獨自的創傷性腹膜內膀胱破裂：個案及文獻回顧

廖凡霆、曹書瀚、陳建綸、林友翔、侯鎮邦、蔡翰宇、陳昱廷

林口長庚紀念醫院外科部泌尿科

Traumatic Isolated Intraperitoneal Bladder Rupture: A Case Report and Literature Review

Fan-Ting Liao, Shu-Han Tsao, Chien-Lun Chen, Yu-Hsiang Lin, Chen-Pang Hou, Han-Yu Tsai, Yu‑Ting Chen

Division of Urology, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan

Purpose:

Traumatic bladder injury is a rare occurrence, and isolated intraperitoneal bladder rupture (IIBR) related to blunt abdominopelvic trauma is even less common. We present a unique case of isolated intraperitoneal trauma in a female who abused hypnotic drugs, following a low-impact fall without pelvic fracture or other organ injuries.

Presentation of Case:

        A 21-year-old female has medical history of single episode of depression with auditory hallucinations, suspecting schizophrenia. An Affective stressor, a breakup, resulted in recurrence of depression with insomnia and suicidal ideations. The patient was recently admitted to local hospital’s ER for gastric lavage due to overdose of hypnotic and muscle relaxant. Days later, the patient had a falling incident and suffered from suprapubic impaction. Subsequent low abdominal pain and difficult voiding were noted. Physical examination showed drowsy conscious with E4V5M6, mild confusion, and bilateral low abdominal tenderness with rebounding tenderness. First aid at local hospital where CT revealed massive intra-abdominal fluid accumulation and intraperitoneal bladder wall disruption. The patient was then referred to our emergency department. Upon arrival, stable vitals without shock or fever were observed at triage. Lab results showed leukocytosis with WBC 19.7*1000/uL with left shift, elevated blood urea and acute kidney injury with Cr 6.66. Urine analysis showed microscopic hematuria and borderline pyuria. Foley catheter was inserted for urine drainage, and empirical Ceftriaxone was administered to cover intra-abdominal urine leak related peritonitis.

The patient underwent low mid-line exploratory laparotomy, revealing a 4cm rupture wound on the urinary bladder dome. Necrotic and poor tissue quality were noted at edge of rupture and were trimmed. Cystorrhaphy was then performed by 2-layer suture. Normal saline gravity filling to 300ml showed no obvious leakage. A Jackson-Pratt drain was positioned at Cul-de-sac. Post-operative recovery was smooth, and drainage removed at post-operative day 4. The patient was discharged on the same day with take-home Foley catheter. Cystography was arranged on outpatient department follow up with no evidence of leakage. The patient recovered fully with normal voiding and absence of lower urinary tract symptoms.

Discussion:

Traumatic bladder injury is uncommon in clinical practice, with a low overall incidence of 1.6% in blunt abdominopelvic trauma. Bladder trauma is further classified as extraperitoneal (22.4-66.1%) and intraperitoneal (38.9-65.8%), with varying incidence across series. Intraperitoneal bladder rupture (IBR) is typically caused by blunt trauma to the low abdomen, with common mechanisms being motor vehicle accidents, falls from height, and direct blows to the lower abdomen. Isolated intraperitoneal bladder rupture (IIBR) has an even lower incidence with absence of associated injuries to adjacent organs or structures.

Clinical presentation may be insidious and initially neglected by the patient at the time of insult. Mokoena and Naidu (1995, British Journal of Surgery) demonstrated a mean delay in diagnosis by 5.4 days due to initial unspecific presentations. Common presentations include low abdominal pain, hematuria, and difficult voiding. Early recognition and prompt surgical repair of IIBR are important to prevent development of more severe consequences such as peritonitis, sepsis, urinary ascites, uremia, and increased serum creatinine. Standard diagnostic imaging for IIBR would be computed tomography (CT).

Definite treatment involves surgical repair of bladder rupture, typically with open surgery. Case report have shown possible successful laparoscopic repair. Overall outcome is favorable if prompt intervention, with low rates of mortality and morbidity.

Conclusion:

Isolated intraperitoneal bladder rupture (IIBR) is a rare but potentially serious condition that requires prompt diagnosis and intervention. Diagnostic imaging should be performed for patients with a high level of suspicion for urinary tract injury despite vague presentations. Timely repair of IIBR often results in excellent clinical outcomes.