Intraperitoneal bladder rupture following mild blunt trauma: A rare case report

Abstract

Introduction and importance

Intraperitoneal bladder rupture is a rare complication of blunt abdominal trauma, occurring in less than 1 % of cases. Prompt diagnosis and surgical management are crucial to prevent severe complications.

Case presentation

We report a 62-year-old male presenting with hypogastric pain and peritonitis following a low-impact fall. Imaging revealed intraperitoneal bladder rupture without pelvic fractures. Emergency laparotomy confirmed a 13 cm rupture of the bladder dome, treated with two-layer repair, cystostomy, and lavage. Postoperative recovery was uneventful, with complete bladder integrity confirmed after 15 days.

Clinical discussion

Bladder trauma management depends on rupture type: extraperitoneal ruptures are typically managed conservatively, whereas intraperitoneal ruptures require surgical intervention. For intraperitoneal injuries, guidelines recommend laparotomy for repair and postoperative cystography.

Conclusion

This case underscores the importance of recognizing rare presentations of bladder trauma and addressing underlying risk factors like urinary retention to improve patient outcomes.

Highlights

• •Traumatic bladder rupture is an uncommon injury, comprising less than 1 % of blunt abdominal traumas.
• •Intraperitoneal ruptures typically result from blunt compression of a distended bladder, often affecting the bladder dome
• •Simple cystography and CT cystography are the most sensitive and specific techniques for detecting bladder injuries.
• •The repair is usually done in one or two layers using absorbable sutures, leaving a urinary catheter in place.

1. Introduction

Traumatic bladder rupture can be intraperitoneal in 15 % of cases, extraperitoneal in 80 %, and combined in 5 % [1,2]. It should always be suspected in the presence of a pelvic fracture. The cardinal sign of the clinical presentation is macroscopic hematuria [3]. A delay in diagnosis and management can significantly increase mortality.

We present a case of isolated bladder rupture following blunt abdominal trauma. The rarity of this case can lead to misdiagnosis or delayed diagnosis, as clinicians may not initially suspect bladder rupture in patients with seemingly minor trauma, so we reinforces the importance of a thorough patient history, physical examination, and targeted investigations to prevent missed diagnoses.

2. Methods

This work was completed in line with the SCARE criteria [11].

3. Case presentation

A 62-year-old man with a history of severe depression, treated with Temesta, Amipride, and Sevral, presented to the emergency department with hypogastric abdominal pain that had appeared 24 h after a fall from his own height onto a blunt object. On examination, he was febrile at 38.7 °C, hemodynamically and respiratorily stable, with a distended abdomen and tenderness in the lower abdominal area. Inflammatory markers were elevated, with impaired renal function. Ultrasound and Non-contrast CT abdomen showed an intraperitoneal bladder rupture with simple fluid density without other post-traumatic injuries to intra-abdominal organs or pelvic fractures (Fig. 1, Fig. 2). The patient underwent emergency laparotomy, where purulent peritonitis was found due to a 13 cm rupture of the bladder dome with no associated injuries (Fig. 3). The bladder tear was repaired in two layers, a cystostomy was performed, and peritoneal lavage was carried out. The cystostomy tube was clamped on the third postoperative day and removed on the tenth day. A follow-up CT scan 15 days postoperatively showed complete bladder integrity with no leakage (Fig. 4). The urinary catheter was then removed. The patient's antidepressant regimen was adjusted to avoid urinary retention.

Fig. 1.

Non-contrast CT pelvis showing ruptured bladder wall (red arrow) with simple fluid density (urine) in pelvic space. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2.

Non-contrast CT abdomen showing simple fluid (urine) in perihepatic and left paracolic gutter.

Fig. 3.

Intraoperative view of low midline laparotomy showing ruptured bladder dome.

Fig. 4.

Postoperative delayed phase of contrast-enhanced CT demonstrating full bladder with no leakage.

4. Discussion

Our case report can serve as a valuable educational resource for emergency physicians, trauma surgeons, and urologists by emphasizing that bladder rupture can occur even in the absence of significant external trauma. This could lead to earlier intervention and better patient outcomes, preventing complications associated with delayed treatment.

The distinction between extraperitoneal and intraperitoneal bladder rupture is fundamental for managing bladder trauma. Indeed, extraperitoneal ruptures are more frequent and usually occur alongside pelvic fractures, involving the anterolateral bladder wall, the trigone, and the bladder neck. Intraperitoneal ruptures, on the other hand, typically result from blunt compression of a distended bladder, often affecting the bladder dome [4]. Patients taking selective serotonin reuptake inhibitors (SSRIs) are at increased risk of urinary retention, as was the case with our patient [5], due to their anticholinergic effects. The main signs of bladder rupture are macroscopic hematuria, failure to void even after suprapubic catheterization, and associated pelvic fractures [6]. Radiological exams are crucial for detecting bladder ruptures. In the setting of trauma, contrast-enhanced CT scans, provided renal function is normal, with delayed phase can help diagnose bladder rupture. Ultrasound and non-contrast CT can detect free intra-abdominal fluid but cannot identify the continuity break in the bladder wall [7]. Simple cystography and CT cystography are the most sensitive and specific techniques for detecting bladder injuries, except in unstable patients or with peritoneal signs.

Intraperitoneal bladder rupture may result in a variety of outcomes that depends on elements such as the timing of diagnosis, presence of other relevant injuries, and management methods employed. Delayed diagnosis cause extreme morbidity and potentially lead to peritonitis due to urine outside the bladder cavity and infection.

The guidelines from the American Urological Association and the Eastern Association for the Surgery of Trauma recommend non-operative treatment using a urinary catheter for most extraperitoneal ruptures, while surgical repair is mandatory for intraperitoneal ruptures [8,9]. Laparotomy is preferred, especially in cases of multi-organ trauma, although laparoscopy is a viable option with encouraging results reported in several series [4]. The repair is usually done in one or two layers using absorbable sutures, leaving a urinary catheter in place with the balloon inflated.

In post-operative period, patients are monitored for signs of peritonitis, infection, or persistent urinary leakage. A Foley catheter is typically left in place for 10–14 days to allow bladder healing. Intravenous antibiotics may be administered to prevent infection.

For postoperative control cystography, the Eastern Association for the Surgery of Trauma has defined two groups of intraperitoneal lesions: simple ruptures (a full-thickness tear) and complex ruptures (associated with other bladder injuries). Postoperative cystography is not necessary for simple ruptures but is strongly recommended for complex ruptures [8]. Prophylactic antibiotic therapy may reduce the risk of catheter-associated urinary tract infections [10].

Patients should be evaluated for any voiding difficulties or signs of bladder dysfunction. In some cases, a follow-up ultrasound or cystoscopy may be considered if symptoms persist.

Adjusting long-term treatment (SSRIs) or switching to another drug class is essential to prevent recurrences in this class of patients [5].

5. Conclusion

Although rare, intraperitoneal bladder rupture is possible, especially in individuals at risk of urinary retention following blunt abdominal trauma. Despite the low-energy mechanism of injury, the presence of underlying risk factors such as a distended bladder especially in patients taking selective serotonin reuptake inhibitors. This case highlights the importance of considering bladder rupture in patients with lower abdominal pain, even after minor trauma, to prevent delays in management and associated complications. Postoperative management of urinary retention risk factors is also essential.

Author contribution

Zied Hadirch and ElMontassar belleh Zaafouri Conceptualization, Writing - Original Draft, Conceived the study, collected data, wrote draft.

Aziz Atallah, Mohamed Hajri and Nada Essid Data Collection, Writing - Review & Editing, Assisted in data collection, reviewed and edited.

Sahir omrani Supervision, Validation Provided supervision and validated findings.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval for this study was provided by the Ethical Committee, on 07 September 2024.

Guarantor

Hadrich Zied.

Research registration number

N/A.

Funding

N/A.

Conflict of interest statement

N/A.