Intra-peritoneal urinary bladder rupture

Clinical History

A man was hospitalized with macroscopic haematuria and dysuria. He had relapsed rectal cancer (chemo-radiotherapy and surgery) and metastasized prostate cancer.
He developed abdominal pain, distension and fecaloid vomit. His Foley was deobstructed and nasogastric tube was placed.
Blood tests revealed decreased haemoglobin and sodium and increased urea, creatinine, potassium, C-reactive protein.

Imaging Findings

A slight improvement followed by sudden aggravation was noted and an abdomino-pelvic CT was requested.
Intravenous contrast administration was not performed due to renal failure.
Unenhanced CT showed moderate ascites and spontaneously hyperdense free fluid in the peritoneal cavity, as well as hyperdense fluid in the bladder. There was associated pneumoperitoneum and gas in the bladder. Several retroperitoneal lymph nodes and bilateral hydronephrosis due to desmoplastic reaction surrounding both ureters were also noted. Colic and pelvic intestinal loops were distended, however, an obstructive cause was not identified. Bilateral pleural effusion was also observed. Left colostomy was demonstrated.
This study was complemented by CT cystography.
Extravasation of contrast material to the peritoneum confirmed an intraperitoneal bladder rupture.

Discussion

Spontaneous bladder rupture (SBR) is rare (1:126000) and more frequent in men (79%). [1] SBR can be associated with urinary tract infection; urinary retention; bladder calculi; pelvic malignancy; erosion of indwelling catheter; previous radiation therapy; neurogenic bladder; vaginal delivery; alcoholism; inflammatory cystitis; bladder tuberculosis; enterocystoplasty; diabetes; anatomic outflow obstructions; congenital and acquired diverticulum; schistosomiasis; intra-arterial chemotherapy and atherosclerotic emboli. [1, 2, 3, 4, 5, 6, 7]
Bladder ruptures may be extraperitoneal (80-90%), intraperitoneal (15-20%) and combined (12%). [8]
Radiation therapy induces pathological changes to all layers of the bladder wall and vasculature, predisposing to SBR. [9, 10]
The incidence of SBR after radiation therapy can reach 2%. [10, 11]

The symptoms of SBR are vague and include diffuse suprapubic pain, tenderness, distension, guarding, evidence of mild shock, oliguria (the bladder drains into the abdominal cavity and so gives this impression), and mildly raised renal function (caused by reabsorption of urine through the peritoneum). [1, 3, 5, 6, 12]

Conventional cystography was the procedure of choice, however, it is time-consuming, cannot provide information on surrounding structures, is potentially limited by the presence of overlying fracture or fixation devices and requires patient collaboration. [8]
Ultrasound may demonstrate pelvic fluid. [1, 5, 10]
CT may show unusual fluid collections, unusual gas collections, abnormal location of Foley catheter and defect in an enhancing bladder wall. [2]
CT cystography is now the method of choice, with the advantage of multiplanar reformations (MPR's) ability. It has several pitfalls: the Foley catheter tip may occlude the contrast extravasation; the presence of pelvic hematoma may result in incomplete bladder dissension, if full bladder distension cannot be achieved and the contrast agent is extravasated only into the extraperitoneal component, a combined rupture may be missed. [8]

SBR is a urologic emergency, potentially fatal. [12]
Surgical repair is mandatory for intraperitoneal and combined ruptures. Catheter drainage is required for extraperitoneal rupture. [2, 8] A bladder biopsy is necessary to exclude any pathology. [4]
The mortality rate associated with a delay in diagnosis of 24 hours or more is 25% and overall mortality rate is 47-50%. [1, 7, 10, 11]

A waxing and waning course of events is typical and attributed to adherence of omentum and intestinal loops to the tear and dislodgement with distension of the bladder. [4]
A diagnosis of SBR should be kept in mind in cases of acute abdomen with disproportionately elevated serum urea and creatinine levels. [1]
The larger peritoneal space allows greater dilution of contrast material by urine, presumably leading to the less concentrated extravasated contrast solution seen in intraperitoneal rupture. [2]

Differential Diagnosis List

Final Diagnosis

Intraperitoneal urinary bladder rupture following pelvic surgery and radiation therapy

URL:	https://www.eurorad.org/case/13806
DOI:	10.1594/EURORAD/CASE.13806
ISSN:	1563-4086