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Iatrogenic rupture of the urinary bladder


Further evaluation of the patient revealed no evidence of an underlying disorder of the lower urinary tract that would predispose her to bladder rupture. Urinalysis performed on a sample of urine obtained by transurethral catheterization following bladder rupture revealed changes consistent with trauma, for example, numerous red blood cells in the urine sediment and moderate proteinuria. There was no evidence of inflammation; in-vitro bacterial culture was negative. The urine specific gravity was 1.042. Results of a CBC and serum chemistry profile were normal (serum urea nitrogen = 22 mg/dl and serum creatinine = 1.6 mg/dl). Retrograde positive contrast cystography revealed escape of radiopaque contrast solution from the bladder lumen through the bladder wall into the peritoneal cavity (Figure 1). Initial treatment of the iatrogenic rupture of the bladder wall consisted of an indwelling transurethral catheter attached to a closed drainage system.

The dog was given an oral antibiotic (Clavamox) to minimize the risk of ascending bacterial infection associated with the indwelling catheter.

The indwelling catheter was removed after four days. Just before removal of the catheter, a urine sample was obtained from the bladder lumen for urinalysis and aerobic bacterial culture. Results of the urinalysis revealed no abnormalities with the exception of mild hematuria (red blood cells = 15 to 20 per 450X magnification; specific gravity = 1.047). The urine was bacteriologically sterile. Also, prior to removal of the urinary catheter, radiopaque contrast solution was injected through it under fluoroscopy. Extravasation of contrast solution through the bladder wall into the peritoneal cavity was not observed (Figure 2). Peritoneal fluid was not detected around the serosal surface of the urinary bladder. The serum concentrations of creatinine (1.0 mg/dl) and urea nitrogen (17 mg/dl) were normal.

Evaluation of the patient two weeks later revealed no abnormalities of the urinary tract. A positive contrast cystogram revealed that the contrast solution was retained in the bladder lumen (Figure 3). Urinalysis results and the serum concentrations of creatinine (1.2 mg/dl) and urea nitrogen (18 mg/dl) were normal. Follow-up of the patient during the next five years revealed no evidence of lower urinary tract disease.

What is the point? The point to be emphasized is that surgical closure might not be necessary to successfully manage all patients with ruptured urinary bladders. If the margins of the walls of tears in the bladder wall are not devitalized, and if they remain in close apposition by maintaining the bladder lumen in a nondistended state for an appropriate period, then it is plausible that these conditions would simulate those created by use of surgical sutures.

We are not advocating an all-or-none choice. Since the clinical status of patients with ruptured urinary bladders can vary from that characterized by only hematuria and dysuria to life-threatening post-renal uremia, a range of surgical and medical options should be considered.


Source: DVM360 MAGAZINE,
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