Idiopathic Rupture of the Bladder

[

,: Vol. 116, November Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1976 by The Williams & Wilkins Co.

IDIOPATHIC RUPTURE OF THE BLADDER ROGER A. EVANS, RICHARD W. REECE

AND

M. J. V. SMITH

t·

From the Division of Urology, Medical College of Virginia, R ichmond, Virginia

ABSTRACT

Non-traumatic spontaneous rupture of the otherwise normal bladder is a rare occurrence. The literature is reviewed and 4 new cases are reported. Experimental data are presented and a theory is reviewed regarding the frequent intraperitoneal location of the rupture. The frequent paucity of symptoms compared to the high mortality rate is stressed. Spontaneous rupture of the bladder should be t hOJight...ofin 2 Drains were placed and a suprapubic tube was left indwelling. dist inct categories. It may occur in the pathologic bladder, that The peritoneal cavity was normal on exploration. Convalesis one with predisposing conditions such as tumor, tuberculo- cence was stormy but the patient recovered . Comment: The peritoneal tap had been exfraperitoneal sis, oost rucbon and so foi~:Y---he-a-£p.o.ll.t.ang_Q_us rupture of a normal bladder, or what we term idiop~thic secondary to marked obesity and drained an extravasated rupture of t he filadder This rare entity is clinically important pocket of urine. The hyperosmolar coma, with decreased because it occurs in all age groups and has a protean clinical consciousness and increased urinary output, likely contributed presentation that accounts for the frequent diagnostic delay to this idiopathic rupture. Interestingly, this rupture was and high mortality rate. 1 posterior but below the peritoneal reflection. Case 3. E. H ., 5283323, a 6-pound 11-ounce black boy, was During the last 10 years we have seen 4 cases of idiopathic rupture. These are discussed, the literature is reviewed and born vaginally without difficulty. When the child was 3 days old he was returned to the hospital because he had never experimental work is presented. voided. The abdomen was distended. The urea nitrogen was 51 CASE REPORTS and carbon dioxide was 12. An excretory urogram (IVP) Case 1. A 38-year-old white woman, 9538720, was seen in the revealed bilateral hydroureteronephrosis. Foley catheterization emergency room after having stumbled on the sidewalk. Severe lower abdominal pain and extreme urgency developed but the patient was unable to void. A Foley catheter was inserted but there was no return from the bladder. Physical examination revealed a patient in some pain but with normal vital signs. Obvious signs were present of an acute abdomen with guarding and rigidity, more marked in the lower portion of the abdomen. A cystogram revealed intraperitoneal rupture of the bladder. At exploration a 3 cm. tear in the posterosuperior aspect of the bladder was biopsied, debrided and closed in 2 layers. Comment: This patient denied any trauma when she stumbled. The abrupt Valsalva maneuver with_a..
TABLE

Age- Sex (yrs.) 58- M 64- M

72- F 53-M 63- M 75-M

Accepted for publicat ion April 9, 1976. Read at annual meet ing of Mid-At lantic Sect ion, American Urological Association, White Sulphur Springs, West Virginia, October 29- November 1, 1975.

1

Cause of Death

Volume (cc)

Myocardial infarct Lung Ca Cere brovascular Cirrhosis Stomach Ca Emphysema

1,500

Supra pubic

Int ra peritoneal

1,400 1,200

Suprapubic Umbilical

Intraperitoneal Intra peritoneal

1,400 1,800

Umbilical None

Intra peritoneal Intra peritoneal

1,600

None

Int ra peritoneal

Pressure

Re marks

produced 250 cc bloody urine and a cystogram demonstrated intraperitoneal extravasation of dye. Exploration was done immediately and a necrotic bladder dome was resected. A suprapubic cystotomy tube was left indwelling. Pathological examination showed only hemorrhagic necrosis. Convalescence was prolonged but eventually the baby was able to void satisfactorily. Several voiding cystograms and cystoscopies failed to reveal any evidence of outlet obstruction or neurogenic bladder. Comment: Neither you:qg_!!ge nor_l_arge return on bla dder catheterizatioriexcluded spontaneous perforation. Case 4. T. T., 3017759, a 40-year-old black man, was seen in the emergency room with a 4-day history of hematuria. Two days before the patient was hospitalized distension was noted and he could void only intermittently in small amounts. Urologic history was denied. The blood pressure was 150/ 110, pulse 130 and temperature 100 degrees. The abdomen was tympanitic and t ense to t he umbilicus. A Foley catheter was passed without difficulty and 1,600 cc bloody urine was obtained. To determine whether all the clots had been removed the bladder was irrigated with 50 cc a ir. A subsequent chest x-ray showed free a ir under t he diaphragm and a contrast cystogram confirmed int raperitoneal rupture. The bladder was opened and a loop of small bowel was

565

;

,

I:

566

EVANS, REECE AND SMITH

seen within it, which was reduced. The bladder was closed over a cystostomy tube and the retroperitoneum was drained. Postoperative evaluation revealed a normal IVP, voiding cystourethrogram and cystoscopy. Pathologic examination of the bladder disclosed only some hemorrhage into the muscle. Comment: There was a strong possibility of recent alcohol excess in this case, which increases output and decreases 'mental awareness. The classic test of the air cystogram with extravasation was done by serendipity. EXPERIMENTAL STUDIES

To better understand the problem of leak location, cadavers were catheterized and a sandbag weighing 10 pounds was laid on the umbilicus. The bladder was then filled with water until rupture occurred, at which time the volume was recorded. At subsequent autopsy the site of the rupture, the character of the bladder musculature and the fullness of the intrapelvic organs

were noted. These results are tabulated in table 1. In 2 cases no sandbags were placed and we watched these events through a laparoscope. As the bladder fills it causes only slight bulging of the peritoneum up to a volume of approximately 200 ml. Thereafter, expansion of the bladder is mainly intraperitoneal. This expansion eventually tears longitudinally over the thinnest part. There is remarkably little distortion at the-site of entry of the umbilical ligaments, which do not move duringfilliJg (seefigure). '····· Our experimental findings strongly support the conce.Qt.that the -pelviccliaphragm,pubis, pubic .ligaments, anterior abdomilllUWa1lan]:_l!~-biJ!~l!Liig_1!.l!f~.11r· artn·elativelynxea-_and provulestrong external support for the bladder. The expansion of the blaaaer mtotnepernoneal cavity means that this is au~ally the thinnest port10n of the blaader and offers the least resistance to a sudaen change m mtravesical or mtra;---a--_=,=::.:.::_:::.....::;_:~===-_.:::.~r~=-===c:.:c=-----·-·· a~ommal pressu,re. 2 ~ce, unli.k~~unsupporteqJ:i_alLoon that explodes into many pieces when pressure is suddenly

Umbilicus ligament (Urachus)

Transversalis fascia Preperitoneal space-=---+--1-t--'i:!,-:-A!ll;iiiiiiiiii.1;~ (perivesical space)

Denonvilliers fascia Rectum

Pubis

Prostate

Pelvic diaphragm Intraperitoneal portion of bladder is not supported TABLE 2.

Stone Arch. Surg., 1974 Puerperal Postoperative Ill in bed Straining, coughing or retching Intoxicated Miscellaneous Totals

Idiopathic rupture of the bladder Bastable and Associates Brit. J. Urol., 1959

Collected Cases 1' 72-, 2'·.

6

4 1 1 2

3 6 21

5 2 15

6

101,

826-30

'Graves, J.: Brit. Med. J., 1: 403, 1960. 'Yarwood, G. R.: Brit. J. Urol., 31: 87, 1959. 'Mansberger, A. R., Jr. and Young, J. D., Jr.: J. Urol., 94: 125, 1965. 'Wheeler, M. H.: Brit. J. Surg., 59: 983, 1972. 'Aberdeen, J. D.: Aust. Paediat. J., 9: 316, 1973. 'Maxwell, D.R., Baugh, D. 0., Kleit, S. A. and Szwed, J. J.: J. Indiana State Med. Ass., 66: 35, 1973. 7 Altman, B. and Horsburgh, A. G.: Brit. J. Urol., 38: 85, 1966. 'Bliss, B. P., Clark, W. G. and Saunders, M.: Brit. J. Surg., 51: 446, 1964. 'Ko, K. W., Randolph, J. and Fellers, F. X.: J. Urol., 91: 343, 1964. "Beresford-Jones, A. B.: Brit. J. Surg., 29: 154, 1941. 11 Hammar, B.: Brit. J. Urol., 33: 289, 1961. "Rexford, W. K.: Amer. J. Surg., 46: 641, 1939. "Whitby, M.: S. Afr. Med. J., 18: 229, 1944. "Oliver, J. A. and Taguchi, Y.: Brit. J. Urol., 36: 524, 1964. 15 Culver, H. and Baker, W. J.: J. Urol., 43: 511, 1940. 16 Ruckley, C. V. and Rintoul, R. F.: J. Roy. Coll. Surg. Edinb., 15: 95, 1970. "Clinton-Thomas, C. L.: Brit. J. Urol., 27: 235, 1955. 18 Toporas, M., Beldie, I., Heller, E. and Jacob, 0.: Chirurgia, 21: 513, 1972. 19 Stel'makh, K. G.: Klin. Khir., 8: 75, 1969. 20 Usova, A. F.: Vestn. Khir., 108: 1190, 1972. 21 Dvoeglazov, M. V. and Mirsamatou, M.: Klin. Khir., 9: 80, 1966. "Baker, S. C.: J. Irish Med. Ass., 54: 96, 1964. "Drobner, V. L. and Safonova, K. G.: Klin. Khir., 2: 90, 1967. "Thompson, I. M., Johnson, E. L. a,;id Ross, G., Jr.: Arch. Surg., 90: 371, 1965. "Kamat, M. H., Corgan, F. J. and Seebode, J. J.: Arch. Surg., 100: 735, 1970. '"Miller, A. L., Jr., Sharp, L., Anderson, E. V. and Emlet, J. R.: J. Urol., 83: 630, 1960. 27 Suarez, R. U., Fikri, E. and Felderman, R. E.: Int. Surg., 57: 585, 1972. 26 Stoica, S. and Duceac, S.: Chirurgia, 20: 1047, 1971. 29 Gontier, F. and Alperovitch, R.: J. Chir., 88: 293, 1964. 30 Freidrich, K.: Zentralbl. Chir., 93: 694, 1968.

Totals 11 8 4

19

9.14

1615-2.(

44

Present Report

1 1 4

25 17 84

J 567

IDIOPATHIC RUPTURE OF BLADDER

increased, the bladder is fixed in many areas and simply tears at the weak, unsu orted intrapentonea port ion. DISCUSSION

Spontaneous bladder rupture is rare, whether idiopathic or pathologic. However, it does occur and the diagnosis can be missed since the early symptoms can be minimal and, frequently, t he physician does not consider the possibility. In fact , Thompson and associates have suggested that all patients wit h an acute abdomen have a cystogram done to possibly decrease the mortality rate of a delayed diagnosis. 3 Initial findings may be minimal with a relatively benign abdomen. Shock is not a feature of rupture of the bladder unless infection supervenes. Not infrequently the patient may have an apparently normal amount of urine in the bladder. Thfa may be caused by the extreme s asm that occurs in the injure e rusor causing the rent to be at least partially closed aoo may be compounded b the defect bein Ju ed with oowe as m one of our cases) or omentum. The patient will usually complain of extreme urgency and pain with voiding of small amounts of urine . This is a classic finding in intraperitoneal rupture. An irregularity of the bladder wall on the cystogram is an extremely helpful roentgenographic sign. Our report is concerned with idiopathic rupture of the bladder, with particular attention to those cases in which there was spontaneous rupture of the apparently normal bladder. Table 2 contains the cases we have collected from the literature and compares these with ones previously reported in reviews. 1 • • Adding our 4 cases to those previously discussed the total is now 84. Until 1959 spontaneous rupture in children had had a demonstrable cause, usually tuberculosis. 3 Since that tim~

there have been at least 3 idiopathic neonatal ruptures reported and we believe our patient represents the fourth. There has been a recent increase in reports on neonatal urinary ascites. It is noteworthy that the bladder has not been the source of these leaks even in cases in which severe vesical outlet obstruction exists. We might suggest that the distended bladder is strong in regard to this slow pressure buildup but is weak regarding a sudden increase in pressure, something from which the fetus should be well protected. CONCLUSION

Spofltaneous rupture of the bladder is not a common occurrence. Cases secondary to intrinsic bladder pathology are not usually difficult to diagnose since the focus has been guided towards the bladder. However, the idiopathic spontaneous rupture frequently goes unnoticed for some time. The clinician should remain alert for this disease if we hope to decrease the unduly high mortality rate. Mrs. Jane Crane and Drs. Richard Feit and Nicholas H ranowsky assisted in the translation of articles from foreign journals. REFERENCES

1. Bastable, J . R. G., De Jode, L. R. and Warren, R. P.: Spontaneous rupture of the bladder. Brit. J . Urol., 31 : 78, 1959.

2. Oliver, J. A. and Taguchi, Y.: Rupture of the full bladder. Brit. J. Urol. , 36: 524, 1964.

3. Thompson, I. M., Johnson, E. L. and Ross, G., Jr.: The acute abdomen of unrecognized bladder ·rupture. Arch. Surg., 90: 371, 1965. 4. Stone, E.: Spontaneous rupture of the bladder. Arch. Surg., 23: 129, 1931.