Urinary Ascites

Abstract

Introduction: Atraumatic bladder rupture is a rare occurrence and therefore not considered highly on the differential for a patient who presents with new onset ascites. We present this case to show the complexity of diagnosing and managing ascites secondary to bladder rupture. Case Report: A 43 year-old female with untreated multiple sclerosis (MS) presented with abdominal pain beginning immediately after voiding. Initial labs revealed mild leukocytosis with normal liver function, creatinine and lipase. Contrast tomography (CT) abdomen/pelvis showed large ascites with normal appearing liver. Pelvic ultrasound demonstrated a small left paraovarian cyst. General surgery and gynecology ruled out acute abdomen, thought the presentation was due to ruptured ovarian cyst and recommended conservative management. Paracentesis fluid was concerning for secondary bacterial peritonitis with labs showing serum albumin-ascites gradient of > 1.1, white blood cell count of 3610, polymorphonuclears of 88%, total protein of 1.3, glucose of 36, and creatinine of 8.27. Five days later, the patient started to have worsening abdominal pain, leukocytosis and renal function. Repeat CT of the abdomen/pelvis showed a marked increase in abdominal ascites as well as an abnormality of the bladder wall that likely represented a bladder diverticulum, but a bladder wall rupture or diverticular rupture could not be excluded. Cystogram confirmed bladder rupture which was thought to be from obstructive uropathy secondary to neurogenic bladder from her untreated MS. She failed conservative management with increased abdominal pain and ileus and subsequently underwent a cystoscopy, cystorrhaphy, and diverticulectomy with drain placement. Discussion: While traumatic rupture of the bladder is a more common occurrence, ascites secondary to a spontaneous bladder rupture is a rare occurrence, documented sparsely in case reports. Due to the delay in diagnosis, patients have poorer outcomes and a high mortality rate. A PubMed search found two other cases of bladder rupture in MS patients, but unlike our patient they presented with signs of acute abdomen. Conclusion: Perforated urinary bladder should be considered in the differential diagnoses in patients presenting with new onset ascites and acute kidney injury without any evidence of chronic liver or heart disease or any other common causes of ascites. Early diagnosis can greatly improve the patient's hospital course and overall outcome.