Spontaneous bladder rupture after alcohol binge presenting as a rare cause of acute abdomen: A case report and review of literatures

Abstract

Introduction and importance

Bladder rupture, or perforation, is the rupture of the urinary bladder, which is often clinically classified as intraperitoneal, extraperitoneal, or combined types. Spontaneous bladder perforation is an extremely rare event and constitutes less than 2 % of bladder ruptures. It is often associated with previous bladder manipulation, lower urinary tract obstruction, instrumentation, pelvic radiotherapy or surgery, inflammation, and malignancy. Blood work will demonstrate leukocytosis with left shift, hematuria on urinalysis, and an ascites to serum creatinine ratio of more than one, which is highly suggestive of bladder rupture.

Case presentation

A 38-year-old male patient presented with abdominal pain for 8 h and loss of consciousness lasting 4 h. The patient was acutely sick-looking with borderline blood pressure of 90/60 mmHg, pulse rate of 120, and has alcoholic breath. With a diagnosis of viscus perforation, he was operated and there was a 1 × 1 cm bladder dome perforation, which looks fresh. The ruptured edge was refreshed and repaired in two layers. The patient has recovered well, discharged and was fine on subsequent follow-ups.

Clinical discussion

Bladder rupture commonly develops after blunt abdominal trauma, of which more than 60 % is extraperitoneal. Intraperitoneal bladder rupture constitutes only a small fraction of all cases of rupture. There are only a few reports of spontaneous bladder rupture in the scientific literature. The risk of bladder rupture may be increased in the alcohol-impaired patient owing to decreased bladder filling sensation and abnormal behavioral responses.

Conclusion

Bladder rupture is a rare diagnosis in surgical patients, and spontaneous rupture is by far a very rare finding. The diagnosis of bladder perforation is often overlooked preoperatively for the obvious reason of its rarity and non-specific presentation. Early identification and timely management decrease mortality.

Highlights

• •The rupture of the urinary bladder, also known as a perforation, is frequently clinically classified as intraperitoneal, extraperitoneal, or combined types.
• •Less than 2% of bladder ruptures are the result of spontaneous bladder perforation, which is additionally known as idiopathic bladder perforation.
• •Bladder dome is directly related to the peritoneum, and rupture at this site is almost invariably intraperitoneal.
• •Binge drink may depress sensation of bladder filling and alcohols diuretic effect distend bladder to the extent of rupture.
• •Intraperitoneal perforation always needs surgical intervention.

1. Introduction

Bladder rupture, or perforation, is the rupture of the urinary bladder, which is often clinically classified as intraperitoneal, extraperitoneal, or combined types. It is a life-threatening complication when it isn't diagnosed and managed accordingly [1]. Blunt abdominal trauma is the commonest cause of bladder perforation, and 90 % of the ruptures are associated with pelvic fractures. However, bladder injuries are uncommon and happen in less than 5 % of abdominal traumas. Extraperitoneal rupture accounts for more than 60 % of all cases of bladder rupture [[2], [3], [4]].

Bladder injuries are associated with multisystem trauma. Since the amount of energy transferred needed for bladder perforation is significant, mortality from adjacent structure injuries is high [5].

Spontaneous bladder perforation, often designated as idiopathic, is an extremely rare event and constitutes less than 2 % of bladder ruptures. It is often associated with previous bladder manipulation, lower urinary tract obstruction, instrumentation, pelvic radiotherapy or surgery, inflammation, and malignancy. However, rupture after an alcohol binge in a healthy adult without a previous history of genitourinary complaints is exceedingly rare. There are also reports of spontaneous perforation due to tuberculous and candida cystitis [6,7]. The bladder dome is the weakest point and most susceptible site of rupture following a sudden intravesical pressure change or slow chronic bladder volume change. The bladder dome is directly related to the peritoneum, and rupture at this site is almost invariably intraperitoneal. The collection of urine in the peritoneal space will lead to urine absorption into the systemic circulation and auto-dialysis. Furthermore, auto-dialysis of urine will lead to major electrolyte and metabolic abnormalities [8].

In many cases, diagnosis and findings from investigations falsely pointed towards a gastrointestinal cause, posing a significant challenge in diagnosis, and a high rate of misdiagnosis is frequently encountered. Patients usually present with a sudden onset of pelvic and abdominal pain that gets intense over time. Likewise, more than half of patients with spontaneous bladder perforation have hematuria, anuria (difficulty voiding), renal failure, urinary ascites and sepsis. However, most of these symptoms can also be presented due to an intestinal cause of acute abdomen, and more than half of bladder perforation is an intraoperative finding at laparotomy [9,10].

Blood work will demonstrate leukocytosis with left shift, hematuria on urinalysis, and an ascites to serum creatinine ratio of more than one, which is highly suggestive of bladder rupture. However, the sensitivity of ascites to the serum creatinine ratio may be erroneous, as reverse auto-dialysis of urine through peritoneal absorption may lead to elevations of serum urea and creatinine. Imaging workup with contrast leakage out of the bladder or cystoscopy finding of bladder wall defect is diagnostic of bladder perforation [11].

Complications include urinary ascites, urosepsis, renal failure, and chemical or infective peritonitis. Intraperitoneal bladder perforation needs emergent laparotomy and surgical repair of the perforation site; however, extraperitoneal perforation can be managed conservatively with catheter drainage [12,13]. Here we present a case of spontaneous bladder perforation diagnosed intraoperatively in an intoxicated patient who initially presented with a diagnosis of acute abdomen. Case reporting is done according to the SCARE guidelines [14].

2. Case presentation

A 38-year-old male patient presented to our emergency department with abdominal pain of eight hours duration. Associated with this, he also had a loss of consciousness for 4 h, as reported by his attendants. Prior to the onset of abdominal pain, he was taking alcohol and get intoxicated. He also had decreased urine production and abdominal distention. However, he has no previous abdominal complaints and nor visited a healthcare service before this presentation.

On presentation, he was acutely sick-looking with borderline blood pressure of 90/60 mmHg, pulse rate of 120 beats per minute, and a respiratory rate of 28 breaths per minute, but he was afebrile. He had alcoholic breath, a dry tongue, and a dry buccal mucosa. His abdomen was distended and diffusely tender, with a positive sign of fluid collection but no bladder distension. There was scanty stool in the rectum but no mass or blood on the examining finger. The prostate has a normal size with a palpable median sulcus. Blood work showed a white cell count of 13,500 per microliter with a left shift and serum creatinine of 2.5 mg/dl.

With a diagnosis of perforated viscus, intravenous fluid resuscitation and broad-spectrum antibiotics were commenced. The patient took 2 l of crystalloid and produced 2.5 l of urine in 2 h. He wasn't producing urine before the catheter insertion, and the urine drained was yellow-tan in color. Surgical management was planned as the patient had signs of peritonitis, and the patient gave consent for surgical treatment. A midline laparotomy was done, revealing 3 l of urinoma with the catheter in the peritoneum (Fig. 1A and B). There was a 1 × 1 cm bladder dome perforation, which looks fresh but has no bleeding, ulceration or intravesical mass. The gastrointestinal tract and other solid organs appear normal.

Fig. 1.

A & B. Shows Folley catheter balloon in the peritoneum upon laparotomy passing thru bladder dome perforation.

The urine collected in the peritoneum was sucked out. The ruptured edge was refreshed and repaired in two layers. The abdomen was lavaged with warmed saline and closed in a layer. Enteral feeding was resumed via a nasogastric tube on post-operative day one. Antibiotics continued for 72 h, and the patient regained consciousness and got out of intoxication after 72 h. Antibiotics continued for a total of 72 h. Patient's altered mental status resolved, and sobriety was achieved after 72 h. Serum creatinine down trended and normalized on postoperative day three. The Foley catheter was removed on postoperative day seven, and there was no need for a contrast study since we were confident about our good repair, and the patient was discharged to home on postoperative day eight. Patient was recovering appropriately on follow-up at two and six weeks after discharge.

3. Discussion

Bladder rupture commonly develops after blunt abdominal trauma, of which more than 60 % is extraperitoneal. Despite trauma being the most common cause of bladder perforation, only 5 % of trauma is associated with bladder perforation. A lower abdominal blow in the presence of a full bladder causes a sudden translation of energy to cause rupture of the bladder [4].

Trauma associated with bladder perforation is often high-energy, and mortality is high in this group of patients. The diagnosis in these patients is often overlooked, and the finding of bladder perforation is a postmortem finding. Investigations misguided the diagnosis and make professionals to falsely ascribe causes for gastrointestinal ailments [10]. Our patient was misdiagnosed as having viscus perforation, and bladder rupture wasn't considered at all.

Intraperitoneal bladder rupture constitutes only a small fraction of all cases of rupture. Furthermore, spontaneous bladder rupture is a very rare finding. There are only a few reports of spontaneous bladder rupture in the scientific literature [15]. It is also true in our setup that no single case of spontaneous bladder perforation has been reported so far. Etiologically, rupture is caused by external mechanical force or the physiological dynamics of the bladder itself.

Reddy et al. performed a systematic review of all cases of spontaneous rupture of the urinary bladder to provide a description of the demographic information, related comorbidities, clinical presentation, diagnosis, pertinent laboratory findings, contributing factors, management, morbidity, and mortality. They included 278 articles in total, of which 240 are case reports and 38 are case series. The presenting complaint was abdominal pain in 76 % of the cases, misdiagnosis in 64 %, and about 42 % of the cases were diagnosed intraoperatively. The commonest cause was pelvic irradiation, followed by alcohol intoxication in 11 % of all bladder perforations. Intraperitoneal rupture is the commonest type in spontaneous rupture, and the bladder dome is involved in 55 % of the conditions [16]. There are also more rare causes of spontaneous perforation, like Candida cystitis, tuberculosis, and forceful vomiting [[17], [18], [19]]. Similarly, our patient presented with abdominal pain with alcohol intoxication, misdiagnosed initially as viscus perforation, and the intraoperative finding was consistent with bladder dome perforation.

Likewise, an intoxicated patient presents a diagnostic dilemma due to a vague presentation and lack of communication. The risk of bladder rupture may be increased in the alcohol-impaired patient owing to decreased bladder filling sensation and abnormal behavioral responses. In addition to the sheer volume of booze consumed and its diuretic effect, the bladder fills up rapidly, frequently to the point of significant distension. This distention might end in an atonic decompensated bladder that is so thin and easily prone to rupture, frequently at the bladder dome [20]. We thought that the patient had lost the sensation of bladder filling and failed to void as he got intoxicated, resulting in bladder perforation. Surprisingly, the patient took 2 l of crystalloid, and the catheter drained about 3 l of yellow-tan fluid, but the source of this extra output wasn't elucidated until the finding of the catheter in the peritoneum upon laparotomy.

Investigations are usually misleading to gastrointestinal causes. A finding of leukocytosis with left shift, an elevated serum creatinine level with renal failure, and abdominal fluid collection are typical findings in most cases. Rupture of the bladder is missed as renal failure due to auto-dialysis of urine by peritoneal reabsorption of urea and creatinine. Biochemical and electrolyte derangements like hyperkalemia, hypernatremia, uremia, and acidosis can be observed [21]. Our patient has an elevated white cell count with left shift and elevated serum creatinine, which masquerade bladder perforation as renal failure.

The management of bladder perforation depends on the type of perforation and associated organ injuries. Extraperitoneal bladder perforation is managed conservatively unless there is an associated pelvic fracture with a fragment of bone in the bladder, an associated rectal or vaginal injury, or infected pin. In contrast to extraperitoneal perforation, intraperitoneal perforation always needs surgical intervention, as per the recommendation set by the American Urological Association guideline. A single- or double-layer repair may be used, and catheter drainage of the bladder is required after drainage [22]. In the same way, we repaired the bladder in two layers after refreshing the perforation edges, and we left the Foley catheter in the bladder for a week.

4. Conclusion

Bladder rupture is a rare diagnosis in surgical patients, and spontaneous rupture is by far a very rare finding. Extraperitoneal rupture is the predominant finding when it happens. Spontaneous rupture is designated as idiopathic, and there is no identifiable mechanical predisposition in the bladder. Binge-drinking may depress the sensation of bladder filling, and alcohol's diuretic effect distend the bladder to rupture. The diagnosis of bladder rupture is often overlooked preoperatively for the obvious reason of its rarity and non-specific presentation. The diagnosis is often an intraoperative finding. Intraperitoneal rupture is managed surgically, while extraperitoneal is managed conservatively with catheter drainage. Hence, early identification and timely management decrease mortality.

Consent for publication

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.

Provenance and peer review

Not commissioned, externally peer-review.

Ethical approval

Ethical approval for case report is exempted in our institution. Consent from the patient is said to be adequate in the case of case report.

Funding

This work does not receive funds.

Author contribution

OTM and NSB contributed substantially from the organizing to writing up, and in revision of the paper.

Guarantor

Nebiyou S. Bayileyegn will take the primary responsibility of the study.

Research registration number

Name of the registry: researchregistry.com.

Unique identifying number or registration ID: researchregistry7735.

Hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.researchregistry.com/browse-the-registry#home/.

Conflict of interest statement

The author declares that there are no competing interests.