Spontaneous rupture of the urinary bladder

Last revised by Daniel J Bell on 7 Jul 2021

A spontaneous rupture of the urinary bladder is usually on a background of a pre-existing pathology and is a urological emergency.

For a general discussion of the perforation of the urinary bladder, please refer to the article on urinary bladder rupture.

Intraperitoneal bladder tears account for approximately 10%–20% of bladder injuries, extraperitoneal bladder tears constitute approximately 80%–90% of all bladder tears and combined extra and intraperitoneal 12% 1,2.

Spontaneous urinary bladder perforation is rare, making up less than 1% of all bladder injuries, with an overall mortality rate around 50% 2,3.

Bladder perforations occur most frequently due to abdominal trauma but maybe iatrogenic or spontaneous 1,4. The anatomical types of bladder tears are extraperitoneal, intraperitoneal, or combined intra and extraperitoneal 1,5. Spontaneous rupture of the urinary bladder is usually intraperitoneal 1,5

Signs and symptoms of spontaneous bladder rupture are commonly non-specific and vague, often delaying diagnosis and treatment 3,5. Therefore, It must be considered in patients with suspected acute abdomen, intraperitoneal free fluid, and a disproportionate rise in serum creatinine and urea levels, even in the absence of classical features of bladder rupture 5.

Most patients present with a complaint of diffuse pelvic pain, tenderness, distension, dysuria, hematuria, difficulty voiding, renal failure, urinary ascites, and sepsis 3. The diagnosis requires a high index of suspicion 4.

Appropriate techniques includes retrograde cystography, ultrasonography, CT, and CT cystography 1,4,5. Ultrasound may reveal peritoneal/pelvic fluid 4, and retrograde cystography does not provide information about surrounding pelvic structures, as CT cystography, which is the investigation of choice in this condition 1,2,4.

In the case of intraperitoneal rupture, CT of the abdomen/pelvis and CT cystogram usually shows the free fluid in the peritoneum, a defect/rupture in an enhancing bladder wall, and abnormal location of a Foley catheter 1. In addition, identifying the contrast medium outside the limits of the bladder in the peritoneum and between the intestinal loops confirms diagnosis 1. In extraperitoneal rupture, the contrast extravasation is around the bladder - in the perivesical space - and occasionally, it extends beyond the perivesical space to the thigh, scrotum and perineum 1.

Intraperitoneal and combined ruptures usually require surgical repair 1,4. Extraperitoneal perforations may be managed non-operatively with a Foley catheter 1.

In 1929, Sisk and Wear were the first to use the term spontaneous rupture of the urinary bladder 4.

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Cases and figures

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