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Perforation of the Bladder During Cystoscopy Examination
PERFORATION OF THE BLADDER DURING SCOPIC EXAMINATION
CYSTO-
SEYMOUR F. WILHELM From the Srrgical Division of the M ontefiore Hospital, Dr. Harold N euhof, Director, New York City
Since Nitze supplied the instrumental eye by means of which we are able to visualize the urinary bladder, the use of the cystoscope has steadily increased to its present universal application. It is impossible to overestimate its tremendous value, both in the diagnosis and the treatment of diseases of the genito-urinary organs and their adjacent structures. However, with its more widespread use under varied conditions, it is to be expected that accidents will occur. A short time ago, a patient suffering from renal and vesical tuberculosis, whom I was examining cystoscopically under gas and oxygen anesthesia, suddenly had a generalized tonic spasm, violently raising his pelvis about a foot off the operating table, with a resultant perforation of the anterior wall of the bladder. Subsequently, I consulted the experience of several urologic surgeons as to the frequency of cystoscopic rupture, and was able to add 2 cases to my own. Since these cases have occurred in the hands of skilled cystoscopists in an optimal surgical environment, the assumption may be made that such accidents are far more frequent than is commonly supposed. A review of the literature has revealed a dearth of reports of similar occurrences. It appears most likely that the great majority of these cases are lost in a purposeful oblivion which spares us from so many memories. Because of the universal use of the cystoscope, I deem it important to record the following 3 cases of traumatic perforation of the bladder during cystoscopic examination. Case I. Montefiore Hospital, No. 14309. This man was first admitted in December, 1926. The diagnosis then made was bilateral 555
556
SEYMOUR F. WILHELM
pulmonary tuberculosis, moderately advanced, fibroid in type. He was readmitted October 4, 1927, complaining of occasional hematuria, dysuria, pyuria, frequency and loss of weight since the previous June. Physical examination was negative, except for signs of the old pulmonary lesion. On October 10 he was examined cystoscopically, gas oxygen anesthesia being employed because of his apprehension and unwillingness to cooperate. While under the anesthesia, he unexpectedly vomited and had a generalized spastic contraction, raising his buttocks about a foot off the operating table. A few drops of pure blood flowed out of the cystoscope sheath. The instrument was immediately withdrawn. On recovery from the anesthesia, he complained of severe lower abdominal and perineal pain, and was in a state of shock. Slight tenderness and rigidity were elicited in both lower quadrants. A sterile catheter was passed, and a few drops of blood again obtained. A diagnosis of traumatic perforation of the bladder was made. To confirm this, 300 cc. of sterile boric acid solution were introduced and only 150 cc. recovered. Signs of intraperitoneal fluid were found now. Immediate coeliotomy was performed. There was free fluid in the peritoneal cavity, and the retroperitoneal and perivesical tissues were also markedly infiltrated by fluid. No intraperitoneal perforation could be found. The bladder was then freed extraperitoneally, and a small perforation was demonstrated on the anterolateral wall, communicating with the space of Retzius. This was sutured in two layers and adequate drainage provided to the space of Retzius and the retroperitoneal tissues. The peritoneum was closed without drainage. The patient did fairly well for seven days. On the eighth day, a small piece of fat, recognized as omentum, was found between the skin edges. The wound was further opened, and it was seen that small intestine lay immediately beneath the skin (subcutaneous evisceration). The wound was widely opened, the intestinal coils packed back with iodoform gauze, and the skin margins tightly strapped. Following this, however, his course was progressively downhill, he vomited repeatedly despite lavage, became more toxic, hiccoughed, and died on October 22, thirteen days postoperative. His temperature had varied between 97 and 102, but was normal or subnormal in the last four days. At autopsy, the perforation had completely healed, a slight puckering indicating the lesion. There was localized fibropurulent peritonitis (B. coli) at the site of the evisceration. Several localized purulent collections were found around the bladder. In addition, there was
--
-------------------
PERFORATION OF BLADDER
557
acute hemorrhagic cystitis and tuberculosis of the right kidney, bladder, peritoneum, prostate, seminal vesicles and lungs.
Case II. (Courtesy of Dr. Paul Aschner), No. 199383. This man was admitted to Mount Sinai Hospital July 16, 1920. On cystoscopy, a papillary carcinoma of the bladder was found. This was resected with cautery on July 21, 1920 and the edges of the bladder sutured. On September 15, cystoscopy revealed a soft white calculus, but no recurrence. An attempt at removal of the stone with a cystoscopic forceps was unsuccessful. Two days later, he was again examined cystoscopically, gas and oxygen anesthesia being used at his request. The patient twitched under anesthesia, and "the instrument seemed to enter a pocket further in, from which free flow of irrigating fluid was not obtained." The instrument was removed and a soft catheter inserted. Free flow of irrigating fluid was obtained. That afternoon his condition and color were poor, and he complained of severe abdominal tenderness with rebound. Bloody urine flowed from the catheter. Of 120 cc. of boric acid solution injected, 60 cc. were returned, and again, of 90 cc. injected, 45 cc. were withdrawn. A diagnosis of perforation of the bladder was made, and immediate laparotomy performed. There was clear watery fluid in the pelvis, and a small slit-like perforation was found low on the posterior wall of the bladder. The vesical wound was closed, the old fistula tract reopened, and the calculus removed. A tube was left in the bladder, and another in the space of Douglas. He had an uneventful convalescence except for a mild periostitis of the pubis. One month postoperative the wound was healed and the urine clear. Case III. (Courtesy of Dr. Ira Cohen, personal communication.) This patient, during cystoscopy under local anesthesia, suddenly raised his buttocks off the table. Immediately it was noticed that the irrigating fluid flowed out of the rectum. He complained of very severe pain, and the cystoscope was immediately withdrawn. A permanent catheter was inserted, and constipation was induced. In about two weeks the wound had completely healed. He had no further trouble.
In the first two of these cases gas and oxygen anesthesia was employed at the request of the patient. The difficulty of maintaining an even gas and oxygen anesthesia is well known, and it is obvious that vomiting, muscular twitchings or contractures with a stiff instrument in the bladder, invite vesical traumatism.
558
SEYMOUR F. WILHELM
The hazards of cystoscopic examination with unruly patients is illustrated by case III. Epidural or spinal anesthesia can be used in those cases where intraurethral injection does not suffice. It is interesting to note that all of these cases were in males. Anatomically, it seems that cystoscopic perforation in the female would be unlikely to occur. In the literature, cases of perforation of the bladder during cystoscopic examination are few. In a table listing 15 cases of instrumental vesical traumatism, Young and Davis (1) briefly report 5 cases of cystoscopic perforation. Three were extraperitoneal, one of these possibly also intraperitoneal. The outcome was fatal in aH except one extraperitoneal extravasation which was incised. In 1914, Rytina (2) reported a case of one of his assistants. The patient lunged while the cystoscope was being introduced, and fluid feces came out through the sheath. The instrument could be felt in the rectum. Of a liter of fluid injected into the bladder, only 600 cc. was returned. The patient, however, refused operation. Two weeks later the opening had closed and he was voiding clear urine. He had no trouble subsequently. Perforation of the bladder may be intra or extraperitoneal. In the latter type, the opening may lead into the peri-vesical cellular tissues or into a hollow viscus, as the rectum or vagina. Experience (1) has shown that, "practically, wounds of the bladder caused by intravesical instruments are confined to pathological bladders, though a normal bladder may be perforated without too much difficulty when spasmodically contracted." As early as 1887 Ulman (3) showed experimentally that rupture was more likely to occur in cases of cystitis than with a normal bladder. One inflamed bladder burst after injection of 360 cc. of fluid, while a normal bladder held as much as 2070 cc. before rupture. All of our cases showed pathological changes in the bladder. We may conclude that instrumental perforation is by far most common in previously diseased bladders, though the possibility of rupture of a normal bladder by a more violent traumatic insult cannot be precluded. The scope of this paper does not permit a detailed discussion of the symptomatology and diagnosis of bladder perforation.
PERFORATION OF BLADDER
559
This is adequately described in the literature. Suffice it to say that sudden severe pain, shock, great desire for micturition with inability to void, burning, a feeling of tearing or "something giving way," and hematuria, are early symptoms. Later on the symptoms of peritonitis or extraperitoneal extravasation supervene. Often, one or many of these symptoms are absent. On examination shortly after the trauma, tenderness and rigidity of the lower recti muscles may already be found. Shifting dulness or even a fluid wave may be elicited. These findings, however, do not exclude an extraperitoneal perforation (case I). Wool:-:ey (4) has reported a case of extraperitoneal rupture with free bloody fluid in the peritoneal cavity. In case I the presence of shifting dulness led me to make a diagnosis of intraperitoneal perforation. At operation, however, no such opening could be found, but a rupture leading into the space or Retzius was demonstrated. It may be assumed that intraperitoneal free fluid is formed by irritation through an at least grossly untorn peritoneum. With rupture into a hollow viscus, the symptoms and signs of rectovesical or vesico-vaginal communication are to be seen. Several diagnostic procedures, ingenious in their apparent simplicity, have been devised. One of these, the introduction of sterile fluid through an aseptic catheter with subsequent withdrawal, has been widely used. The inability to withdraw an equal, or nearly equal amount to that introduced, has been considered evidence of a pathologic opening in the bladder. However, the unreliability of this test was pointed out by White and Martin (5) when they wrote, "The injection of an antiseptic solution is by no means an infallible test, since even an extensive rupture may so quickly close by inflamm
5
560
SEYMOUR F. WILHELM
of this procedure, Louis Frank (6) suggested fluoroscopy after the introduction of sodium bromide solution . Recently, Vaughn and Rudnick (7) injected gas into 4 cases of bladder rupture and on fluoroscopy, found a gas shadow under the diaphragm, or in the perivesical tissues. A short time ago a fifth case (8) was reported. It is interesting to note that all 5 cases died. In 1895 Walsham (9) reported a case of collapse following the injection of air for diagnosis of bladder rupture. The advisability of the introduction of instruments into a torn bladder has long been a disputed question. It would seem that the gentle introduction of a sterile catheter does not carry any great risk. However, the introduction of foreign solutions or gases into a perforated bladder certainly does help the spread of infective material throughout the peritoneal cavity or into t he loose perivesical and retroperitoneal tissues. This was clearly demonstrated in case I by the marked retroperitoneal extravasation following the injection of boric acid solution, necessitating much more extensive drainage than would otherwise have been required. Cystoscopic examination has proved of little value in the diganosis of bladder rupt ure. Bleeding obscures the picture and the danger of introducing irrigating fluids has been pointed out. The diagnosis of bladder perforation can and should be made on the clinical picture alone. In case of doubt, exploratory laparotomy appeals as a safer and more rational procedure than intravesical manipulations or irrigations. Immediate surgical intervention is imperative in the treatment of intra and extraperitoneal bladder perforation, except for those rupturing into the rectum or vagina. In the latter, because drainage into a hollow viscus has already been established, because of t he often great technical diffculty in closing such a perforation and because the chance of spontaneous healing is good (see case III and Rytina's case), non-operative treatment (retention catheter, induced constipation, urinary antiseptics) is indicated. If the opening does not heal after a reasonable time, the problem becomes one of surgical closure of a recto-vesical or vesico-vaginal fist ula . In case of doubt as to the site of perforation, exploratory laparotomy should be done.
PERFORATION OF BLADDER
561
The differential diagnosis between intra and extraperitoneal perforation is difficult, if not impossible. The symptoms and signs are practically the same in both. Furthermore, a rupture may be both intra and extraperitoneal or there may be multiple tears. Therefore, the peritoneum should be opened to enable a thorough inspection of the bladder wall and of the perivesical and retroperitoneal tissues in order to find the site of perforation. The latter should be closed by two or three layers of sutures. If no intraperitoneal opening can be found, the peritoneum is closed and the bladder freed extraperitoneally till the rupture can be demonstrated and repaired. Extraperitoneal extravasations require drainage. When the perforation is inaccessible or too great to be adequately sutured, or in the case of a grosslyinfected urine, the establishment of suprapubic bladder drainage may be preferred. The question of drainage of intraperitoneal perforations depends upon the competency of the bladder repair, the time of operation and the condition of the peritoneum. Statistics before 1878, in the pre-surgical era, show a very high mortality. Gross had stated that rupture of the bladder is nearly always fatal. Of 169 cases collected by Max Bartel (10) in 1878, 152 died, a mortality of almost 90 per cent. However, of 22 cases since 1892, reported by D. F. Jones (11), 15 had recovered, a mortality of 31 per cent. Of our 3 cases, one died, (extraperitoneal) on the thirteenth day postoperative, and two recovered; one, (intraperitoneal) with operation and the other, (into rectum) without operation. It is evident that the prognosis depends upon the general condition of the patient, the type of perforation, and when indicated, on early operative intervention. CONCLUSIONS
l. Perforation of the bladder during cystoscopic examination occurs more often than the literature would indicate. 2. Gas and oxygen anesthesia is unsuitable and hazardous for cystoscopic examination. Cystoscopy should not be attempted with unruly and uncooperative patients. 3. Diagnostic tests involving the injection of fluids or gas, are dangerous and unreliable and should be discarded.
562
SEYMOUR F. WILHELM
4. The diagnosis of bladder perforation should be made on the clinical picture. The differential diagnosis between intra and extraperitoneal perforation is difficult, if not impossible. Exploratory laparotomy is to be preferred in case of doubt. 5. The treatment of perforation into the rectum or vagina is non-operative. In all other perforations of the bladder immediate surgical intervention is indicated. REFERENCES (1) YouNG, HuGH H., Al'i'D DAvrs, D. M.: Young's Practice of Urology, ii, 146154, 1926. (2) RYTINA, A.G.: Discussion at the Genito-Urinary Section at the Sixty-fifth Annual Session of the American Medical Association, Jour. Amer. Med. Assoc., lxiii, 2118 (December 12), 1914. (3) ULLMANN, E.: Wien. Med. Woch., xxxvii, 795, 1887. (4) WOOLSEY, GEORGE: Ann. Surg., August, 1913. (5) WHITE, J. W., AND MARTIN, E.: Textbook of Genito-Urinary and Venereal Diseases, 1906. (6) FRANK, Lours: ,South. Med. Jour., xviii, 683, 1925. (7) VAUGHN, R. T., AND RUDNICK, D. F.: A new and early sign of ruptured bladder, Jour. Amer. Med. Assoc., lxxxiii, 9, 1924. (8) ErsEKDRATH, D. N., AND RoLNICK, H. C.: Jour. Amer. Med. Assoc., xci, 1548, (November 17), 1928. (9) WALSR;AM, W. J.: Trans. Med. Chir. Soc., lxxviii, 275, 1895. (10) BARTEL, MAX: Arch. f. Klin. Chir., xxii, 789, 1878. (11) JONES, D. F.: Ann. Surg., xxxvii, 216, 1903.
CYSTO-
SEYMOUR F. WILHELM From the Srrgical Division of the M ontefiore Hospital, Dr. Harold N euhof, Director, New York City
Since Nitze supplied the instrumental eye by means of which we are able to visualize the urinary bladder, the use of the cystoscope has steadily increased to its present universal application. It is impossible to overestimate its tremendous value, both in the diagnosis and the treatment of diseases of the genito-urinary organs and their adjacent structures. However, with its more widespread use under varied conditions, it is to be expected that accidents will occur. A short time ago, a patient suffering from renal and vesical tuberculosis, whom I was examining cystoscopically under gas and oxygen anesthesia, suddenly had a generalized tonic spasm, violently raising his pelvis about a foot off the operating table, with a resultant perforation of the anterior wall of the bladder. Subsequently, I consulted the experience of several urologic surgeons as to the frequency of cystoscopic rupture, and was able to add 2 cases to my own. Since these cases have occurred in the hands of skilled cystoscopists in an optimal surgical environment, the assumption may be made that such accidents are far more frequent than is commonly supposed. A review of the literature has revealed a dearth of reports of similar occurrences. It appears most likely that the great majority of these cases are lost in a purposeful oblivion which spares us from so many memories. Because of the universal use of the cystoscope, I deem it important to record the following 3 cases of traumatic perforation of the bladder during cystoscopic examination. Case I. Montefiore Hospital, No. 14309. This man was first admitted in December, 1926. The diagnosis then made was bilateral 555
556
SEYMOUR F. WILHELM
pulmonary tuberculosis, moderately advanced, fibroid in type. He was readmitted October 4, 1927, complaining of occasional hematuria, dysuria, pyuria, frequency and loss of weight since the previous June. Physical examination was negative, except for signs of the old pulmonary lesion. On October 10 he was examined cystoscopically, gas oxygen anesthesia being employed because of his apprehension and unwillingness to cooperate. While under the anesthesia, he unexpectedly vomited and had a generalized spastic contraction, raising his buttocks about a foot off the operating table. A few drops of pure blood flowed out of the cystoscope sheath. The instrument was immediately withdrawn. On recovery from the anesthesia, he complained of severe lower abdominal and perineal pain, and was in a state of shock. Slight tenderness and rigidity were elicited in both lower quadrants. A sterile catheter was passed, and a few drops of blood again obtained. A diagnosis of traumatic perforation of the bladder was made. To confirm this, 300 cc. of sterile boric acid solution were introduced and only 150 cc. recovered. Signs of intraperitoneal fluid were found now. Immediate coeliotomy was performed. There was free fluid in the peritoneal cavity, and the retroperitoneal and perivesical tissues were also markedly infiltrated by fluid. No intraperitoneal perforation could be found. The bladder was then freed extraperitoneally, and a small perforation was demonstrated on the anterolateral wall, communicating with the space of Retzius. This was sutured in two layers and adequate drainage provided to the space of Retzius and the retroperitoneal tissues. The peritoneum was closed without drainage. The patient did fairly well for seven days. On the eighth day, a small piece of fat, recognized as omentum, was found between the skin edges. The wound was further opened, and it was seen that small intestine lay immediately beneath the skin (subcutaneous evisceration). The wound was widely opened, the intestinal coils packed back with iodoform gauze, and the skin margins tightly strapped. Following this, however, his course was progressively downhill, he vomited repeatedly despite lavage, became more toxic, hiccoughed, and died on October 22, thirteen days postoperative. His temperature had varied between 97 and 102, but was normal or subnormal in the last four days. At autopsy, the perforation had completely healed, a slight puckering indicating the lesion. There was localized fibropurulent peritonitis (B. coli) at the site of the evisceration. Several localized purulent collections were found around the bladder. In addition, there was
--
-------------------
PERFORATION OF BLADDER
557
acute hemorrhagic cystitis and tuberculosis of the right kidney, bladder, peritoneum, prostate, seminal vesicles and lungs.
Case II. (Courtesy of Dr. Paul Aschner), No. 199383. This man was admitted to Mount Sinai Hospital July 16, 1920. On cystoscopy, a papillary carcinoma of the bladder was found. This was resected with cautery on July 21, 1920 and the edges of the bladder sutured. On September 15, cystoscopy revealed a soft white calculus, but no recurrence. An attempt at removal of the stone with a cystoscopic forceps was unsuccessful. Two days later, he was again examined cystoscopically, gas and oxygen anesthesia being used at his request. The patient twitched under anesthesia, and "the instrument seemed to enter a pocket further in, from which free flow of irrigating fluid was not obtained." The instrument was removed and a soft catheter inserted. Free flow of irrigating fluid was obtained. That afternoon his condition and color were poor, and he complained of severe abdominal tenderness with rebound. Bloody urine flowed from the catheter. Of 120 cc. of boric acid solution injected, 60 cc. were returned, and again, of 90 cc. injected, 45 cc. were withdrawn. A diagnosis of perforation of the bladder was made, and immediate laparotomy performed. There was clear watery fluid in the pelvis, and a small slit-like perforation was found low on the posterior wall of the bladder. The vesical wound was closed, the old fistula tract reopened, and the calculus removed. A tube was left in the bladder, and another in the space of Douglas. He had an uneventful convalescence except for a mild periostitis of the pubis. One month postoperative the wound was healed and the urine clear. Case III. (Courtesy of Dr. Ira Cohen, personal communication.) This patient, during cystoscopy under local anesthesia, suddenly raised his buttocks off the table. Immediately it was noticed that the irrigating fluid flowed out of the rectum. He complained of very severe pain, and the cystoscope was immediately withdrawn. A permanent catheter was inserted, and constipation was induced. In about two weeks the wound had completely healed. He had no further trouble.
In the first two of these cases gas and oxygen anesthesia was employed at the request of the patient. The difficulty of maintaining an even gas and oxygen anesthesia is well known, and it is obvious that vomiting, muscular twitchings or contractures with a stiff instrument in the bladder, invite vesical traumatism.
558
SEYMOUR F. WILHELM
The hazards of cystoscopic examination with unruly patients is illustrated by case III. Epidural or spinal anesthesia can be used in those cases where intraurethral injection does not suffice. It is interesting to note that all of these cases were in males. Anatomically, it seems that cystoscopic perforation in the female would be unlikely to occur. In the literature, cases of perforation of the bladder during cystoscopic examination are few. In a table listing 15 cases of instrumental vesical traumatism, Young and Davis (1) briefly report 5 cases of cystoscopic perforation. Three were extraperitoneal, one of these possibly also intraperitoneal. The outcome was fatal in aH except one extraperitoneal extravasation which was incised. In 1914, Rytina (2) reported a case of one of his assistants. The patient lunged while the cystoscope was being introduced, and fluid feces came out through the sheath. The instrument could be felt in the rectum. Of a liter of fluid injected into the bladder, only 600 cc. was returned. The patient, however, refused operation. Two weeks later the opening had closed and he was voiding clear urine. He had no trouble subsequently. Perforation of the bladder may be intra or extraperitoneal. In the latter type, the opening may lead into the peri-vesical cellular tissues or into a hollow viscus, as the rectum or vagina. Experience (1) has shown that, "practically, wounds of the bladder caused by intravesical instruments are confined to pathological bladders, though a normal bladder may be perforated without too much difficulty when spasmodically contracted." As early as 1887 Ulman (3) showed experimentally that rupture was more likely to occur in cases of cystitis than with a normal bladder. One inflamed bladder burst after injection of 360 cc. of fluid, while a normal bladder held as much as 2070 cc. before rupture. All of our cases showed pathological changes in the bladder. We may conclude that instrumental perforation is by far most common in previously diseased bladders, though the possibility of rupture of a normal bladder by a more violent traumatic insult cannot be precluded. The scope of this paper does not permit a detailed discussion of the symptomatology and diagnosis of bladder perforation.
PERFORATION OF BLADDER
559
This is adequately described in the literature. Suffice it to say that sudden severe pain, shock, great desire for micturition with inability to void, burning, a feeling of tearing or "something giving way," and hematuria, are early symptoms. Later on the symptoms of peritonitis or extraperitoneal extravasation supervene. Often, one or many of these symptoms are absent. On examination shortly after the trauma, tenderness and rigidity of the lower recti muscles may already be found. Shifting dulness or even a fluid wave may be elicited. These findings, however, do not exclude an extraperitoneal perforation (case I). Wool:-:ey (4) has reported a case of extraperitoneal rupture with free bloody fluid in the peritoneal cavity. In case I the presence of shifting dulness led me to make a diagnosis of intraperitoneal perforation. At operation, however, no such opening could be found, but a rupture leading into the space or Retzius was demonstrated. It may be assumed that intraperitoneal free fluid is formed by irritation through an at least grossly untorn peritoneum. With rupture into a hollow viscus, the symptoms and signs of rectovesical or vesico-vaginal communication are to be seen. Several diagnostic procedures, ingenious in their apparent simplicity, have been devised. One of these, the introduction of sterile fluid through an aseptic catheter with subsequent withdrawal, has been widely used. The inability to withdraw an equal, or nearly equal amount to that introduced, has been considered evidence of a pathologic opening in the bladder. However, the unreliability of this test was pointed out by White and Martin (5) when they wrote, "The injection of an antiseptic solution is by no means an infallible test, since even an extensive rupture may so quickly close by inflamm
5
560
SEYMOUR F. WILHELM
of this procedure, Louis Frank (6) suggested fluoroscopy after the introduction of sodium bromide solution . Recently, Vaughn and Rudnick (7) injected gas into 4 cases of bladder rupture and on fluoroscopy, found a gas shadow under the diaphragm, or in the perivesical tissues. A short time ago a fifth case (8) was reported. It is interesting to note that all 5 cases died. In 1895 Walsham (9) reported a case of collapse following the injection of air for diagnosis of bladder rupture. The advisability of the introduction of instruments into a torn bladder has long been a disputed question. It would seem that the gentle introduction of a sterile catheter does not carry any great risk. However, the introduction of foreign solutions or gases into a perforated bladder certainly does help the spread of infective material throughout the peritoneal cavity or into t he loose perivesical and retroperitoneal tissues. This was clearly demonstrated in case I by the marked retroperitoneal extravasation following the injection of boric acid solution, necessitating much more extensive drainage than would otherwise have been required. Cystoscopic examination has proved of little value in the diganosis of bladder rupt ure. Bleeding obscures the picture and the danger of introducing irrigating fluids has been pointed out. The diagnosis of bladder perforation can and should be made on the clinical picture alone. In case of doubt, exploratory laparotomy appeals as a safer and more rational procedure than intravesical manipulations or irrigations. Immediate surgical intervention is imperative in the treatment of intra and extraperitoneal bladder perforation, except for those rupturing into the rectum or vagina. In the latter, because drainage into a hollow viscus has already been established, because of t he often great technical diffculty in closing such a perforation and because the chance of spontaneous healing is good (see case III and Rytina's case), non-operative treatment (retention catheter, induced constipation, urinary antiseptics) is indicated. If the opening does not heal after a reasonable time, the problem becomes one of surgical closure of a recto-vesical or vesico-vaginal fist ula . In case of doubt as to the site of perforation, exploratory laparotomy should be done.
PERFORATION OF BLADDER
561
The differential diagnosis between intra and extraperitoneal perforation is difficult, if not impossible. The symptoms and signs are practically the same in both. Furthermore, a rupture may be both intra and extraperitoneal or there may be multiple tears. Therefore, the peritoneum should be opened to enable a thorough inspection of the bladder wall and of the perivesical and retroperitoneal tissues in order to find the site of perforation. The latter should be closed by two or three layers of sutures. If no intraperitoneal opening can be found, the peritoneum is closed and the bladder freed extraperitoneally till the rupture can be demonstrated and repaired. Extraperitoneal extravasations require drainage. When the perforation is inaccessible or too great to be adequately sutured, or in the case of a grosslyinfected urine, the establishment of suprapubic bladder drainage may be preferred. The question of drainage of intraperitoneal perforations depends upon the competency of the bladder repair, the time of operation and the condition of the peritoneum. Statistics before 1878, in the pre-surgical era, show a very high mortality. Gross had stated that rupture of the bladder is nearly always fatal. Of 169 cases collected by Max Bartel (10) in 1878, 152 died, a mortality of almost 90 per cent. However, of 22 cases since 1892, reported by D. F. Jones (11), 15 had recovered, a mortality of 31 per cent. Of our 3 cases, one died, (extraperitoneal) on the thirteenth day postoperative, and two recovered; one, (intraperitoneal) with operation and the other, (into rectum) without operation. It is evident that the prognosis depends upon the general condition of the patient, the type of perforation, and when indicated, on early operative intervention. CONCLUSIONS
l. Perforation of the bladder during cystoscopic examination occurs more often than the literature would indicate. 2. Gas and oxygen anesthesia is unsuitable and hazardous for cystoscopic examination. Cystoscopy should not be attempted with unruly and uncooperative patients. 3. Diagnostic tests involving the injection of fluids or gas, are dangerous and unreliable and should be discarded.
562
SEYMOUR F. WILHELM
4. The diagnosis of bladder perforation should be made on the clinical picture. The differential diagnosis between intra and extraperitoneal perforation is difficult, if not impossible. Exploratory laparotomy is to be preferred in case of doubt. 5. The treatment of perforation into the rectum or vagina is non-operative. In all other perforations of the bladder immediate surgical intervention is indicated. REFERENCES (1) YouNG, HuGH H., Al'i'D DAvrs, D. M.: Young's Practice of Urology, ii, 146154, 1926. (2) RYTINA, A.G.: Discussion at the Genito-Urinary Section at the Sixty-fifth Annual Session of the American Medical Association, Jour. Amer. Med. Assoc., lxiii, 2118 (December 12), 1914. (3) ULLMANN, E.: Wien. Med. Woch., xxxvii, 795, 1887. (4) WOOLSEY, GEORGE: Ann. Surg., August, 1913. (5) WHITE, J. W., AND MARTIN, E.: Textbook of Genito-Urinary and Venereal Diseases, 1906. (6) FRANK, Lours: ,South. Med. Jour., xviii, 683, 1925. (7) VAUGHN, R. T., AND RUDNICK, D. F.: A new and early sign of ruptured bladder, Jour. Amer. Med. Assoc., lxxxiii, 9, 1924. (8) ErsEKDRATH, D. N., AND RoLNICK, H. C.: Jour. Amer. Med. Assoc., xci, 1548, (November 17), 1928. (9) WALSR;AM, W. J.: Trans. Med. Chir. Soc., lxxviii, 275, 1895. (10) BARTEL, MAX: Arch. f. Klin. Chir., xxii, 789, 1878. (11) JONES, D. F.: Ann. Surg., xxxvii, 216, 1903.