Spontaneous bladder rupture diagnosis based on urinary appearance of mesothelial cells: a case report

Abstract

IntroductionSpontaneous bladder rupture is an extremely rare clinical event that is associated with urinary ascites and apparent acute renal failure. This event is difficult to diagnose clinically, even with advanced techniques such as computed tomography; however, the timely diagnosis of this condition is critical. Here, we report a case of a patient who experienced a spontaneous intraperitoneal bladder rupture 10 years after postoperative pelvic irradiation for the treatment of uterine cancer. In this report of a rare case, we describe the contribution of the appearance of mesothelial cells in the urine to the diagnosis of this condition.Case presentationOur patient was a 71-year-old Asian woman who experienced lower abdominal pain and vomiting of two days duration. On admission, abdominal computed tomography showed intraperitoneal fluid collection and her blood tests revealed acute renal failure and hyperkalemia. She underwent hemodialysis and a transurethral catheter was inserted. The transurethral catheter was removed three days after her admission. Four days after the catheter removal, her symptoms recurred and her serum creatinine and blood urea nitrogen levels were elevated. We noted the presence of mesothelial cells in her urine, which led to a diagnosis of intraperitoneal bladder rupture. She underwent surgical repair of her bladder and hyperbaric oxygen therapy, and was discharged after her renal function returned to normal.ConclusionUrine analysis is a simple and non-invasive test and we believe that a thorough urine analysis may contribute to the early diagnosis of an intraperitoneal bladder rupture. We think that the findings presented in this case report will significantly enhance our understanding of the etiology of bladder rupture. Moreover, these case findings may help nephrologists and urologists to rapidly diagnose this condition.

Pseudo-renal failure: bladder rupture with urinary ascites

“…Bladder rupture can occur following blunt trauma,7 irradiation to the pelvis,5 or surgical procedures,8 9 or may be spontaneous 10. Bladder rupture following binge alcohol drinking is multifactorial including increased urine volume causing bladder distention, decreased perception of desire to void and blunt trauma 11.…”

“…Therapeutic procedures also cause bladder rupture. Hayashi et al 5 described an elderly woman with spontaneous bladder rupture 10 years after pelvic irradiation for uterine cancer. Kim and Yang12 reported an elderly patient with delayed bladder perforation following radical TUR-BT for invasive urothelial cancer.…”

“…In patients with urinary ascites, the serum–urinary ascites albumin gradient will be >1.1 g/dL, because urine does not contain significant albumin. Mesothelial cells in urine cytology suggest the transposition of mesothelial cells from the peritoneal cavity to the urinary bladder 5. CT cystography is the most sensitive and accurate diagnostic test for bladder rupture.…”

“…The most common cause is urinary ascites, which occurs when upper or lower urinary tract rupture causes intraperitoneal urine leakage followed by reverse intraperitoneal dialysis of urine 5–10. Laboratory findings in urinary ascites closely mimic AKI, including elevated blood urea nitrogen, elevated creatinine, hyperkalaemia and metabolic acidosis,5 and the concomitant presence of ascites may suggest hepatorenal syndrome. However, kidney and liver function are maintained in this condition, and renal replacement therapy is not generally required 5.…”

“…Laboratory findings in urinary ascites closely mimic AKI, including elevated blood urea nitrogen, elevated creatinine, hyperkalaemia and metabolic acidosis,5 and the concomitant presence of ascites may suggest hepatorenal syndrome. However, kidney and liver function are maintained in this condition, and renal replacement therapy is not generally required 5. Management of rupture of the urinary system is the key to recovery.…”