自發性膀胱破裂之罕見案例報告及文獻分析

廖偉創、黃建勳、張彰琦、邱逸淳

臺北市立聯合醫院忠孝院區外科部泌尿科

Spontaneous rupture of the urinary bladder: case report and literature review

Wei-Chuang Liao, Chien-Hsun Huang, Yi-Chun Chiu, Chang-Chi Chang

Division of Urology, Department of Surgery, Taipei City Hospital, Zhongxiao Branch

Introduction

Rupture of the urinary bladder is a highly life-threatening emergent condition requiring prompt diagnosis and management. The majority of cases of bladder rupture are secondary to bladder injury or trauma, however, there is 3.4% of cases without history of trauma. Spontaneous rupture of the urinary bladder (SRUB) appears to be a relatively rare condition, with the incidence previously been described as 1:50000. We reported a rare case of SRUB in 57-year-old man presenting with lower abdominal pain and gross hematuria.

Case presentation

A 57-year-old man without prior history of trauma or urinary catheterization presented with lower abdominal pain, gross hematuria and acute urinary retention to emergency room within one day. Past medical history included spastic type cerebral palsy with quadriplegia and gastroesophageal reflux disease. Physical exam revealed abdominal rigidity with rebound pain and lower abdominal tenderness. Computed Tomography (CT) scan reported that large hyperdense mass within urinary bladder (UB), irregular intraperitoneal hyperdense lesion abutting to urinary bladder and moderate amount of ascites (Fig 1a). Emergent transurethral blood clots evacuation and cauterization for hemostasis were performed, however a defect was found at the posterior wall of the UB. Immediately, the patient underwent exploratory laparotomy and a bladder biopsy was collected from the rupture site to exclude any abnormal pathology. Then repair of the bladder wall defect was performed in 2 layers by running suture to confirm a water-tight closure (Fig. 1b). An indwelling urinary catheter was removed at postoperative 14 days. The histopathological findings were chronic inflammation and stromal fibrosis. He was discharged nursing home with a regular follow-up in the out-patient department.

Discussion

SRUB is defined as perforation or rupture of the bladder without trauma or direct stimulation [1]. The pathogenesis of SRUB has previously been attributed to a predisposition of compromised bladder wall integrity in combination with increased intravesical pressure and/or increased intra-abdominal pressure [2].

SRUB is often as­sociated with malignant disease, bladder outflow obstruction, neurogenic bladder, or combined factors [3]. A systemic review also identified that pelvic radiation and alcohol intoxication appear to be associated with an increased incidence of SRUB, and the dome of the bladder is the most vulnerable region [4]. The majority of symptoms were lower abdominal pain, followed by gross hematuria, abdominal distention and difficulty in voiding, acute urinary retention, nausea and vomiting [4]. In this present case, intraperitoneal blad­der rupture was diagnosed by CT scan and required immediate exploratory laparotomy and suturing of the urinary bladder dome. Neurogenic bladder combined with bladder outflow obstruction may be attributed to the etiology of urinary bladder rupture.

Conclusion

In conclusion, spontaneous bladder rupture is a rare event with ambiguous clinical manifestations. Patients with ascites and acute onset of lower abdominal pain should have this diagnosis excluded, especially those with urinary symptoms, such as difficulty in void and gross hematuria. Moreover, early recognition is important for prompt management, which eventually minimizes the morbidity and improves prognosis.