A Rare Case of Female Bladder Spontaneous Rupture

Abstract

Bladder spontaneous rupture in the woman represents an extremely rare urologic emergency; its cause can be iatrogenic, neoplastic or diabetic.

Materials and Methods

A 56-year-old woman was referred to our unit because of the presence of acute abdominal pain, oligoanuria and vomiting for two days. At physical examination, the patient presented with confusional state, acute urinary retention and gross hematuria after urethral catheterization. Laboratory data demonstrated important metabolic abnormalities: hyperglycemia (946 mg/dL), acute renal failure (serum creatinine: 3.25 mg/dL), hyponatremia (120 mEq/L) and metabolic acidosis. At the CT of her abdomen and pelvis, a suspected bladder rupture (right lateral wall) was revealed, and confirmed after performing a retrograde cystography. Personal history was negative for trauma; glycemia was never controlled despite an important familiarity for type I diabetes. An episode of painless gross hematuria had occurred one month before, treated by the physician with antibiotics. Firstly the metabolic and electrolyte imbalance was corrected and then an emergency explorative laparotomy was performed. An important urinary leakage in the pelvis and a mild peritoneal effusion were documented. Furthermore, an important leak of papillary-like neoplastic material from the vesical breach was detected. The neoplasm seemed to involve the whole bladder. The surgical treatment consisted in bladder raphia, accurate washing of perivesical space, difficult salvage cystectomy (tenacious adhesions due to the urinary leakage) and bilateral ureterocutaneostomy. During the postoperative stay, the patient showed a difficult glycemia control with insulin therapy and wound dehiscence healed by second intention. The hospital discharge was on day 30, with the patient in good health and acceptable glycemia control.

Results

The pathological diagnosis was a G2 non-invasive urothelial carcinoma, also involving a vesical diverticulum; the neoplasm was associated with an erosive chronic cystitis with aspects of transparietal micro-abscessual flogosis (pT1 G2 N0 Mx). The patient will perform a CT scan 3 months after surgery before possibly starting chemotherapy.

Conclusions

Bladder spontaneous rupture in the woman is an extremely rare pathology; in the reviews we analyzed, it is dealt with as a clinical condition that more often occurs in patients submitted to pelvic surgery followed by adjuvant radiotherapy. Invasive bladder neoplasms, predominantly the sarcomatoid ones, are the second more frequent cause mentioned in the literature. Diabetic uropathy of the bladder associated with purulent bacterial cystitis in the elderly is the third cause, which is mentioned in two articles only. At last, only one study indicates the superficial urothelial bladder cancer (pT1- G2) as the responsible for this dramatic event. In our case, the suspected bladder diabetic uropathy, characterized by reduced perception of micturition stimulus, the increase in vesical capacity and detrusorial hypocontractility, were probably an important concomitant cause of this dramatic clinic condition, in association with the large superficial urothelial neoplasm. Moreover, diabetic neuropathy could explain the delay of patient presentation to the physician. Urinary leak, probably occurred 2 days before diagnosis, created an important metabolic imbalance and remarkable surgical difficulties. The timely treatment allowed for the resolution of a clinical condition associated with an elevated mortality due to septic shock.