Presentation
Two-day history of macroscopic hematuria following self-catheterization for atonic bladder. Mild suprapubic tenderness but soft abdomen without signs of peritonism.
Patient Data
Thickened urinary bladder wall with surrounding fat stranding. An irregular 4.4 x 4.1 x 4.6 cm fluid collection is on the left.
A large left bladder diverticulum and smaller right diverticulum with leak of contrast.
Contrast instilled into the bladder via an indwelling catheter with leak into left and right bladder diverticulae. No gross contrast extravasation beyond here.
Case Discussion
This 75-year-old male has a past medical history of chronic recurrent benign prostatic hyperplasia despite multiple resections of prostatic tissue. He had been performing self-catheterization for two years without complications this far.
He proceeded to the operating theater for flexible cystoscopy, which revealed a small bladder wall perforation in the right bladder diverticulum. Due to its extraperitoneal nature, it was treated non-operatively.
Rupture of bladder diverticula can be traumatic/atraumatic and intra/extraperitoneal. Although traumatic rupture is rare (<1% of all bladder injuries), it is life-threatening with mortality approaching 50%. There is variability in clinical presentation and, even with modern medical imaging, diagnosis can be challenging. Cases have been reported from vaginal birth, malignancy, radiation, infection and urinary retention.
CT cystography is the gold standard of imaging; however, occult perforation and bladder wall contusion can be difficult to detect - as was the case with this patient. If there are clinical risk factors (e.g. dysfunctional voiding, chronic prostatic hyperplasia) and equivocal evidence of bladder perforation from imaging the patient should proceed to diagnostic cystoscopy.
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