Presentation
Postpartum 1 week (unplanned home birth), presented with abdominal distention, lethargy, and shortness of breath. Gross hematuria when catheterized.
Patient Data
The urinary bladder is well-distended upon instillation of approximately 300ml dilute water-soluble contrast (1:10 concentration).
Intraperitoneal contrast extravasation from a small defect on the posterior body of the urinary bladder, filling the vesicouterine pouch up to the right paracolic gutter. No contrast extravasation within the retro or extraperitoneal spaces.
Clotted blood (attenuation 66HU) and Foley's catheter balloon are present in the urinary bladder.
Both kidneys enhance homogenously, with the contrast flowing smoothly within the pelvicalyceal systems and ureters. No hydronephrosis. No evidence of ureteric injury.
Free fluid with peripheral enhancement at the pelvic and lumbar region in keeping with urinoma.
The uterus is bulky without focal lesion, consistent with recent postpartum history.
Case Discussion
Isolated spontaneous intraperitoneal urinary bladder perforation following a normal vaginal delivery is rare, posing a great challenge not just to the clinicians in detecting it, also to the radiologists to utilize the proper modality to diagnose it preoperatively in a safe and timely manner. In this case, even though the patient's presentation had initially led the clinicians toward puerperal sepsis of other etiologies, it was the gross hematuria upon catheterization that had triggered the working diagnosis of spontaneous bladder rupture, enabling the radiologist to proceed with CT Cystography rather than just an IV contrast-enhanced study for a more conclusive finding.
The patient, unfortunately, self-discharged herself against medical advice, disallowing diagnosis confirmation.
Case courtesy of Dr Assyifaa binti Nik Mazian, Medical Lecturer and Radiologist, Universiti Sains Islam Malaysia (USIM).
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