Iatrogenic rupture of the urinary bladder

Iatrogenic rupture of the urinary bladder

Oct 01, 2004

Carl A. Osborne DVM, Ph.D., Dipl. ACVIM
Surgical repair is considered the definitive treatment for rupture of the urinary bladder. In fact, one could state that surgical repair of rents in the excretory pathway of the urinary system is therapeutic dogma. Although this recommendation is logical, there apparently have been no studies to compare surgical versus medical therapy of bladder wall rents by controlled clinical trials.

Clinical experience with nonuremic patients We found it necessary to evaluate the totality of this therapeutic philosophy in the late 1970s following our experience with iatrogenic rupture of the urinary bladder of an adult male cat with nonazotemic urethral outflow obstruction. At that time, the technique of retrograde positive contrast urethrocystography had just been developed. Following removal of matrix-crystalline urethral plug, a retrograde urethrocystogram was performed to evaluate the lower urinary tract. Overdistention of this cat's urinary bladder at the time of this radiographic procedure was performed resulting in escape of a considerable amount of radio-paque contrast solution into the peritoneal cavity.

The exact site of escape of contrast medium through the bladder wall could not be identified on the radiographs or by evaluation of the serosal surface of the urinary bladder at the time of celiotomy.

Figure 1: Positive contrast cystogram (lateral view) of the abdomen of a 10-year-old spayed female Golden Retriever illustrats extravasation of contrast solution through the caudoventral aspect of the bladder wall into the peritoneal cavity. The irregularity of the bladder wall at the site of bladder rupture likely is associated with the formation of a blood clot.
A cystotomy was not performed; we had no option but to manage this iatrogenic problem medically. Because the urethra was patent and the cat's urinary bladder remained small because of pollakiuria, therapy was limited to an orally administered antibiotic to prevent ascending bacterial urinary tract infection, as well as modification of diet to minimize struvite crystalluria. During the next five days, the cat had no evidence of uroperitoneum or azotemia. Follow-up low-pressure positive contrast cystography revealed no loss of contrast medium from the bladder into its wall or the peritoneal cavity.

During the past 30 years of evaluating feline lower urinary tract disease by retrograde positive contrast urethrocystography, antegrade positive contrast cystourethrography and double-contrast cystography, we have observed leakage of contrast medium from the maximally distended bladder lumen into the peritoneal cavity on several occasions.

Affected cats had hematuria and dysuria but did not have bacterial urinary tract infection. Some had urethral outflow obstruction, but none had post-renal uremia at the time of radiography. In two obstructed male cats, the bladder wall was ruptured during attempts to re-establish urethral patency. In most cases, we could not ascertain the site(s) of discontinuity of the bladder wall by evaluation of positive contrast radiography. We successfully managed all cases by nonsurgical therapy.

Figure 2: Fluroscopic image of a positive contrast cysto-gram (lateral view) of the abdomen of the dog described in Figure 1 obtained four days later. There is no evidence of loss of contrast media through the filling defect in the vertex of the bladder wall into the peritoneal cavity.
Medical management In our opinion, medical management of iatrogenic rupture of the urinary bladder may be considered, provided:
  • There is no evidence of an underlying atraumatic lesion (neoplasm, etc.) that predisposed the bladder to rupture.
  • The bladder wall is not hypotonic and unable to contract.
  • There is no evidence that the wound's edges are devitalized.
  • There is no evidence of significant urosepsis.
  • There are no other complications requiring celiotomy.
  • The patient can be appropriately monitored for a sufficient time.