A Rare Case of Recurrent Generalized Peritonitis Caused by Spontaneous Urinary Bladder Rupture after Radiotherapy: A Case Report and Literature Review

Since generalized peritonitis is a fatal disease, accurate diagnosis and treatment are important. In this paper, we report a case of recurrent generalized peritonitis associated with spontaneous urinary bladder rupture (SBR). A 65 year old woman, who underwent radiotherapy 21 years prior, was diagnosed with generalized peritonitis. Although the cause of the generalized peritonitis could not be identified, the patient recovered with conservative treatment in short period. However, recurrent episodes of generalized peritonitis occurred four times. We diagnosed the patient with urinary ascites due to SBR, based on a history of radiotherapy and dysuria. No recurrence of generalized peritonitis had occurred after accurate diagnosis and treatment with long-term bladder catheter placement. Since SBR often occurs as a late complication after radiotherapy, it is difficult to diagnose SBR, which leads to delayed treatment. This case and literature review of similar cases suggest that the information of the following might be helpful in the diagnosis of SBR: (i) history of recurrent generalized peritonitis, (ii) pseudo-renal failure, (iii) history of radiotherapy, (iv) dysuria, and (v) increase or decrease of ascites in a short period. It is important to list SBR in the differential diagnosis by knowing the disease and understanding its clinical features. This case and literature review will serve as a reference for future practices.

Intraperitoneal Bladder Injury – A Conservative Approach

Iatrogenic bladder injuries with Intra-peritoneal extravasations are standardly managed surgically. However, we are presenting a case of iatrogenic intra-peritoneal bladder injury which developed after an emergency caesarean section that was managed successfully by conservative therapy. The trial of conservative approach may prove beneficial to minimize the chances of any invasive interventions in such cases. Bladder injuries are of two types namely intra-peritoneal and extra-peritoneal. Of which, extra-peritoneal is most common type.1 Bladder laceration happens during separation of bladder from uterine cervix during caesarean sections and abdominal hysterectomies.2 Usually bladder injuries are identified intra-operatively and managed on table. If diagnosis is made post-operatively, then management becomes challenging due to non-specific clinical features, exposure to radiation, sepsis due to urinary extravasation and prolonged hospital stay, psychological stress to both patient and surgeon. The clinical features suspicious of bladder injury are abdomen distension, urinary ascites, blood-stained urine, abdominal pain, paralytic ileus, fever and deranged renal parameters.3 Extra-peritoneal and intra-peritoneal bladder ruptures are treated differently. According to American Urological Association (AUA) guidelines, Intraperitoneal bladder injury needs surgical repair. There are limited case reports in literature about conservative management of small intra-peritoneal bladder lacerations. This is a case report of one such intra-peritoneal bladder injury treated with non-operative approach.

Urinary ascites in a neonate with posterior urethral valve

Urinary ascites in a newborn is an extremely rare condition, most commonly due to posterior urethral valves, due to transmission of high intravesical pressure to calyceal fornices, and subsequent urinary ascites either by calyceal perforation or filtration through walls of urinary tract and their rupture. We describe a newborn male baby, who presented with huge abdominal distension at birth, and diagnosed as urinary ascites on paracentesis. Baby was asphyxiated and required resuscitation at birth, and ventilatory support for 4 days in v/o significant abdominal distension. Micturating cystourethrogram (MCUG) and magnetic resonance imaging (MRI) showed posterior urethral valves. Baby also had a left sided urinoma and grade 4 vesicoureteral reflux (VUR) on MCUG. Post paracentesis and drainage of 400ml of ascetic fluid, and urinary catheterization, baby had significant improvement of deranged renal parameters, and diuresis, and could be weaned from ventilation. In v/o inability to negotiate a urethroscope, a vesicostomy was done for urinary drainage and fulguration of valves planned on follow-up.