Spontaneous urinary bladder rupture after cocaine use: early diagnosis with excretory-phase multidetector CT

Clinical History

Immigrant from Maghreb with unremarkable medical history, admitted to emergency department with abrupt onset of acute abdomen. Apyretic at physical examination with cutaneous sweating, stable vital signs, severe tenderness and peritonism on lower abdomen, blood-stained urine.
Increased white blood cell count (30000/mmc); C-Reactive Protein and serum creatinine within normal limits.

Imaging Findings

Thorax and abdomen plain radiographs (not shown) yielded inconclusive findings. On further questioning, he denied previous surgery, trauma, abdominal and urogenital disorders, but admitted recreational cocaine inhalation the day before. His clinical conditions rapidly worsened with severe abdominal pain and vomiting.
After bedside ultrasound (not shown) detection of ascites, contrast-enhanced multidetector CT (Fig.1) was performed four hours after initial admission. Diffuse fluid-attenuation peritoneal effusion was present, without appreciable lesions of the solid abdominal viscera. The urine-filled bladder showed minimal, uniform mural thickening along its anterior and right antero-lateral aspect.
Additional excretory-phase images (acquired because of noted haematuria) detected urine extravasation from a right paramedian focal discontinuity of the bladder dome, causing increased density of peritoneal cul-de-sac effusion.
Laparotomic surgery included drainage of 1 liter of urinary ascites, peritoneal cavity lavage, and suture of bladder dome rupture. Ten days later, at hospital discharge, radiographic cystography (Fig.2) confirmed successful bladder repair with absence of intra-abdominal contrast leakage.

Discussion

Non-traumatic spontaneous urinary bladder rupture (SUBR) is a rare surgical emergency, which may prove life-threatening when diagnosis and treatment are delayed or missed. In the vast majority of cases, SUBR occurs secondary to previous irradiation and inflammatory, neoplastic, or obstructive disorders including tuberculosis, chronic infections, diverticula, urothelial carcinoma, prostatic enlargement, or urethral stricture. Patients with augmentation enterocystoplasty, neurogenic bladder with long-term indwelling urethral or suprapubic catheters are at highest risk. Exceptionally SUBR without underlying bladder lesions may result from urinary retention during postpartum or alcohol intoxication [1-8].
Differently from traumatic bladder injuries which are mostly extraperitoneal, SUBR invariably communicates with the peritoneal cavity. Rupture may occur at the site of focal bladder disease, at the posterior wall with previous radiotherapy, anteriorly during puerperium, or at the bladder dome following binge alcohol drinking. Cocaine use has not been described as a cause for SUBR. However, in this case the site is typical for rupture seen in inebriated patients, and considering the context, the history and lack of alternative risk factors, cocaine use seems to be relevant. Typically, SUBR manifests with sudden pelvic pain, sometimes with hematuria, difficulty or inability to void, abdominal distension with diffuse tenderness. Unfortunately, SUBR represents an uncommon, challenging diagnosis with clinical findings suggesting peritonitis. Poorly symptomatic SUBR cases may go unrecognized in elderly patients [8, 9].
Resulting from either intravesical pressure or weakened bladder wall, urine leaking in the peritoneal cavity causes diffusion of urea and creatinine across the serosal membrane into the blood, ultimately biochemical abnormalities mimicking renal failure [2, 4-7].
In the past, SUBR was diagnosed on the basis of high creatinine levels in aspirated peritoneal fluid, and confirmed by conventional radiographic cystography showing extravasating iodinated contrast with accumulation in the peritoneal cavity [2, 5-7].
Whereas ultrasound is limited to confirmation of peritoneal effusion, currently multidetector CT is promptly used to investigate acute abdomino-pelvic complaints. As this case exemplifies, correct CT technique allows accurate identification of the focal bladder wall defect from which urine extravasates. Without excretory-phase acquisition confident diagnosis of SUBR is impossible and misinterpretation as ascites is the rule [8, 10].
In conclusion, although very rare SUBR should be considered in the differential diagnosis of lower abdominal pain with peritoneal effusion, particularly in patients with the above-mentioned risk factors including intoxication, and with associated complaints or laboratory changes hinting to the urinary tract. Prompt surgical repair is needed in most cases [4, 8].

Differential Diagnosis List

Final Diagnosis

Spontaneous urinary bladder rupture after cocaine use

URL:	https://eurorad.org/case/11235
DOI:	10.1594/EURORAD/CASE.11235
ISSN:	1563-4086