non - traumatic , spontaneous urinary bladder rupture is a rare complication of ureterovesical stones , radiotherapy , binge alcohol drinking , or malignancy1 ) .
however , its symptoms are often nonspecific , and misdiagnosis is common , and sometimes , it can be a life - threatening event2,3 ) .
we experienced a case presenting as oliguria with hydronephrosis and ascites on admission that was initially misdiagnosed as obstructive uropathy due to metastatic cancer , and later diagnosed as post - radiotherapy urethral stricture and spontaneous rupture of the urinary bladder .
a 55 year - old woman was admitted to inha university hospital with abdominal pain , distension , and oliguria .
she had undergone radical hysterectomy for uterine cervical cancer and received post - operative concurrent chemoradiation therapy 13 years previously . after a 5-year follow - up period
, there was no evidence of the disease state and the patient was asymptomatic , and thus , regular follow - up was discontinued . at the time of admission , she had a 20 pack - year smoking history and consumed 1 - 2 bottles of alcohol per day , 3 - 4 times per week .
four days before admission , she visited another hospital with nausea , vomiting , abdominal pain , and abdominal distension of 7 days duration that started after drinking .
physician recommended admission because of the presence of features of acute kidney injury ( blood urea nitrogen ( bun ) : 78mg / dl , creatinine : 4.9mg / dl ) , but she refused .
four days after discharge , she was admitted at the emergency department of our hospital due to aggravation of her symptoms .
she had an acute ill - looking appearance , and her blood pressure , heart rate , respiration rate , and body temperature were 153/112mmhg , 109 pulses per minute , 20 per minute , and 36.6 , respectively .
she complained of general weakness , anorexia , weight loss ( 6 kg per 1 month ) , abdominal pain and distension , oliguria , and generalized edema .
chest auscultation showed a regular heart beat without murmur and clear breath sounds without crackle .
she had moderate abdominal distension with hypoactive bowel sounds , and mild direct and rebound tenderness of the whole abdomen without organomegaly or a palpable mass .
she had edematous lower legs but there was no definite pre - tibial pitting edema .
laboratory findings were as follows : bun 162.9 mg / dl ( reference range , 7.8 - 26 ) , creatinine 7.74 mg / dl ( 0.3 - 1.2 ) , ph 7.24 , hco3 11.6mmol / l , pco2 28 mmhg , sodium 119meq / l , potassium 6.1meq / l , serum osmolality 313mosm / kg . complete blood cell count results showed mild leukocytosis ( 13,600/mm with 90% neutrophils ) , elevated hemoglobin ( 16.5 g / dl ) , and a normal platelet count .
liver function and coagulation battery tests were normal . computed tomography ( ct ) without contrast media showed bilateral hydroureteronephrosis and a large amount of ascites but no evidence of liver cirrhosis ( fig .
her urine output was less than 500ml per day and her renal function , including hyperkalemia and metabolic acidosis , were not improved by conservative management .
cell count and chemistry of ascites were as follows : rbc 2/mm , wbc 42/mm , polymorphonuclear leukocyte count 11% , glucose 152mg / dl , protein < 1.0 g / dl , ldh 25u / l , bun and creatinine level were not evaluated . on the third hospital day ,
bilateral percutaneous nephrostomy catheters were inserted , a large amount of urine was drained , her creatinine level decreased dramatically ( 2 and 4 days after catheter insertions creatinine levels were 1.45 and 0.73mg / dl , respectively ) , and ascites decreased simultaneously without additional paracentesis .
contrast enhanced ct showed improved hydronephrosis and ascites without evidence of malignancy or an obstructing stone . to determine the cause of the obstruction and to resolve the obstruction by d - j stent insertion , retrograde pyelography was performed . during the procedure
, a severe urethral stricture was found , and after urethral dilation , contrast leakage revealed a bladder wall defect open to the peritoneal cavity at the posterior bladder wall ( fig .
multiple bladder wall thinning and severe inflammation were visualized during cystoscopy but no mass or ureteral stricture .
the patient was transferred to our urology department and open abdominal surgery was performed to repair the ruptured bladder wall .
spontaneous bladder rupture is a rare event , but can be life - threatening . thus , prompt diagnosis followed by surgical intervention is important to achieve a satisfactory treatment outcome .
the symptoms of spontaneous bladder rupture at presentation vary from abdominal distension to acute abdomen , and its most common cause is chronic inflammation ( other possible causes are detailed in table 1)4 ) .
diagnosis is made by history taking and radiologic examination , computed tomography ( ct ) , and urinary cystography .
although cystography is the diagnostic test of choice , lowe et al . reported the successful use of ct for confirming the diagnosis when cystography was negative or equivocal5 ) .
therefore , ct and cystography in combination appear to provide an accurate , non - invasive means for the diagnosis of bladder pathologies , such as , spontaneous bladder rupture .
several cases of bladder rupture detected at an early stage have been reported1 ) , and several cases6,7,8,9 ) of spontaneous bladder rupture presenting as acute kidney injury have been described , but no case of spontaneous bladder rupture combined with definite bilateral hydroureteronephrosis has been previously published .
initially , we considered a diagnosis of post - renal aki caused by recurrent cervical cancer or intraperitoneal metastasis from an unknown gastrointestinal tract cancer , because the patient was cachexic and complained of substantial weight loss , rather than of urinary frequency , residual urine sensation , or voiding difficulty , and thus , we did not suspect complications of radiotherapy .
however , our investigation showed that the primary cause of the bilateral hydronephrosis and spontaneous bladder rupture was severe urethral stricture . except for mechanical injury
, the mechanisms of spontaneous bladder rupture are increased intravesical pressure and weakening of the bladder wall4 ) . in our case
that is prior radiotherapy could have weakened the bladder wall10 ) and caused the urethral stricture , which then progressively increased intravesical pressure and led to bilateral hydronephrosis and finally to spontaneous bladder rupture .
theoretically , radiation damagesthe dna contents of actively dividing cells , and cause chronic fibrosis , progressive endarteritis , and tissue scarring in poorly oxygenated submucosal and muscular tissues , leading to radiation cystitis , hemorrhagic cystitis , neurogenic bladder , and ureteral and urethral stricture .
ureteral stricture and radiation cystitis are the most common long - term post - radiation urinary complications in cervical cancer patients11 ) .
however , only a small number of reports have mentioned urethral stricture associated with cervical cancer .
in particular , fujikawa reported that hydronephrosis was the second most common radiation - induced complication rather than urethral stenosis in japanese patients10 ) .
reported the case of 65-year - old man with spontaneous bladder rupture after a bout of heavy drinking .
this case was diagnosed by testing creatinine level in ascitic fluid following retrograde cystography , and the defect was repaired surgically7 ) .
although the relationship is unclear , some authors have suggested that a diminished sense of voiding and a sudden change in intravesical pressure caused by alcohol intoxication increase the risk of spontaneous bladder rupture12 ) . in our case ,
alcohol was a possible cause because of her drinking habit and the timing of symptom onset . in conclusion
, we experienced a case of bilateral hydronephrosis and spontaneous rupture of the urinary bladder due to urethral stricture . when a patient with an acute abdomen or ascites with oliguria of unknown origin presents , especially when there is a history of radiotherapy to the pelvis , the possibility of spontaneous bladder rupture should be considered . in cases of bladder rupture ,
prompt , precise diagnosis and proper surgical treatment are mandatory to avoid the risk of mortality .
 non - traumatic , spontaneous urinary bladder rupture is a rare complication of urethral stricture . 
 furthermore , its symptoms are often nonspecific , and misdiagnosis is common . 
 the authors experienced a case of urethral stricture with spontaneous bladder rupture and bilateral hydronephrosis , mimicking obstructive uropathy attributed to cancer metastasis . 
 a 55-year - old woman was admitted with abdominal pain and distension , oliguria , and an elevated serum creatinine level . 
 she had undergone radical hysterectomy for uterine cervical cancer and received post - operative concurrent chemoradiation therapy 13 years previously . 
 non - contrast enhanced computed tomography showed massive ascites and bilateral hydronephrosis . 
 the initial diagnosis was acute kidney injury due to obstructive uropathy caused by malignant disease . 
 after improvement of her renal function by bilateral percutaneous nephrostomy catheterization , contrast - enhanced computed tomography and a cytologic examination of ascites showed no evidence of malignancy . 
 however , during retrograde pyelography , a severe urethral stricture was found , and subsequent cystography showed leakage of contrast into the peritoneal cavity and cystoscopy revealed a defect of the posterior bladder wall . 
 after urethral dilatation and primary closure of the bladder wall , acute kidney injury and ascites were resolved . 
Introduction
Case Report
Discussion