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D.R. BASAVARAJ, K.K. ZACHARIAH and J.G.W FEGGETTER
Department of Urology, Wansbeck General Hospital, Ashington, Northumberland, UK
Spontaneous perforation of the urinary bladder is a rare clinical condition presenting as an acute abdomen. It should be suspected in patients with a past history of radiotherapy to the pelvis, enterocystoplasty and those suspected of having a tumour in the bladder. Disproportionately elevated serum urea and creatinine should raise the index of suspicion. A case of spontaneous perforation of the bladder, five years following successful treatment of a bladder tumour by radiotherapy, is reported.
Keywords: bladder, perforation, radiotherapy, spontaneous
J.R.Coll.Surg.Edinb., 46, October 2001, 316-317
Spontaneous intra-peritoneal rupture of the urinary bladder is a rare event.1 The incidence of spontaneous bladder rupture has been reported to be 1:126000; 79% of all cases are reported in men, with an overall mortality of 47%.2 A pressure of more than 300 cm of water is required to rupture a normal bladder.3
A 78-year-old man presented with an acute onset of lower abdominal pain provoked by an attempt to void. Five years ago an invasive transitional cell carcinoma of the urinary bladder was treated by radical radiotherapy with no evidence of subsequent recurrence. The patient was clinically stable but had signs of peritonism in the lower abdomen. Serum urea and creatinine levels were elevated at 11.8 m.mols/litre and 182 m.mols/litre, respectively (normal range, urea 2.5-7 mmols/litre and creatinine 53-124 mmols/litre). An ultrasound scan of the abdomen revealed free intra-peritoneal fluid and bladder catheterisation drained only 75 mls of urine. A diagnosis of spontaneous rupture of the bladder was made and a cystogram was arranged but failed to demonstrate a leak in the bladder. Catheterisation and antibiotics resulted in rapid clinical recovery and return of renal function to normal. A trial without catheter after two weeks reproduced abdominal pain but this was successful after another four weeks.
The patient presented four months later with a similar clinical picture and a cystogram on this occasion demonstrated intraperitoneal leak from the bladder (Figure 1). Antibiotics and catheterisation resulted in rapid recovery and return of the raised levels of serum urea (16 m.mols/Litre) and creatinine (417 m.mols/Litre) to normal values within 48 hours. Six weeks later his catheter was removed with no subsequent clinical problems. Cystoscopy was normal. Urodynamic studies failed to demonstrate outlet obstruction but showed detrusor instability and the patient leaked at a low pressure of <20 cm of water. He has been advised to void at regular intervals to prevent overdistension of the bladder.
Figure 1: Cystogram demonstrating intra-peritoneal leak of the contrast
A Medline search of abstracts revealed various conditions associated with spontaneous perforation of the bladder (Table 1); most were case reports. Nearly always, an underlying pathology that weakens the bladder wall is present to precipitate a perforation. This is either not readily apparent during initial evaluation or is missed. The commonest causes are a previous enterocystoplasty, pelvic radiotherapy or undiagnosed bladder tumour. A review of more than 100 occurrences demonstrated that bladder perforation was an intra-operative finding.4 The majority of the patients present with diffuse abdominal pain, more so in the lower abdomen and passage of low volumes of urine. Lower abdominal tenderness is elicited due to chemical peritonitis and a bacterial peritonitis may be superimposed if the diagnosis is delayed. There should be a high index of suspicion in patients with an acute abdomen, biochemical evidence of renal dysfunction but are relatively haemodynamically stable and have associated conditions listed in Table 1. Renal dysfunction (as assessed biochemically) is due to reabsorption of urea and creatinine (peritoneal self-dialysis). Ultrasonography shows free intra-peritoneal fluid but a cystogram demonstrating a leak in the bladder is diagnostic. Most patients need laparotomy to confirm the diagnosis and to repair the perforation. However, a subgroup of patients with history of pelvic radiotherapy may be managed conservatively with antibiotics and prolonged bladder drainage (4-6 weeks). Fugikama et al (1999), in their report of six patients with spontaneous bladder perforation following radiotherapy for cervical cancer, reported reperforation in three of the five patients who had surgical repair.1 It is difficult to repair a diseased bladder following radiotherapy whose vascularity is compromised. It is important to exclude outlet obstruction, bladder tumour and detrusor instability. Voiding at regular intervals prevents overdistension of the bladder, thereby, minimising risk of reperforation.
A diagnosis of spontaneous perforation of the bladder should be considered in patients presenting with an acute abdomen in a relatively stable condition and blood biochemistry showing a disproportionately elevated urea and creatinine. A general surgeon, who is more likely than an urologist to encounter such patients in the first instance, should be aware of this possibility in the differential diagnosis of an acute abdomen. We recommend conservative management of spontaneous perforation of the bladder following radiotherapy, with antibiotics and prolonged bladder drainage.
Table 1: Causes of spontaneous perforation of the bladder
| Causes of spontaneous perforation of the bladder |
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1. Fugikawa K, Yamamichi F, Nonomura M, Soeda A, Takeuchi H . Spontaneous rupture of
the urinary bladder is not a rare complication of radiotherapy for cervical cancer: report
of six cases. Gynecologic oncology 1999; 73: 439-42
2. Hansen HJ, Eldrup J. Spontaneous rupture of the urinary bladder: a late complication of
Radiotherapy. Scandinavian Journal of Urology and Nephrology 1989; 23: 309-10
3. Peters PC. Intra-peritoneal rupture of the bladder. Urol Clin North Am 1989; 16:279-82
4. Schraut WH, Huffman J, Bagley DH. Acute abdominal pain caused by spontaneous
perforation of the urinary bladder. Surg Gynecol Obstet 1983; 156: 589-92
Copyright date: 30th October 2000
Correspondence: D.R. Basavaraj, Wansbeck General Hospital Ashington, Northumberland
NE63 0JJ, UK
E-mail: raj@dbasavaraj.freeserve.co.uk