Bedside ultrasound diagnosis of atraumatic bladder rupture in an alcohol-intoxicated patient: a case report

Abstract

Most commonly, patients who present to the emergency department with a history and physical examination suggestive of urinary bladder rupture report a preceding traumatic event. Spontaneous atraumatic bladder rupture is relatively uncommon, but can occur in the context of a recent alcohol binge. The alcohol-intoxicated patient presents diagnostic and therapeutic challenges to the emergency physician (EP) that take on additional urgency given the high mortality of unrecognized bladder rupture. This case report reviews bladder anatomy, the unique physiological changes in the alcohol-intoxicated patient, and the high mortality rate of a ruptured urinary bladder. We review the historical diagnostic imaging options followed by a discussion of how bedside ultrasound could expedite diagnosis and management. We present the case of a patient with spontaneous atraumatic rupture of the urinary bladder after a recent alcohol binge. Bedside ultrasound was utilized by the EP to determine the need for emergent surgical consultation and intervention. We recommend that EPs consider bladder rupture in their initial evaluation of patients presenting with nonspecific abdominal pain in the context of recent alcohol intoxication. When using bedside ultrasound to evaluate the pelvis, the presence of anterior or posterior vesicular fluid collections, the loss of normal pelvic landmarks, or irregularities in the bladder wall may increase the EPs suspicion for this disease entity and expedite time-sensitive management.

Delayed diagnosis of intraperitoneal bladder perforation after blunt trauma

“…Daignault et al . remarked that intoxicated patients lose urinary sensation and the power to void resulting in urinary retention, which lead to over‐distention and a thinning bladder wall . The weakest site on the urinary bladder is the dome, and a sudden increase in intravesical pressure due to blunt trauma frequently results in intraperitoneal urinary bladder perforation.…”

Spontaneous bladder perforation unrelated to trauma or surgery

“…There has also been an increase in the number of patients with spontaneous rupture in non-diseased bladders due to binge alcohol consumption 8. While imaging modalities, including retrograde cystography, delayed CT cystography and CT retrograde cystography have been utilised to evaluate patients with suspected bladder injuries,9 it is often challenging to clinically diagnose a bladder perforation.…”

Spontaneous bladder rupture of a urinary bladder with non-muscle invasive bladder cancer

“…The commonest cause is overdistension, but this is unusual in the absence of a pre-existing bladder abnormality such as bladder inflammation, ulceration or fibrosis (caused by tuberculosis/radiotherapy) or secondary to malignant infiltration 1. Case reports have highlighted that spontaneous atraumatic bladder rupture can occur also in the context of alcohol intoxication whereby diuresis, the dampening effect of alcohol and the reduction in the urge to micturate can contribute to a sudden rise in intravesical pressure therefore increasing the risk of rupture 2 3. Other risk factors cited include previous pelvic radiotherapy,4 bladder diverticulum5 and a neurogenic bladder 6…”