An unusual cause of abdominal distension: intraperitoneal bladder perforation secondary to intermittent self-catheterisation

Abstract

SUMMARYWe report a strikingly unusual case of traumatic intraperitoneal perforation of an augmented bladder from clean intermittent self-catheterisation (CISC), which presented a unique diagnostic challenge. This case describes a 48-year-old T1 level paraplegic, who had undergone clamshell ileocystoplasty for detrusor overactivity, presenting with abdominal distension, vomiting and diarrhoea. Initial investigations were suggestive of disseminated peritoneal malignancy with ascitic fluid collections, but the ascitic fluid was found to be intraperitoneal urine from a perforation of the urinary bladder. This was associated with an inflammatory response in the surrounding structures causing an appearance of colonic thickening and omental disease. Although the diagnostic process was complex due to this patient's medical history, the treatment plan initiated was non-operative, with insertion of an indwelling urinary catheter and radiologically guided drainage of pelvic and abdominal collections. Overdistension perforations of augmented urinary bladders have been reported, but few have described perforation from CISC. BACKGROUND

Cystoscopically Guided Repair of a Posterior Perforation of Augmented Bladder

“…The presentation of these cases can vary from nausea with vomiting, diffuse abdominal pain to shoulder pain from peritonitis. 3 It is imperative that clinicians have a high index of suspicion and treat abdominal pain with distention, nausea, vomiting, or fever in a patient with history of augmentation as a perforation until proven otherwise. This is especially important given the historical unreliability of the plain film cystogram in patients who have undergone augment given the redundancy of the bowel and the occasional increased capacity.…”

“…There are several reports of patients who have been effectively managed nonoperatively 2,3 ; however, the standard of care remains exploratory laparotomy with identification and repair of the defect, large volume irrigation, and drain placement. Opening the augmented bladder to inspect from the inside out is an alternative approach in cases where the defect cannot be readily identified but carries the risk of impaired healing from ischemia.…”

“…Risk factors for perforation have been examined and behavioral factors have been implicated, with the highest level of concern in patients with substance abuse and other mental disorders. 3 It is, therefore, imperative that these patients receive regular counseling and follow-up for reiteration of the risks associated with catheter noncompliance.…”

Urinary bladder rupture secondary to indwelling catheterisation: two case reports

“…Presentation with acute abdomen and peritonitis is rare, as many patients are chronically debilitated with impaired sensation. [10][11][12] The cardinal sign of gross haematuria is uncommon, especially in the first 24 to 36 hours of rupture. 9,13,14 Signs of progressive abdominal distension with anuria, or frank discrepancy between bladder irrigation balance should prompt further investigations.…”

Pneumoperitoneum and peritonitis secondary to perforation of an infected bladder

“…Spontaneous urinary bladder rupture is a rare complication of urosepsis [ 1 , 2 ]. Catheterization or indwelling catheter may also be a risk or contributing factor for bladder rupture [ 1 , [3] , [4] , [5] , [6] , [7] , [8] ]. Among the other associated complications with bladder perforation, the occurrence of pneumoperitoneum is very unusual [ 2 , [4] , [5] , [6] , 9 , 10 ].…”