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Rom J Leg Med [23] 9-13 [2015]
DOI: 10.4323/rjlm.2015.9
© 2015 Romanian Society of Legal Medicine Idiopathic spontaneous rupture of the urinary bladder - A rare cause of death
Beatrice Ioan1, Irina Manoilescu1, Dan Dicu Șerban2, Marius Neagu1,*, Adriana Grigoraş1, Simona Damian1
_________________________________________________________________________________________
Abstract: Spontaneous rupture of the urinary bladder is a rare clinical condition, with a prevalence of about 1 in
126.000 hospitalizations. Idiopathic rupture is even more rarely encountered, constituting less than 1% of all cases. Given the low
incidence, atypical symptoms and poor history data, the diagnosis is often established late and treatment is delayed, resulting in a
high rate of mortality. Also, spontaneous rupture of the urinary bladder may be a surprise at the autopsy. In this paper, the authors
present the case of a 67 years old woman who died due to idiopathic spontaneous rupture of the urinary bladder after ingestion of
alcoholic beverages. The autopsy showed no signs of pathological or traumatic injury and the toxicological examination revealed
a blood alcohol concentration of 2.05 g ‰. The case is analyzed in the context of existing literature data, taking into account the
elements of anatomy, physiology and pathophysiology that can determine or favour the idiopathic spontaneous rupture of the
urinary bladder.
Key Words: urinary bladder, idiopathic spontaneous rupture, alcohol.
T
he spontaneous rupture of the urinary
bladder can occur intra or extra-peritoneal
or in the pelvic tissue, with no history of trauma, having
an incidence of approximately 1:126.000 hospitalized
cases [1, 2]. Idiopathic spontaneous rupture is a very rare
entity, representing about 1% of all the cases of bladder
rupture. Acute alcohol intoxication is an important risk
factor for idiopathic spontaneous rupture of the bladder.
The diagnosis is often delayed and therefore treatment is
delayed, resulting in increased morbidity and mortality.
Sometimes the idiopathic spontaneous rupture of the
bladder is not even diagnosed or suspected during the
victim’s life, being revealed during the autopsy.
Case presentation
R.D., a 67 years old woman, was found dead
few hours after ingestion of a large amount of alcoholic
beverages. The victim’s medical records showed that
she was not suffering from any pathological condition.
Investigation by police revealed no recent trauma suffered
by the victim.
The autopsy was performed 24 hours after death,
and the blood and organ samples were collected to
perform toxicology and microscopic examinations.
External examination of the corpse found a
stature of 165 cm, good nutritional status and signs of
death completely expressed. No external traumatic
lesions were observed.
Internal examination of the body revealed
1000 ml of liquid blood mixed with urine and blood
clots into the peritoneal cavity (Fig. 1). On the rear wall
of intraperitoneal urinary bladder it was discovered
a transversal rupture of about 4 cm length and 3
cm width at maximum tensile, with irregular and
hemorrhagic infiltrated edges. Inside the urinary bladder
we observed about 700 ml of blood clots (Figs 2, 3).
Further macroscopic examination of the urinary bladder
1) “Grigore T. Popa” University of Medicine and Pharmacy, Institute of Legal Medicine, Iași, Romania
* Corresponding author: Resident Forensic Pathologist, Email: mariusneagu87@gmail.com
2) Focsani, Romania
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Ioan B. et al.Idiopathic spontaneous rupture of the urinary bladder - A rare cause of death
Figure 2. Transversal rupture of the rear wall of the urinarry
blader; intracavitary blood clot.
Figure 1. Liquid blood and clots mixed with urine in the
peritoneal cavity.
revealed no other pathological or traumatic lesions. No
other pathological or traumatic lessions were discovered
during the internal examination.
During the autopsy we collected blood samples
and samples of organs (stomach, liver, kidney) for
toxicology examination and also samples of organs for
microscopic examination.
Toxicology examination revealed a blood alcohol
concentration of 2.05g ‰. No other toxic substances
such as drugs, pesticides or drugs were detected.
Microscopic examination
The urinary bladder samples collected during
the autopsy were preserved in formol 10% and processed
by inclussion in paraffin. The sections were coloured with
the standard method HE and the tricromic coloration
Masson for a better differentiation of the tissue elements
which are normally present in the wall of the urinary
bladder. The sections were examined with the optic
microscope Olympus Bx51, and the images were captured
with the camera Olympus SP 350, QuickFoto program.
The microscopic examination revealed focal
postmortem autolysis lessions in the urothelium and
vascular hyperemia (Figs 4, 5) associated with focal
hemorrhagic necrosis in the mucosal membrane and
in the smooth muscle fibres of the muscular membrane
(Figs. 6, 7) and also extensive hemorrhage in the entire
wall of the urinary bladder (Fig. 8). The hemorrhage
consisted of normal red cells and a few white cells,
accompanied by a minimal inflamatory infiltration.
The microscopic examination did not reveal any
granulomatous inflamation suggestive for tuberculosis
(Fig. 9).
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Figure 3. Urinarry bladder wall with hemorrhagic infiltration
in the margines of the wall rupture.
Microscopic examination of the samples
collected from the other organs did not reveal any
pathological aspects which could determine or contribute
to the rupture of the urinarry bladder.
Summarizing, in this case, the medical records
and autopsy showed no evidences of previous illnesses
or traumatic injuries. The only macroscopic autopsy
findings were: the rupture of the urinary bladder and
an important break of urine mixed with blood in the
peritoneal cavity. The microscopic examination of the
samples of urinary bladder wall collected during autopsy
revealed the hemorrhagic infiltration caused by the
rupture of the wall without detecting any pathological
or traumatic lesions of the bladder. Toxicological
examination revealed a blood alcohol concentration of
2.05 g%o. Based on these findings, it was concluded that
the victim died as a result of the spontaneous idiopathic
bladder rupture due to over-distension in the context of
the acute alcohol intoxication.
Romanian Journal of Legal Medicine Vol. XXIII, No 1(2015)
Figure 4. Postmortem autolysis of the urothelium and
congestion of the vassels in the lamina propria (Masson, x 40).
Figure 5. Overview of the urinary bladder wall showing
hemorrhage and congestion of the vassels in the serous
membrne (H.E., x 40).
Figure 6. Hemorrhages in the mucosal membrane of the
urinary bladder (Masson, x 100).
Figure 7. Focal hemorrhagic necrosis in the muscles of the
urinary bladder wall (Masson, x 100).
Figure 8. Hemorrhages in the urinary bladder wall, more
important in the serous membrane and muscles (H.E., x 40).
Figure 9. Reduced inflamatory infiltration in the muscle of the
urinary bladder wall (H.E., x 100).
Discussion
Rupture of the urinary bladder occurs mainly
in the context of an abdominal-pelvic or iatrogenic
trauma, or during obstetrical, urological and orthopedic
maneuvers. Traumatic rupture of the bladder may occur
intra-peritoneal, as a result of a contusion trauma of the
abdomen or extra-peritoneal frequently associated with
pelvic fractures.[15].
Spontaneous rupture occurs less frequently
than the traumatic one, often against a background
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Ioan B. et al.Idiopathic spontaneous rupture of the urinary bladder - A rare cause of death
of pre-existing pathology, at a rate of about 1/126.000
hospitalizations [2, 12, 15, 16]. Most cases occur in people
aged 50 years or over who suffer from certain pathological
diseases [3]. The first case of spontaneous rupture of the
bladder bladder was reported by Bastable et al., in 1959
[16].
Spontaneous bladder rupture is often difficult
to distinguish from other causes of acute abdomen [1,
2, 4, 5], representing a diagnostic challenge [2]. Due to
diagnostic difficulties that often delay the treatment, it
is estimated that mortality caused by the spontaneous
rupture of the urinary bladder is about 47% [15].
Intra-peritoneal ruptures are divided in two
categories, depending on their etiology: rupture of the
bladder due to a pathological lesion and rupture by
over-distension. The pathological conditions that can
determine the rupture of the urinary bladder wall are:
chronic infections [2], tuberculosis [9], urethral rupture
of infected rupture, eosinophilic or necrotic cystitis [1,
2], inflammation [5, 12], pelvic irradiation for cervical
cancer [17], urinary squamous cancer [4]. In children,
spontaneous rupture may occur due to a congenital
bladder diverticulum [7], and in newborn risk factors are
represented by hypoxia and bladder diverticula [8]. The
break of the urinary bladder wall by over- distensionis
determined by the retention of urine determined by:
tabes dorsalis, urethral obstruction by the gravid or
fibroid uterus, puerperal or postoperative retention [3, 6].
The spontaneous rupture of the bladder can be facilitated
by excessive alcohol consumption [22].
Clinical aspects of the bladder rupture are varied.
Before the rupture the victim suffers from commonly
urinary tract symptoms, and after the rupture the signs
and symptoms of peritonitis and urinary difficulties can
be observed [3]. In many cases the clinical triad of pain,
difficulty or impossibility of urinating and contracture
of the abdominal wall can be identified [19]. In some
instances, the rupture may remain painless for several
days, but with progressive abdominal distension due to
urinary ascites [15, 21]. After about 24 hours from the
occurrence of the rupture, the phenomenon of selfperitoneal dialysis occurs resulting in the reabsorption
of urea and creatinine, which determine metabolic
disturbances with toxic blood concentrations of urea,
creatinine, potassium (which can cause EKG changes),
ammonia and hyponatremia, leading to metabolic
acidosis and mimicking the biochemical acute renal
failure. The peritoneal fluid, in turn, shows an increased
concentration of creatinine [3, 13, 15, 17, 22].
Complications caused by the leakage of the urine
into the peritoneal cavity and pelvis are: pelvic abscess,
septic shock, abdominal or chest wall phlegmon [1].
Bladder rupture is difficult to diagnose due to
nonspecific symptoms (abdominal aches and contracture
of the abdominal wall), no history of trauma and low
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incidence. The diagnosis should be suspected when
the following signs are identified: free peritoneal fluid,
decrease demission of urine, hematuria, increased
levels of urea and creatinine in serum and/or peritoneal
fluid [21]. The investigation of choice for the detection
of bladder rupture is cystography [3, 11, 20]. However,
many times the spontaneous rupture of the bladder is
not clinically suspected, being discovered by exploratory
laparotomy or during autopsy [20].
This clinical entity is a surgical emergency
and can be rapidly fatal if diagnosis and treatment are
delayed, early and adequate treatment being essential
[1]. The treatment consists of laparotomy and suture as
continuous leakage of urine does not allow spontaneous
closure of the breach [15].
Idiopathic spontaneous rupture of the urinary
bladder wall appears in the absence of traumatic or
pathological lesions being a very rare occurrence [10, 12,
14, 24], with an incidence of approximately 1% of all the
ruptures [15]. The typical aspect is that of intraperitoneal
rupture of the rear wall, most often affecting the bladder
dome [17-19, 22].
The mechanism of the idiopathic spontaneous
rupture of the urinary bladder is the excessive increase of
the intra-vesical pressure [22], the most vulnerable part
being the intra-peritoneal bladder [15].
The main cause of this clinical entity is the
excessive consumption of alcoholic beverages [10, 15]. The
acute alcohol intoxication increases the urine production
due to the diuretic effects of alcohol and leads to overdistension in the context of the sensitivity disturbances
due to the α - sympathomimetic effect and CNS depression
produced by the alcohol. In men, congestion of the
prostate and prostatic urethra aggravates the obstruction
of the outlet [15, 22, 23]. Studies in animals showed that
ethanol affects the contractility of the detrusor in vivo
and in vitro and the chronic exposure to ethanol and
acetaldehyde decreases the contractility of the urinary
bladder. Therefore, chronic alcohol consumption is more
prone to urinary retention than acute intoxication [23].
It is possible that the rupture to occur after minor
trauma frequently forgotten by the patient due to the
state of ethanol intoxication, resulting in diagnosis errors
or delay. [11, 22]. Thus, in many cases initially classified
as idiopathic were identified signs of minor trauma
associated with the abuse of alcoholic beverages [15].
Urinary bladder rupture in the context of
excessive alcohol consumption has a favorable prognosis
if diagnosed and treated in due time [10]. Unfortunately,
the morbidity and mortality of idiopathic rupture is
increased as a result of late diagnosis and treatment.
Barstable et al., in 1959 assessed a mortality rate of
approximately 50 % [22], while Festini et al., in 1991
reported a mortality rate of 12% [24].
Romanian Journal of Legal Medicine Conclusion
Due to the difficulties of diagnosis and rapid
evolution, idiopathic spontaneous bladder rupture may
be primarily discovered during the autopsy. Such cases
may be reffered to the service of Forensic Medicine due
to the suspect and sometimes sudden nature of the death.
The post-mortem diagnosis of the idiopathic spontaneous
rupture of the urinary bladder requires a thorough autopsy
and laboratory examination. The correct diagnosis
requires exclusion of any pathological or traumatic causes
of breakage in addition to the discovery of the rupture
Vol. XXIII, No 1(2015)
itself accompanied by an important quantity of urine in
the peritoneal cavity as an evidence of the bladder overdistension. As showed above, idiopathic spontaneous
bladder rupture occurs mostly in the context of acute
ethanol intoxication. As such a high blood alcohol
concentration revealed by the toxicological examination
is an important criteria for this diagnosis.
Although the idiopathic spontaneous rupture of
the urinary bladder is a rarely encountered in the forensic
practice, the professionals in this field have to be aware
of this entity and collect all the evidences that support its
post-mortem diagnosis.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Arnaout F. Spontaneous atraumatic rupture of urinary bladder. Internet Journal of Urology 2008; 5(2).
Aber A, Hyder SA, Arumuham V. An unusual case of spontaneous bladder perforation with associated autodialysis of ensuing urinary
ascites. Case Reports in Medicine 2011; vol. 2011, Article ID 145084, 3 pages, doi:10.1155/2011/145084.
Faraj R, O’Donovan P, Jones A, Hill S. Spontaneous rupture of urinary bladder in second trimester of pregnacy. Internet Journal of
Gynecology & Obstetrics 2009;10(2):2.
Ohzawa H, Arai W, Kondo Y, Endo S, Morita T, Matsubara S. Urinary bladder rupture associated with squamous cell carcinoma of the
bladder. Internet Journal of Urology 2010;7(2):1.
Gogus C, Turkolmez K, Savas B, Sertcelik A, Baltaci S. Spontaneous bladder rupture due to chronic cystitis 20 years after cystolithotomy.
Urologia Internationalis 2002;69(4):327-328.
De Leon J, Liu S, Wan Yi Ng, McGregor R, Tse V. Spontaneous bladder rupture in a patient with adult Ehlers-Danlos Syndrome without
bladder diverticulae. UroToday International Journal 2011;4(3):1-3.
Stein RJ, Matoka DJ, Noh PH, Docimo SG. Spontaneous perforation of congenital bladder diverticulum. Urology 2005;66(4):881-881.
Wiygul J, Palmer LS. Spontaneous bladder perforation in a neonate. Urology 2010;76(1):164-165.
Sallami S, Gargouri M, Tayeb M, Slima MB, Makhlouf M. Spontaneous intraperitoneal perforation of the bladder secondary to tuberculosis.
UroToday International Journal 2010;3(5):1-4.
Parker H, Hoonpongsimanont W, Vaca F, Lotfipour S. Spontaneous bladder rupture in association with alcoholic binge: A case report and
review of the literature. Journal of Emergency Medicine 2009;37(4):386-389.
Appeltans BMG, Schapmans S, Willemsen PJA, Verbruggen PJEM, Denis LJ. Urinary bladder rupture: laparoscopic repair. British Journal
of Urology 1998;81:764-765.
O’Neill GFA, Alexander JH. Spontaneous bladder rupture in a patient with widespread superficial transitional cell carcinoma. Aust. NZJ
Surg 1998;68:79.
Puneet D, Bhupendra KJ. Delayed dehiscence of repaired urinary bladder. Indian Journal of Surgery 2004;66(1):49-50.
Eu Chang Hwang, Dong Deuk Kwon, Chan Jong Kim, Taek Won Kang, Kwangsung Park, Soo Bang Ryu, Jae Sook Ma. Eosinophilic cystitis
causing spontaneous rupture of the urinary bladder in a child. International Journal of Urology 2006;13:449-450.
Jurisic D, Glavan E, Cugura JF, Vidovic D. Splenic rupture following idiopathic rupture of the urinary bladder presenting as acute abdomen.
J Postgrad Med 2007;53(1):39-40.
Muthukumaran R, Salem MJ. Rare case of spontaneous rupture of a urinary bladder carcinoma causing intestinal obtruction and peritonitis.
Surgical Practice 2007;11:44-47.
Vohra SB, Kapur S. Diagnosis of bladder rupture by arterial blood gas analysis. Anaesthesia 2007;62:534-535.
Albrecht K, Schulz F, Kedia G, Breitmeier D, Jonas U, Tsokos M. Spontaneous ruptures of the urinary bladder in the routine forensic
examination. Georgian Med News 2006;140:17-23.
Albrecht K, Gunther D, Oelke M, Wilke N, Wagner C, Troger HD. Spontaneous rupture of the urinary bladder. Arch. Kriminol 2004;213(56):154-164.
Haddad FS, Wachtel TL. Spontaneous intraperitoneal rupture of the bladder. Urol Int 1987;42(6):467-469.
Dubey IB, Mohanty D, Jain BK. Diverse presentation of spontaeous rupture of urinary bladder: review of two cases and literature. Am J
Emerg Med 2012;30(5):832.
Bastable LRG, De Jode LR, Warren RP Spontaneous rupture of the bladder. Br J Urol 1959;31(1):78–86.
Kim HJ, Moon H, Sohng I, Lee HW, Lee G, Lee JG. Effects of ethanol and its metabolite acetaldehyde on responses of the rat bladder. BJU
International 1999;83:686-692.
Festini G, Gregorutti S, Reina G, Bellis GB. Isolated intraperitoneal bladder rupture in patients with alcohol intoxication and minor
abdominal trauma. Ann Emerg Med 1991;20(12):1371–1372.
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