with alcohol abuse is rare, with only 20 cases reported i n t h e English literature t o which we add 2 cases. Heavy alcohol ingestion predisposes t h e bladder t o rupture by t h e large volume of fluid intake, its diuretic effect a n d t h e mental obtusion it produces, clouding sensory cues t o void. a-Sympathomimetic drugs, such a s cocaine a n d methamphetamine, increase t h e resistance at t h e urethral sphincter a n d exacerbate t h e effects of alcohol. Cystography will be diagnostic, and prompt operative repair of intraperitoneal rupture is mandatory. Complete evaluation of t h e bladder, including urodynamic study, is important to eliminate underlying bladder pathological conditions. Substance abuse-related rupture demonstrates a typical constellation of clinical features t h a t necessitate considering it a syndrome separate from other causes of spontaneous bladder rupture. KEYWORDS: bladder; rupture, spontaneous; alcoholism; sympathomimetics Spontaneous rupture of the bladder has been well described. In the vast majority of cases it is associated with disease of the bladder wall or obstruction at the bladder neck. However, when idiopathic, clinical presentation varies widely. Ruptures have occurred in patients during labor and in the puerperal period, postoperatively from unrelated surgery and during increases in abdominal pressure such as when coughing or straining.' Rupture after the ingestion of alcohol and other drugs also has been classified as idiopathic. However, the unique clinical features of these cases set them apart and necessitate considering the syndrome of substance abuse-related spontaneous bladder rupture as a separate entity. We have seen 2 patients with this syndrome, each differing interestingly from the norm of those described in the literature. REPORTS Case I . A 22-year-old woman was awakened with the acute onset of sharp suprapubic pain the morning after consuming 12 beers and "a moderate amount" of cocaine. She voided roskcolored urine and at presentation to the emergency room that evening the pain was quite severe and generalized, and she had not voided in 8 hours. The patient denied losing consciousness the night before, as well as any history of falls or abdominal trauma. She had no history of retention. Physical examination revealed no signs of trauma. The abdomen was diffusely tender with peritoneal signs. Findings on pelvic examination were normal. Hematocrit was 48 gm.% on admission, decreasing to 40 after hydration, white blood count 14,000 with a left shift, blood urea nitrogen (BUN) 13 mg./dl. (normal 10 to 24) and creatinine 2.0 mg./dl. (normal 0.6 to 1.4). A film of the kidneys, ureters and bladder showed a large amount of ascites (fig. 1,A ) . Placement of a Foley catheter was followed by immediate drainage of 1,300 ml. cranberry-colored fluid (fig. 1,B) and urological consultation was obtained. Cystography showed contrast material within the peritoneal cavity without delineation of the bladder (fig. 2). Exploration revealed a 6 cm. tear in the posterior bladder wall with the Foley catheter traversing the rent and resting within the peritoneal cavity. The bladder mucosa and muscle appeared normal and were repaired. Since that time the patient has voided normally. Followup urodynamic profile 2 months postoperatively was normal. CASE
Accepted for publication July 27, 1990. * Requests for reprints: Department of Urology, U-575, University of California, San Francisco, California 94143-0738.
Case 2. A 51-year-old alcoholic man was awakened with a sharp pain in the lower abdomen that radiated to the inguinal region and penile base. During the next few hours diffuse and persistent abdominal pain developed. Urinating was difficult and painful. There was a strong clinical suspicion of an alcoholic binge the night before and no evidence or history of abdominal trauma. He had no significant obstructive symptoms. On physical examination the abdomen was diffusely tender, markedly in the suprapubic region. Findings on rectal examination were normal except for tenderness lateral to the prostate. The patient spontaneously voided a small amount of urine, which showed 20 to 50 red blood cells per high power field. White blood count was 18,000, with neutrophilia, BUN 32 mg./ dl. and serum creatinine 2.6 mg./dl. A film of the kidneys, ureters and bladder revealed a large pelvic mass displacing dilated loops of small bowel superiorly; however, placement of a Foley catheter yielded only 200 ml. grossly clear urine. Excretory urography showed normal upper tracts but the bladder was displaced superiorly from the pelvic floor and considerable extravasation of contrast material was noted from the right anterolateral aspect into the retroperitoneal space and pelvis. No evidence of pelvic fracture was seen. Since the rupture was clearly identified cystography was not performed. Diagnosis was spontaneous extraperitoneal bladder rupture that was treated nonoperatively with 10 days of catheter drainage and intravenous antibiotics. The pain and ileus subsided, and laboratory values returned to normal. A modified cystogram with 100 ml. contrast material 10 days after injury showed no extravasation. Subsequent cystoscopy revealed a normal urethra and small prostate 10 days after the rupture. The bladder was completely normal in configuration without trabeculation. A stellate mucosal fold was seen anteriorly (the probable site of rupture) but the mucosa was otherwise normal. A cystometrogram showed the first sensation of filling at 200 ml. and a capacity of 350 ml. Results of random bladder biopsies were normal. The patient has had no further urological complaints. DISCUSSION
Spontaneous rupture of the bladder has been comprehensively reviewed. Most cases result from bladder wall lesions or , ~may ~ ~ have an area of necrosis secondary outlet o b s t r ~ c t i o nor . ~ 1976 Evans et a1 reviewed 84 to atherosclerotic e m b ~ l u sIn cases in the world literature of spontaceous rupture of a normal
MARSHALL, DIXON AND MCANINCH
FIG. 1. Film of kidneys, ureters and bladder in case 1. A, large amount of intraperitoneal fluid pushing bowel centrally. B, after drainage by Foley catheter located intraperitoneally. TABLE1. Idiopathic bladder rupture in the English literature and cases related to substance abuse No. Reference Evans et all Stone2 Cave6 Lipow and Voge16 Feigal and Polzak7 Ferguson et a18 Nemser and Weinbergers Clinton-Thomas1' Baker1' Thompson et allz Ruckley and Rintoul13 Shumaker et al" Bennett and Delrio15 Kumar and Rao" Desmond et all7 Total
FIG. 2. Cystogram in case 1 demonstrates intraperitoneal contrast material with none seen in bladder. bladder, defining it as idiopathic rupture, including 25 related to alcohol use.' However, on our critical review of the English l i t e r a t ~ r e ~ -we ~ ~found ~ - ~ ' that they had included a series with a traumatic rupture2' a n d they counted 1 case twice." Our search revealed 20 cases of substance abuse-related spontaneous bladder ruptures (table 1). The pathophysiology of rupture in patients abusing alcohol and other drugs is distinct from that of other reported spontaneous ruptures. After ingestion of a large amount of alcohol, the bladder can become markedly overdistended from the sheer volume of alcohol and i t s diuretic effect. Patients are variably obtunded, which clouds their sensory cues to void. In this condition the possibility that they have forgotten or ignored minor causative trauma will always exist, although corroboration of the complete absence of trauma by witnesses to the activities of such patients has been d ~ c u m e n t e d .The ~ , ~scenario of being awakened from sleep with the sudden onset of sharp abdominal pain certainly supports the concept of an atraumatic rupture.~.8,9.11.15 Although neither of our patients was witnessed both presented with this classic history. In all types of spontaneous bladder rupture the site of rupture is almost always in the intraperitoneal portion, thus producing symptoms of peritoneal irritation. Diffuse abdominal pain,
42 3 1 3 5 1
7 1 5 1 1 1
No. Cases Related to Substance Abuse 1 3 1 1 1 1 1 l* 1 1 1 4t 1 1 1 20
* Patient denied history of alcohol excess; authors concluded otherwise. t Clear history of trauma in 1 case. One case of recurrent rupture counted 1:wice.
worse in the suprapubic region, is universal. Patients also may complain of bilateral shoulder pain or hiccups, since the diaphragm is irritated by intraperitoneal urine.' Most present with . ~occasionally . ~ ~ ' ~ ~ ' with ~ ~ a constant the inability to ~ o i d , ' ~ ~ l7 desire and d y s ~ r i a . ~Some , ' ~ patients have associated nausea and ~ o m i t i n g . ~ , ' "Either ,'~ gross or microscopic hematuria may be seen, with amounts on catheterization varying between a few drops and several liters, depending on the size of the tear and the location of the catheter in the bladder or peritoneal cavity (table 2). Spontaneous rupture of the normal bladder is extremely rare in women, with only 4 cases reported previously and only 1 related to substance abuse. The markedly lower resistance of the bladder outlet and urethra in women is probably responsible for this much lower rate. They normally leak urine before the bladder is full enough to burst. The combination of a-adrenergic stimulation and alcohol leading to bladder rupture has been reported previously. Bennett and Delrio described an 18-year-old man who took alcohol and methamphetamine.15 They postulated that the asympathomimetic effect of methamphetamine combined with the diuresis and obtusion produced by the alcohol led to spontaneous rupture as the patient slept. Methamphetamine metab-
SUBSTANCE ABUSE-RELATED SPONTANEOUS BLADDER RUPTURE
TABLE2. Clinical Features of substance abuse-related bladder r u ~ t u r e Clinical Features Site of rupture: Intraperitoneal Extraperitoneal Unspecified Activity a t time of rupture: Awakened from sleep Voiding Vomiting Normal activities Unspecified Reported presenting symptom: Abdominal pain Inability t o void Desire t o void Dysuria Abdominal swelling Nausea/vomiting Hematuria (reported in 13 cases): Gross Microscopic Vol. on catheterization (reported in 11cases): Range Median
Literature Review 171.6-17
Present Cases Case 1 Case 2
Cases 1 and 2
201.6-17 71,6,7,8,11,16,17 26.10 1O' 41,6,7,16 39,10,16 8 3
Cases 1 and 2
of bladder rupture is extremely important in patients presenting to the emergency room after an alcoholic bout with abdominal pain, especially if they complain of an inability to void. Although there have been no deaths since 1935,5 significant delays in diagnosis may add to the morbidity of the syndrome. Full evaluation should include a cystogram with at least 300 ml. contrast material to distend the bladder adequately, along with a post-void or drainage film. Once the diagnosis is made and appropriate therapy is instituted, a search for underlying causes other than substance abuse should be performed. After the injury has healed urodynamic evaluation should be done to exclude previously unrecognized voiding dysfunction. Cystoscopy may be desired to evaluate the nature of the bladder mucosa and to perform biopsy. REFERENCES
1. Evans, R. A,, Reece, R. W. and Smith, M. J. V.: Idiopathic rupture Case 1 Case 2
20-8,000 ml. 200 ml.
olism has a relatively slow half-life of 8 to 9 hours.22Thus, it is reasonable to implicate a prolonged pharmacologic effect on the urethral sphincter after the patient is asleep. The half-life of cocaine in the serum is only 1 hour. It acts a t symrathetic nerve endings and blocks re-uptake of norepin e ~ h r i n eThe . ~ ~ urethral sphincter has a large amount of sympathetic innervation, and cocaine and methamphetamine stimulate sphincteric contraction as part of the systemic adrenergic response. The effect of these drugs, combined with alcoholinduced bladder overdistension and somnolence, helps to set up a state of acute urinary retention. Unfortunately, in case 1 it was impossible to determine the precise temporal relationship between substance abuse and the eventual bladder rupture. However, the potential certainly exists for the combination of cocaine and alcohol to lead to high urethral resistance, large urinary volumes and subsequent rupture. Only 1 to 9% of the administered cocaine is excreted unchanged in the urine and none of the metabolites is locally active; therefore, it is unlikely that any significant local anesthetic properties acted directly on the bladder m u c o ~ a . ~ ~ Urodynamic assessment of patients with spontaneous bladder rupture is critical to rule out underlying bladder and sphincteric dysfunction. Both of our cases demonstrated normal bladder function. In only 2 cases reported in the literature was urodynamic assessment performed: previously unrecognized detrusor-bladder neck dyssynergia was revealed in 117and an unusual sensory deficit attributed to alcohol and possibly syphilis13was demonstrated in the other. Until this report, all cases of idiopathic spontaneous rupture, including those secondary t o substance abuse, have been intraperitoneal. The dome and posterior wall are the least supported portions of the bladder, leading to rupture a t this point.' Thus, the spontaneous extraperitoneal rupture in case 2 was surprising. Evaluation by cystoscopy failed to reveal any anatomical reason, and the patient denied the anticipated history of trauma (indeed, there were no external signs). The presenting symptom of pelvic pain radiating to the groin and penile base suggested extraperitoneal irritation, as did the rectal tenderness lateral to the prostate. Extraperitoneal rupture has been treated successfully by catheter drainage alone.z4Because almost all spontaneous bladder injuries from substance abuse are intraperitoneal, however, operative repair will almost always be required. The syndrome of substance abuse-related spontaneous bladder rupture is a rare but distinct clinical entity. Consideration
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