Intraperitoneal rupture of the bladder after urinary catheterization.

Intraperitoneal rupture of the bladder is a rare cause of peritonitis. Intraperitoneal rupture of the bladder was diagnosed during an emergency laparotomy for suspected mesenteric ischemia. The patient had undergone iterative urinary catheterization after a vascular bypass. The perforation was excised and sutured and the patient was catheterized for urinary rest for 15 days. Urinary catheterization is a possible cause of intraperitoneal rupture of the bladder.

Case Report

A 74-year-old man was admitted for acute stage IV lower limb ischemia. A right femoropopliteal bypass with transmetatarsal amputation was performed. After the operation, he presented with acute urinary retention requiring urinary catheterization, but pulled out the urinary catheter twice because of agitation due to alcoholic stop. For each procedure, a silicon Foley catheter sizing 18 French was placed by the nurses without reported difficulty. On postoperative day 5 (the day following the third urinary catheterization), he presented with acute abdominal pain. On physical examination, there was abdominal guarding with hypotension. His temperature was normal, urine output in the Foley was 200 mL and the blood parameters showed an acute inflammatory response (17000 leukocytes/mm3, C-reactive protein: 17.5 mg/L), with normal creatinine and elevated urea (10 g/L, 2N). Emergency laparotomy was performed for suspected acute mesenteric ischemia. The laparotomy revealed a peritoneal perforation of the urinary bladder, with concomitant urinary peritonitis. The intestine was healthy. The bladder had been perforated by the urinary catheter and there was neither diverticulosis nor tumor (Figure 1). The perforation was excised and the bladder closed with one layer resorbable sutures. The urinary culture was normal. The urinary catheter was left in place for 15 days, and the patient resumed normal urination after its removal. The pathological examination confirmed the absence of tumor and the patient is well after 6 months of follow-up.

Figure 1

Intra-peritoneal rupture of the top of the bladder due to the contact with the urinary catheter.

Discussion

Intraperitoneal perforation of the urinary bladder may occur in particular situations such as trauma, iatrogenicity (cystoscopy, prostatectomy), cancer, radiotherapy, infections or inflammatory lesions (cystitis, schistosomiasis, tuberculosis) and diverticulosis.[1] A few cases of idiopathic rupture that could have been related to the consumption of toxic substances (alcohol, drugs) have been reported. Few cases of rupture after urinary catheterization without other predisposing factors have been described in the literature.[2]

The diagnosis is challenging because the symptoms are not specific (pain, hematuria, oliguria), as well as blood parameters (inflammatory syndrome, renal insufficiency), leading to misdiagnosis and inappropriate or late treatment. The medical history of this patient with several successive urinary catheters may suggest this diagnosis (even if no traumatic difficulty was reported during the catheterization). Retrograde urethro-cystography or an abdominal computed comography scan with bladder opacification can establish the diagnosis and localize the site of rupture.[2,3]

The main factor for the therapeutic management is peritoneal rupture. Retroperitoneal rupture of the bladder is commonly treated with bladder catheterization for 10 days. The classical treatment for intraperitoneal rupture of the bladder is surgical repair and urinary rest (with a Foley catheter left in place for one week at least).[1-3] Laparoscopy is possible in this setting and this approach would have been chosen if the perforation was diagnosed in our case.[4] In selective cases (particularly in the absence of peritoneal signs), conservative management may be effective with a urinary derivation for 15 days.[2,3,5,6]

Idiopathic intra-peritoneal rupture of the bladder is difficult to diagnose due to the non-specific clinical picture. Despite it is widely performed, this procedure have potential risk of morbidity. Urinary opacification is the examination of choice when it is suspected. Conservative management may be sufficient in selective cases. Surgical treatment consists of bladder repair and a search for conditions that increase the risk of rupture (tumor, diverticulosis, infection).