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Trauma Case Rep
Trauma Case Rep
Trauma Case Reports
2352-6440
Elsevier

S2352-6440(24)00133-X
10.1016/j.tcr.2024.101110
101110
Case Report
Delayed bladder rupture following blunt trauma: A case report and literature review
Trang Vo Anh Vinh a
Le Nguyen Hai Dang a
Nguyen Dai Thanh Sang b
Duong Phuc Hai a
Truyen Thien Tan Tri Tai thien.truyen@cshs.org
c⁎
Do Vu Phuong a
a Pham Ngoc Thach University of Medicine, Ho Chi Minh, Viet Nam
b Department of Urology, Binh Dan Hospital, Ho Chi Minh, Viet Nam
c Tan Tao University, Long An, Viet Nam
⁎ Corresponding author at: School of Medicine, Tan Tao University, Long An, Viet Nam. thien.truyen@cshs.org
13 9 2024
12 2024
13 9 2024
54 10111012 9 2024
© 2024 The Authors. Published by Elsevier Ltd.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Delayed bladder rupture, rare condition following trauma, can result from primary laceration or secondary rupture at the lesion site in the bladder wall. Delayed treatment increases mortality. We report the case of a 43-year-old female who presented with an 8-day history of blunt trauma and a 2-day abdominal discomfort. After using point-of-care ultrasound for abdominal paracentesis to confirm the diagnosis, the patient was transferred to the operating room to suture the ruptured bladder. After nine days, she was discharged free of symptoms. This case report and literature review stress the importance of prompt and appropriate intervention for delayed bladder rupture.

Highlights

• Delayed bladder rupture is a rare condition, with only 8 cases reported in the existing literature.

• Delayed bladder rupture should always be considered in patients with a history of independent urination following.

• Patient with delayed bladder rupture suddenly presents with abdominal pain and increased serum creatinine.

• With prompt intervention, the outcome of delayed bladder rupture is favorable.

Keywords

Delayed bladder rupture
Abdominal injuries
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pmcIntroduction

Bladder rupture, a relatively rare condition, is most commonly due to abdominal or pelvic trauma but may be spontaneous or iatrogenic in association with surgical or endoscopic procedures. The cardinal sign of injury to the bladder is gross hematuria, which is present in more than 95 % of cases, while only about 5 % of the patients have microscopic hematuria alone [1]. Clinicians can quickly diagnose and treat bladder injuries when typical clinical signs are present. However, patients with atypical symptoms and significantly delayed bladder rupture may be misdiagnosed, potentially impacting treatment efficacy. We presented a rare case of delayed intraperitoneal bladder rupture resulting from blunt trauma. In this case, because of the near-sepsis condition and hemodynamic instability, we use point-of-care ultrasound and abdominal paracentesis to confirm the diagnosis of bladder rupture. The patient was successfully treated with laparoscopic to suture the bladder rupture, along with medical management, including intravenous fluid, IV antibiotics, and symptomatic controls. She was discharged nine days after hospitalization. This case report and literature review highlight the importance of early detection and management in patients with delayed bladder, aiming to enhance outcomes and reduce mortality rates.

Case presentation

A 43-year-old female presented at our Emergency Department complaining of an acute generalized abdominal pain. Eight days ago, the patient was hit by a motorbike, resulting in a closed left tibial plateau fracture. The patient underwent bone fusion surgery and was discharged after four days without any complications. The patient could urinate independently after the injury, and routine urine analysis showed no obvious abnormalities. Two days ago, the patient experienced hypogastric discomfort accompanied by urinary retention. One hour before admission, the patient felt severe bladder retention and then heard a “poof” sound from her abdomen, which relieved the bladder retention but caused generalized abdominal pain. At admission, the patient reported a sudden, constant, dull pain in the lower abdomen, along with a gradually distending abdomen. Physical examination revealed a pulse of 110 beats per minute, blood pressure of 80/60 mmHg, oxygen saturation of 92 %, and a respiratory rate of 22 breaths per minute. Laboratory tests showed elevated white blood cells (17.55 K/uL) with 91.6 % neutrophils, elevated creatinine (331 umol/L), and high potassium (6 mmol/L). Urinalysis results indicated significant hematuria (+++). No abnormal findings were found on the abdominal X-ray. A point-of-care ultrasound (POCUS) revealed large amounts of abdominal fluid (Fig. 1). Subsequently, abdominal paracentesis showed a yellow-like urine fluid, increasing creatinine levels (1383 umol/L) and urea (44.4 mmol/L) (Fig. 2).Fig. 1 The point-of-care ultrasound demonstrated a substantial volume of free fluid was present in Morison's and Douglas's pouch (yellow arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 1

Fig. 2 A yellow urine-like fluid drainage through ultrasound guidance for abdominal paracentesis. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

The patient was diagnosed with generalized peritonitis due to a late bladder rupture and underwent exploratory laparoscopic surgery. During the surgery, approximately 2.4 L of clear yellow fluid was suctioned from the abdomen, and a hole about 2x3cm in size with rough edges was found at the top of the bladder (Fig. 3). The surgical team decided to biopsy the edge of the perforation and suture it with two-layer Vloc 3.0 sutures, placing an abdominal drain at Douglas. Post-surgery, the patient received intravenous antibiotics, fluids, and painkillers. On the first postoperative day, kidney function and potassium levels returned to normal, and abdominal fluid culture results showed no bacteria. Postoperative pathology results indicated acute cystitis. A follow-up ultrasound on the fourth postoperative day revealed no abdominal fluid. The drainage tube was removed on day five, and the patient was discharged on day nine in stable condition with average laboratory results. A two-week follow-up showed an asymptomatic patient without signs of recurrence or complications.Fig. 3 Laparoscopic surgery revealed a linear contusion measuring 3 cm in length in the bladder dome (yellow star) (3 A) and the bladder lesion after suture with Vlok 3.0 (3B). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

Discussion

Extraperitoneal bladder ruptures are primarily associated with pelvic fractures, accounting for around 80 % of significant bladder ruptures, while intraperitoneal ruptures make up about 15 % [2]. The clinical presentation of delayed bladder rupture includes gross hematuria, abdominal distension, abdominal pain, peritonitis, ileus, sepsis, urine leakage from the wound, decreased urinary output or increased serum creatinine mimicking acute renal failure [3]. Delayed bladder rupture following trauma may result from the masking of a primary laceration or the development of a secondary rupture at the site of a hematoma or another lesion in the bladder wall. This condition is rare, with only eight cases reported in the current literature (Table 1) [1,[4], [5], [6], [7], [8], [9]]. Of these, the male-to-female ratio was 1:1. Hematuria and abdominal pain were the most frequently reported symptoms, while other symptoms included urinary retention, abdominal distention, nausea, and vomiting. Treatment delays varied from 3 to 28 days, with an average delay of about 11. Most ruptures were intraperitoneal, predominantly in the dome and anterior regions, with only one extraperitoneal case. Surgical interventions were the primary treatment methods, with laparotomy and suturing being the most common approaches. Additionally, suprapubic exploration and drainage were employed in some instances. The follow-up results were overwhelmingly positive, with most patients experiencing uneventful recoveries. With high sensitivity and specificity, conventional retrograde cystography and CT cystography are commonly used for clinical bladder injury detection [10]. However, in an urgent case when the patient has unstable vital signs, POCUS combined abdominal paracentesis can be used as an effective modality for assessing acute abdominal conditions, particularly in a traumatic condition [11]. It represents a substantial time-saving tool that allows for timely diagnosis and prompt initiation of treatment.Table 1 Literature review of previous cases report.

Table 1First author, year, country	Patient sex, age	Main symptoms	Vital sign	Delayed days	Imaging modality	Location of laceration	Treatment methods	Follow-up results	
Turnbull et al., 1978, England [4]	M, 42	Urinary retention	NA	16	Cystourethrography	IP, Anterior	Suprapubic exploration, drainge	Void satisfactorily	
Turnbull et al., 1978, England [4]	F, 60	Hematuria	NA	28	Cystoscopy	IP, Left side	Suprapubic exploration, suture	No further urinary problems	
Brown et al., 1986, United States [5]	F, 3	Abdominal pain, vomiting	Stable	10	CT cystography	IP, Dome	Laparotomy, suture	Uneventful	
Laufik et al., 2004, United States [6]	F, 17	Gross hematuria	NA	8	Cystogram	EP, Neck	Bladder catheter drainage	Uneventful	
Alhamzawi et al., 2012, Qatar [7]	M, 23	Abdominal pain, gross hematuria	Stable	3	Cystogram	IP, Dome	Laparoscopic, suture	Uneventful	
Dat et al., 2016, Australia [8]	M, 54	Acute abdomen, ascites	NA	14	CT abdomen	IP, Dome	Laparotomy, suture	Uneventful	
Moonen et al., 2022, Netherlands [9]	M, 63	Abdominal pain, nausea and vomiting	Stable	4	Retrograde cystography	IP, Dome	Laparoscopic, suture	Uneventful	
Ma et al., 2024, China [1]	F, 72	Abdominal pain	Stable	8	Retrograde cystography	IP, Dome	Laparotomy, suture	Uneventful	
M: male; F: female; NA: not applicable; IP: intraperitoneal; EP: extraperitoneal; CT: Computed Tomography.

In our case, the patient was diagnosed with delayed bladder rupture eight days after a vehicle accident. The patient reported that after hearing a “poof” sound from her abdomen, she has abdominal pain and distention, along with microscopic hematuria. Given her nearly shocked condition, a POCUS was performed, revealing a large amount of free intra-abdominal fluid, which was later identified as yellow, urine-like fluid through abdominal paracentesis. Although laparotomy is the primary choice in emergency surgery, we still opt for laparoscopic surgery to achieve better treatment outcomes and reduce hospital stays. Laparoscopic surgery can also be converted to open surgery if necessary. After the car accident, the patient did not show symptoms of gross hematuria or an acute abdomen. The patient was discharged after having bone fixation with independent urination, we hypothesize that the bladder wall injury in our patient started as a partial contusion that had progressed to a complete tear (perforation) due to urine retention, following LaPlace's law, on the eighth day after the accident. The success in this clinical case is attributed to the prompt initiation of emergency surgery based on the patient history, clinical presentation, and combined POCUS findings of significant abdominal fluid without waiting for CT results. Patients should be advised to seek immediate hospital care if they experience abdominal discomfort, and particularly sudden urinary retention following trauma.

Conclusion

Although rare, delayed bladder rupture should be investigated in patients with an acute distended abdomen and a recent history of blunt trauma. With prompt diagnosis and intervention, the outcome of delayed bladder rupture is favorable.

Consent

Informed consent has been obtained from our patient.

Author agreement

All authors have seen and approved the final version of the manuscript being submitted.

Funding

None.

CRediT authorship contribution statement

Vo Anh Vinh Trang: Conceptualization, Investigation, Writing – original draft. Dai Thanh Sang Nguyen: Investigation, Visualization. Phuc Hai Duong: Investigation, Visualization. Thien Tan Tri Tai Truyen: Conceptualization, Writing – review & editing. Vu Phuong Do: Conceptualization, Investigation, Supervision.

Declaration of competing interest

None to declare.
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