Bladder necrosis and perforation in end-stage renal disease and recurrent urinary tract infection: A rare medical emergency.

Bladder necrosis and perforation is a rare and life-threatening medical emergency. Risk factors include trauma, malignancy, previous surgery and/or radiation therapy and diabetes mellitus. Signs, symptoms, and imaging findings are often obscure making the diagnosis difficult. Urinary tract infection is common in end-stage renal disease (ESRD) patients who have residual urine production and associated with increased complication and mortality rates. We describe the case of a 57-year-old female with a medical history of recurrent cystitis, type 2 diabetes mellitus and ESRD on hemodialysis that was admitted for septic shock and presumed ischemic colitis. Urine and blood microbiology studies were notable for Escherichia coli. By the second day of hospital admission, her clinical condition significantly deteriorated and was later found to have bladder necrosis and rupture during laparotomy for suspected peritonitis. It is important that clinicians recognize bladder rupture as a potential complication of recurrent bacterial cystitis in ESRD patients on dialysis.

INTRODUCTION

Bladder necrosis and subsequent rupture is a rare and life-threatening medical emergency.[123] Bladder rupture leads to peritonitis, often diagnosed during surgery and associated with a very high mortality rate.[1] Risk factors include trauma, bladder malignancy, pelvic radiation therapy, previous bladder surgery, and diabetes mellitus.[4] Signs, symptoms, and imaging findings are often obscure and nonspecific making the diagnosis difficult.

Urinary tract infection (UTI) is common in end-stage renal disease (ESRD) patients who have residual urine production.[5] Infections in ESRD patients on dialysis are associated with increased rates of complications and mortality due to immunosuppression.[6] Bladder necrosis and perforation from recurrent UTI in a patient with ESRD has rarely been reported in the literature. This case is structured and reported according to the CARE guidelines and format for reporting of clinical cases.

CASE REPORT

A 57-year-old female with a medical history of hypertension, recurrent cystitis, type 2 diabetes mellitus and ESRD on hemodialysis (3 sessions/week) was brought into the emergency room of an academic hospital. She was apparently in her usual state of health until about 12 h prior to presentation when she was found lethargic and barely conscious. Her medical chart history revealed previous hospital admissions for recurrent UTI and bacteremia. Her last hemodialysis session was 2 days before presentation. Her vital signs were temperature of 95.5F, heart rate 102 beats per minute, respiratory rate 10 cycles per minute, and blood pressure 76/55 mmHg. Other physical examination was remarkable for soft abdomen with mild distension and trace pedal edema. It was difficult to assess for rebound tenderness due to her nearly unconscious state. She was intubated due to concerns for airway protection and admitted to the medical intensive care unit (MICU).

Laboratory findings [Table 1] showed leukocytosis, normocytic anemia, lactic acidosis, and elevated serum creatinine levels. Her hemoglobin A1C level was 6.1%. Arterial blood gas levels were normal. Urinalysis was positive for bacteria, leukocyte esterase, and nitrites. Abdominopelvic computed tomography (CT) scan showed extensive small and large bowel thickening without evidence of obstruction or perforation [Figure 1]; thickening and irregularity of the bladder wall [Figure 2] and mild ascites. Similarly, her abdominopelvic CT scan 1 year prior showed circumferential thickening of the bladder wall consistent with chronic cystitis. Chest X-ray and brain CT scan were normal. She was initiated on intravenous (IV) fluids, empiric wright-based IV antibiotics (Vancomycin and Tazobactam/Piperacillin), norepinephrine for septic shock, and continuous renal replacement therapy for ESRD.

Table 1

Patient’s blood laboratory parameters at presentation and during hospital admission

Tests	Results		References
	Hospital day 1	Hospital day 2
Hemoglobin	10.3 g/dL	9.7 g/dL	11.2-15.0 g/dL
Hematocrit	33.4%	32.0%	34.1-44.9%
MCV	95 fL	97%	81-99 fL
White blood count	15.2 K/mcL	15.2 K/mcL	4-11 K/mcL
Platelet count	328 K/mcL	338 K/mcL	140-440 K/mcL
Serum sodium	137 mmol/l	140 mmol/l	136-145 mmol/L
Serum potassium	4.1 mmol/l	3.6 mmol/l	3.6-5.1 mmol/L
Blood glucose	108 mg/dL	166 mg/dL	70-125 mg/dL
Serum blood urea nitrogen	35 mg/dL	36 mg/dL	8-23 mg/dL
Serum creatinine	6.1 mg/dL	5.4 mg/dL	0.5-1.2 mg/dL
Serum CO2 content	25 meq/L	10 meq/L	22-32 meq/L
Albumin	1.9 g/dL	<1.5 g/dL	3.5-5.0 g/dL
Serum creatine phosphokinase	442 U/L	U/L	38-234 U/L
Alanine transaminase	31 U/L	75 U/L	0-33 U/L
Aspartate transaminase	U/L	299 U/L	0-33 U/L
Total bilirubin	1.1 mg/dL	1.1 mg/dL	0.3-1.2 mg/dL
Brain natriuretic peptide	330 pg	NC	<78 pg
Lactic acid	4.5 mmol/L	5.2 mmol/L	0.5-2.2 mmol/L

Figure 1

Computed tomography scan of the patient's Abdomen and pelvis. (a) Extensive thickening (red lines) of bowel loops consistent with colitis. (b) Hyperenhancement of the bladder mucosa with thickening and irregularity of the bladder wall (red ring), suggestive of cystitis

Figure 2

Computed tomography scan of the patient's Abdomen and pelvis showing circumferential thickening of the bladder wall (red line) consistent with cystitis (1 year before presentation)

The general surgery team was consulted for evaluation possible complicated ischemic colitis based on the abdominal CT findings. The surgical team however made a presumptive diagnosis of ischemic colitis with bacteremia and felt there was no acute surgical intervention warranted in the absence of objectively evident peritonitis. On the second day of admission in the MICU, her clinical condition had severely deteriorated. She was persistently febrile, tachycardic and requiring more doses of norepinephrine to maintain her mean arterial pressure above 65 mmHg. Her abdomen was more distended and laboratory parameters significantly worsened [Table 1]. Blood and urine microbiology studies also resulted for Escherichia coli. At this point, she was taken to the operating room for urgent exploratory laparotomy for suspected peritonitis from colon ischemia.

Interestingly, laparotomy revealed a necrotic and ruptured bladder wall with free fluid in the abdominopelvic cavity without bowel ischemia or perforation. She subsequently had partial cystectomy. The pathologic analysis confirmed bladder tissue inflammation and necrosis without malignancy. Patient's family decided to withdraw life support treatment and care on postoperative day 4 due to a poor prognosis and she died 11 h later.

DISCUSSION

Atraumatic bladder rupture is rare and a medical emergency. Few cases of tuberculous and candida cystitis leading to bladder rupture have been described,[789] however, to the best of our knowledge, this is the first reported case of bladder rupture from recurrent bacteria cystitis in a patient with ESRD. Although UTIs are commonly encountered in hospitalized chronic dialysis patients, Candida is the most frequently observed pathogen.[10] Chronic and recurrent cystitis lead to inflammatory changes in the bladder with progressive weakening of the bladder wall and subsequent perforation. Our patient also had diabetes (optimally controlled) and ESRD (receiving hemodialysis), two conditions that predispose to recurrent UTIs.[11] No other risk factors for bladder perforation were identified in this case. Although the management of dialysis patients with UTI is similar to those without renal failure, antimicrobials should be tailored to cultured organisms and renally dosed.

Spontaneous bladder rupture with peritonitis typically presents with fever, abdominal pain, nausea, vomiting, and inability to pass stool or gas.[12] Furthermore, abdominal and pelvic CT scan studies usually demonstrate free fluid in the peritoneal cavity, with nonspecific bladder findings ranging from distension and thickness to irregularities and defects in the bladder wall.[112] The diagnostic imaging of choice is CT cystography which has now replaced the conventional cystography due to the usual complexity of the injury and wide spectrum of findings.[1314] Timely and appropriate diagnosis of bladder rupture often requires a high index of suspicion.

This case was more clinically challenging because our patient did not report any of the usual peritonitis symptoms. She was severely lethargic and had septic shock at presentation. Similar cases in the literature have also highlighted the atypical presentation, and diagnostic dilemma often encountered in spontaneous or atraumatic urinary bladder rupture.[15] Kivlin et al.[12] described two patients with nonspecific abdominal symptoms on presentation with progression to altered mental status and were eventually diagnosed with urinary bladder rupture through CT cystography, In addition, Limon et al.[16] described a case of a middle-aged woman with diabetes mellitus who presented with abdominal pain without urinary symptoms and was later found to have bladder rupture during laparotomy. The misdiagnosis rate of urinary bladder rupture is more than 50% and mortality from late diagnosis and intervention is close to 50%.[1617]

Our patient's abdominal and pelvic imaging findings at presentation were more consistent with ischemic or infectious colitis, without indication of peritonitis which made a preoperative diagnosis difficult. Retrospectively, her history of recurrent cystitis with chronic bladder inflammatory changes noted on her pelvic CT scan and evidence of sepsis at presentation should have prompted further evaluation with CT cystography for possible bladder necrosis and perforation.

CONCLUSION

The prognosis of bladder rupture is very poor, and early diagnosis may improve mortality outcomes. The diagnosis could be very difficult even with appropriate imaging study and more challenging with an atypical presentation as in this case. Although our patient's history of diabetes mellitus and ESRD at baseline likely contributed to her poor postoperative course; early intervention is still desired. It is important that healthcare providers, particularly acute care and emergency physicians have a high index of suspicion and recognize spontaneous bladder rupture as a potential complication of recurrent bacterial cystitis in ESRD patients on dialysis. Patients with ESRD who develop bacterial cystitis should be adequately treated to prevent recurrence and possible urinary bladder rupture.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. The patient's family signed the consent form for her clinical information and images to be reported and potentially published. The patient's family understand that patient's names and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.