Giant vesicle calculi leading to spontaneous bladder rupture and acute renal failure: an unusual presentation

Abstract

Spontaneous rupture of the urinary bladder is extremely rare. We report a case of a 70-year-old man with spontaneous bladder rupture secondary to neglected giant vesicle calculi who presented as acute renal failure. The patient was stabilised with per-urethral catheterisation and extravesical drain placement. About 700 mL pus mixed with urine was drained through the per-urethral catheter and approximately 2000 mL of pus was drained through the extravesical drain. Cystolithotomy showed two large calculi which were removed.

Background

Spontaneous bladder rupture is an extremely rare and serious urological emergency. It may be secondary to some obstructive pathology and may lead to urosepsis.¹ In some cases, the patient may directly present with serious complications such as acute renal failure and bladder rupture.² We report a case of spontaneous bladder rupture secondary to vesicle calculus who presented as oliguric renal failure and anterior abdominal wall cellulitis.

Case presentation

A 70-year-old man presented with complaints of difficulty in voiding, lower abdominal pain and progressive abdominal distension for the last 4 months. He also gave a history of decreased urine output for 7 days and anuria for 3 days. There was no history suggestive of haematuria, fever, flank pain, diabetes mellitus or previous surgery. The patient never took any treatment for his symptoms in the past. On examination, the patient was conscious; his pulse rate was 120 per minute and blood pressure was 136/82 mm Hg. The lower abdomen was warm, distended and tender (figure 1). There was redness present in the overlying skin.

Figure 1.

Clinical image of the patient showing lower abdominal distension with placement of a drainage catheter.

Investigations

Blood serum chemistries revealed anaemia (haemoglobin 6.7 g/dL, white cell counts 22×10^9/L, platelet count 25×10^9/L), deranged renal function tests (blood urea 118 mg/dL, serum creatinine 10.9 mg/dL), normal serum electrolytes (sodium 136 mEq/L, potassiumK 4.4 mEq/L) and random blood sugar (118 mg%). Imaging with ultrasonography and non-contrast CT scan of the abdomen revealed mildly enlarged prostate (24 cc), two giant bladder calculi (5 cm and 4 cm), bilateral hydroureteronephrosis with extravesical collection (figures 2 and 3).

Figure 2.

Non-contrast CT scan sagittal image of the patient depicting a vesical calculi with extravesical collection extending up to anterior abdominal wall.

Figure 3.

Non-contrast CT scan coronal image of the patient depicting two giant vesical calculi.

Differential diagnosis

1. Bladder outlet obstruction.

2. Neurogenic voiding dysfunction.

Treatment

A provisional diagnosis of bladder rupture with obstructive uropathy with anterior wall cellulitis was made. The patient was stabilised and a per-urethral catheter was placed which drained approximately 700 mL of urine mixed with pus. Patient was also given adequate supportive care including intravenous fluids, antibiotics and blood transfusions. An extravesical drain was placed under ultrasound guidance that drained about 2000 mL pus initially followed subsequently by clear urine. The general condition of the patient improved and the kidney function tests started improving within 48 hours after adequate drainage of the urinary bladder and extravesical collection. The patient was planned for cystolithotomy after 4 weeks. Intraoperative cystourethroscopy revealed normal urethral calibre with two giant calculi inside massively dilated bladder lumen. Calculi were removed.

Outcome and follow-up

Patient’s postoperative recovery was good and uneventful. The extravesical drain was removed on the third postoperative day. Three weeks later, suprapubic catheter and per-urethral catheter were removed sequentially. Postoperative urodynamics revealed low compliance and hypocontractile bladder. The patient was advised tamsulosin 0.4 mg and clean intermittent catheterisation and is doing fine at 3 months follow-up.

Discussion

Spontaneous rupture of the bladder is extremely rare and only a few cases have been reported in the literature.^1–6 The cause of bladder rupture may be idiopathic, lower urinary tract obstruction, drug induced or secondary to bladder wall lesions like chronic cystitis, tuberculosis and malignancy.³ Patients with intraperitoneal rupture usually present with severe pain abdomen, abdominal distension and elevated temperature while extraperitoneal rupture may present with lower abdominal pain and oliguria.⁶ Our patient also presented with lower abdominal distension, severely elevated kidney function tests which gradually declined to normal levels after ensuring adequate bladder drainage and drainage of extravesical collection. Diagnosis of bladder rupture is best confirmed by a contrast-enhanced CT cystogram which was not done in our case due to elevated serum creatinine levels. Management of extraperitoneal bladder rupture with acute renal failure includes adequate bladder drainage (preferably with suprapubic catheter) and removal of extravesical collection.^3–6 Formation of giant vesicle calculi may occur secondary to bladder outlet obstruction (BOO), repeated urinary tract infection, the presence of foreign bodies or neurogenic voiding dysfunction.^{7 8} A urodynamics study can be helpful in evaluation and management of concomitant bladder dysfunction post stone removal.⁸ Most frequent urodynamic findings in patients with vesical calculi include presence of BOO in 51%, detrusor overactivity in 68% and detrusor underactivity in 10% of patients.⁹ In the present case, giant vesicle calculi formation may have occurred due to age-related voiding dysfunction and untreated chronic urinary tract infection.

Learning points.

• Neglected giant vesical calculus for prolonged periods may lead to bladder rupture and renal failure.

• Management of extraperitoneal bladder rupture with acute renal failure includes adequate bladder drainage (preferably with suprapubic catheter) and removal of extravesical collection.

• A urodynamics study can be helpful in evaluation and management of concomitant bladder dysfunction post stone removal.