JCU - January 2022 - 77

828556
URO
Journal of Clinical UrologyChen and Rukin
Case Report. Core urology
Extraperitoneal bladder perforation
secondary to urinary retention in a woman
Michael Y Chen1,2 and Nicholas J Rukin1
Journal of Clinical Urology
2022, Vol. 15(1) 77 -78
© British Association of
Urological Surgeons 2019
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DOI: 10.1177/2051415819828556
journals.sagepub.com/home/uro
https://doi.org/10.1177/2051415819828556
Case report
A 74-year-old woman presented to the emergency department
with an acute onset of lower abdominal pain and
inability to void for 12 hours. She had no previous urinary
symptoms and no history of urinary tract infections. She
denies any symptoms of fever or dysuria. She was catheterised
without difficulty and approximately 200 mL was
drained, but she had persistent tachycardia and lower
abdominal pain. A computed tomography (CT) scan was
performed showing extraperitoneal fluid anterior to the
bladder on the right (Figure 1). In view of the history, a CT
cystogram was arranged, demonstrating an extraperitoneal
bladder perforation (Figure 2). The patient had no history
of previous pelvic surgery, catheterisation, instrumentation
or any preceding trauma to the abdomen. She was managed
conservatively with catheterisation. A urine sample
cultured Escherichia coli and she was treated with appropriate
intravenous/oral antibiotics before being discharged.
A CT cystogram at 3 weeks demonstrated complete bladder
healing, and the catheter was removed without issue.
When reviewed in clinic at 6 weeks, she had made an unremarkable
recovery and a flexible cystoscopy showed no
evidence of malignancy.
Discussion
This case demonstrates an unusual presentation of an
extraperitoneal bladder perforation in a female patient
secondary to acute urinary retention which is likely to be
due to a urinary tract infection. We believe this to be first
female case reported in the literature secondary to retention.
Bladder perforation is commonly secondary to
trauma or iatrogenic injury, with gynaecological procedures
accounting for the majority of iatrogenic injuries.1
Diagnosis on an initial CT scan can be difficult without
a cystogram, but fortunately our radiologist had an index of
suspicion and arranged the cystogram confirming the diagnosis.
A review of traumatic bladder perforations found that
only 61% were correctly diagnosed on CT imaging alone.2
Figure 1. Initial non-contrast computed tomography scan
showing extraperitoneal fluid on the right of the bladder.
Cases of spontaneous perforation are often more challenging
to diagnose. Ahmed et al. (2009) reviewed 15 cases of
spontaneous bladder perforation and found that an accurate
preoperative diagnosis was only made in two cases.3 Their
review highlighted malignancy as a potential cause of
spontaneous perforation, with 11 cases(57.9%) of urothelial
carcinoma and eight cases (42.1%) of squamous cell
carcinoma of the bladder.3 Confirmation of diagnosis relies
on an index of suspicion and cystogram images (either
using image intensifier or CT) to determine if the perforation
is intra or extraperitoneal.
Urinary retention is a rare cause of atraumatic bladder
perforation, with all cases in the literature to date reported in
men.4 Spontaneous rupture is thought to occur due to
increased intravesical pressure or decreased bladder wall
strength. The literature supports a wide variety of causes
including alcohol, stroke, urachal cysts, cytomegalovirus
and tuberculosis.5 In this case, the patient's urinary retention
1Department of Urology, Redcliffe Hospital, Australia
2School of Medicine, University of Queensland, Australia
Corresponding author:
Michael Y Chen, Redcliffe Hospital, Queensland, 3/5 Sovereign St
Indooroopilly QLD 4068, Australia.
Email: michaelyuechengchen@hotmail.com
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JCU - January 2022

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