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Spontaneous intra-peritoneal perforation of the bladder secondary to peritoneal tuberculosis
British Journal of Medical and Surgical Urology (2009) 2, 213—214
CASE REPORT
Spontaneous intra-peritoneal perforation of the bladder secondary to peritoneal tuberculosis Raj P. Pal ∗, Tim R. Terry, Masood A. Khan Department of Urology, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Leicester LE5 4WP, United Kingdom Received 10 January 2009 ; received in revised form 5 May 2009; accepted 13 May 2009
KEYWORDS Bladder perforation; Intra-peritoneal; Tuberculosis
Case report A 28-year-old Indian female presented to the Urology department with acute urinary retention, having being diagnosed 4 weeks previously with peritoneal tuberculosis. Prior to this episode of retention, she had complained of urinary frequency and poor stream for 3 days. Her postcatheterisation residual volume was 1500 ml. She failed a subsequent trial without catheter due to large post-micturition residual volumes, and therefore commenced intermittent self-catheterisation. After 2 weeks of self-catheterisation her residuals became insignificant, and this was discontinued. Spinal magnetic resonance imaging (MRI) to investigate her symptoms revealed no abnormality. Cystoscopy revealed a diverticulum at the dome of the bladder, but otherwise normal bladder mucosa.
∗ Corresponding author. Tel.: +44 01162490490; fax: +44 01162730639. E-mail address: [email protected] (R.P. Pal).
Three weeks following her cystoscopy she re-presented with sudden onset severe lower abdominal pain whilst voiding urine. Physical examination revealed a diffusely tender peritonitic abdomen. Serum laboratory investigations demonstrated an elevated C-reactive protein (46 mg/L) and white cell count (11.9 × 109 ). Pelvic MRI was performed which identified an intra-peritoneal bladder perforation (Fig. 1). The patient underwent a laparotomy, which revealed free urine in the peritoneal cavity with a 3 cm perforation at the bladder dome. The peritoneum directly overlying the bladder perforation contained tuberculous deposits. Primary repair of the defect was performed. She made an uncomplicated recovery following surgery. Continuous bladder drainage was instituted for 3 weeks using a urethral catheter, following which a cystogram was performed, which revealed no urine leak. A subsequent trial without catheter was successful. Her early morning urine samples cultured for Mycobacterium tuberculosis were negative. She received triple drug anti-tuberculous treatment for 6 months.
1875-9742/$ — see front matter © 2009 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2009.05.002
214
R.P. Pal et al.
Figure 1 T1 MRI image displaying perforation at the left posterior lateral aspect of the dome of the bladder.
conventional cystography for detecting bladder rupture [1,5]. However, the use of MRI to detect bladder perforation has not been evaluated against other modalities, perhaps as MRI is less readily performed in the acute setting. The lower urinary tract symptoms and cystoscopic findings preceding our patient’s presentation with abdominal peritonism directed our attention towards a bladder pathology and therefore a pelvic MRI was performed which provided an immediate diagnosis, confirmed on surgical exploration. In conclusion, we present the first reported case of spontaneous bladder perforation arising secondary to peritoneal tuberculosis. This case was successfully managed by primary surgical repair followed by anti-tuberculous medical treatment. Furthermore, we describe the successful use of MRI as a diagnostic tool for bladder rupture.
Discussion Spontaneous bladder perforation is a rare event, which may occur secondary to pelvic radiotherapy, malignancy or previous surgical reconstruction [1—3]. Rare associations with genitourinary tuberculosis have been described [4]. However, this is the first reported case of spontaneous intra-peritoneal bladder perforation arising as a complication of peritoneal tuberculosis. In our patient, bladder wall weakness is likely to have arisen secondary to inflammation of the overlying diseased peritoneum, leading to bladder rupture which occurred during increased intra-vesical pressures whilst voiding. Spontaneous bladder perforation is usually not considered as a differential during the early stages of evaluating a patient with abdominal pain. Therefore cystography, although previously considered the standard for diagnosis, is rarely performed. Alternatively, diagnosis can be made by cystoscopy, computed tomography (CT) or surgical exploration [1,2,4]. CT has been shown to be superior to
Conflict of interest The authors declare that there is no conflict of interest.
References [1] Fontaine E, Leaver R, Woodhouse CR. Diagnosis of perforated enterocystoplasty. J R Soc Med 2003;96:393—4. [2] Kato A, Yoshida K, Tsuru N, Ushiyama T, Suzuki K, Ozono S, et al. Spontaneous rupture of the urinary bladder presenting as oliguric acute renal failure. Intern Med 2006;45(13):815—8. [3] Huffman JL, Schraut W, Bagley DH. Atraumatic perforation of bladder. Necessary differential in evaluation of acute condition of abdomen. Urology 1983;22(1):30—5. [4] Kumar RV, Banerjee GK, Bhadauria RP, Ahlawat R. Spontaneous bladder perforation: an unusual management problem of tuberculous cystitis. Aust N Z J Surg 1997;67(1):69—70. [5] Chan DP, Abujudeh HH, Cushing Jr GL, Novelline RA. CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. Am J Roentgenol 2006;187(November (5)):1296—302.
Available online at www.sciencedirect.com
CASE REPORT
Spontaneous intra-peritoneal perforation of the bladder secondary to peritoneal tuberculosis Raj P. Pal ∗, Tim R. Terry, Masood A. Khan Department of Urology, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Leicester LE5 4WP, United Kingdom Received 10 January 2009 ; received in revised form 5 May 2009; accepted 13 May 2009
KEYWORDS Bladder perforation; Intra-peritoneal; Tuberculosis
Case report A 28-year-old Indian female presented to the Urology department with acute urinary retention, having being diagnosed 4 weeks previously with peritoneal tuberculosis. Prior to this episode of retention, she had complained of urinary frequency and poor stream for 3 days. Her postcatheterisation residual volume was 1500 ml. She failed a subsequent trial without catheter due to large post-micturition residual volumes, and therefore commenced intermittent self-catheterisation. After 2 weeks of self-catheterisation her residuals became insignificant, and this was discontinued. Spinal magnetic resonance imaging (MRI) to investigate her symptoms revealed no abnormality. Cystoscopy revealed a diverticulum at the dome of the bladder, but otherwise normal bladder mucosa.
∗ Corresponding author. Tel.: +44 01162490490; fax: +44 01162730639. E-mail address: [email protected] (R.P. Pal).
Three weeks following her cystoscopy she re-presented with sudden onset severe lower abdominal pain whilst voiding urine. Physical examination revealed a diffusely tender peritonitic abdomen. Serum laboratory investigations demonstrated an elevated C-reactive protein (46 mg/L) and white cell count (11.9 × 109 ). Pelvic MRI was performed which identified an intra-peritoneal bladder perforation (Fig. 1). The patient underwent a laparotomy, which revealed free urine in the peritoneal cavity with a 3 cm perforation at the bladder dome. The peritoneum directly overlying the bladder perforation contained tuberculous deposits. Primary repair of the defect was performed. She made an uncomplicated recovery following surgery. Continuous bladder drainage was instituted for 3 weeks using a urethral catheter, following which a cystogram was performed, which revealed no urine leak. A subsequent trial without catheter was successful. Her early morning urine samples cultured for Mycobacterium tuberculosis were negative. She received triple drug anti-tuberculous treatment for 6 months.
1875-9742/$ — see front matter © 2009 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2009.05.002
214
R.P. Pal et al.
Figure 1 T1 MRI image displaying perforation at the left posterior lateral aspect of the dome of the bladder.
conventional cystography for detecting bladder rupture [1,5]. However, the use of MRI to detect bladder perforation has not been evaluated against other modalities, perhaps as MRI is less readily performed in the acute setting. The lower urinary tract symptoms and cystoscopic findings preceding our patient’s presentation with abdominal peritonism directed our attention towards a bladder pathology and therefore a pelvic MRI was performed which provided an immediate diagnosis, confirmed on surgical exploration. In conclusion, we present the first reported case of spontaneous bladder perforation arising secondary to peritoneal tuberculosis. This case was successfully managed by primary surgical repair followed by anti-tuberculous medical treatment. Furthermore, we describe the successful use of MRI as a diagnostic tool for bladder rupture.
Discussion Spontaneous bladder perforation is a rare event, which may occur secondary to pelvic radiotherapy, malignancy or previous surgical reconstruction [1—3]. Rare associations with genitourinary tuberculosis have been described [4]. However, this is the first reported case of spontaneous intra-peritoneal bladder perforation arising as a complication of peritoneal tuberculosis. In our patient, bladder wall weakness is likely to have arisen secondary to inflammation of the overlying diseased peritoneum, leading to bladder rupture which occurred during increased intra-vesical pressures whilst voiding. Spontaneous bladder perforation is usually not considered as a differential during the early stages of evaluating a patient with abdominal pain. Therefore cystography, although previously considered the standard for diagnosis, is rarely performed. Alternatively, diagnosis can be made by cystoscopy, computed tomography (CT) or surgical exploration [1,2,4]. CT has been shown to be superior to
Conflict of interest The authors declare that there is no conflict of interest.
References [1] Fontaine E, Leaver R, Woodhouse CR. Diagnosis of perforated enterocystoplasty. J R Soc Med 2003;96:393—4. [2] Kato A, Yoshida K, Tsuru N, Ushiyama T, Suzuki K, Ozono S, et al. Spontaneous rupture of the urinary bladder presenting as oliguric acute renal failure. Intern Med 2006;45(13):815—8. [3] Huffman JL, Schraut W, Bagley DH. Atraumatic perforation of bladder. Necessary differential in evaluation of acute condition of abdomen. Urology 1983;22(1):30—5. [4] Kumar RV, Banerjee GK, Bhadauria RP, Ahlawat R. Spontaneous bladder perforation: an unusual management problem of tuberculous cystitis. Aust N Z J Surg 1997;67(1):69—70. [5] Chan DP, Abujudeh HH, Cushing Jr GL, Novelline RA. CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. Am J Roentgenol 2006;187(November (5)):1296—302.
Available online at www.sciencedirect.com