Introduction: Urothelial carcinoma of the bladder causing spontaneous rupture of the bladder is an extremely rare condition with poor outcomes due to it being highly suggestive of advanced malignancy. Case Presentation: We present the case of a 74-year-old man who presented with non-specific signs and symptoms of abdominal pain and haematuria. Abdominal imaging was suggestive of a small bowel obstruction and a bowel perforation. At time of laparotomy, however, the patient was found to have metastatic urothelial carcinoma with peritoneal metastases. The patient unfortunately passed away 2 months following their initial presentation. Conclusion: Bladder perforation secondary to urothelial cancer is a rare pathology associated with poor prognosis. There are fewer than thirty cases reported in the literature, and it is often not considered during initial diagnostic workup of patients with abdominal sepsis in the context of bladder cancer. A high degree of suspicion for bladder rupture is recommended in patients with peritonism and urinary symptoms. Awareness of this condition will help facilitate prompt diagnosis and appropriate management.

Spontaneous rupture of the urinary bladder is a rare event that occurs when the bladder wall is ruptured without surgical intervention or trauma [1]. It presents with non-specific clinical signs and investigation findings, often leading to delayed or missed diagnosis. The condition is associated with significant morbidity and mortality [2]. Spontaneous rupture of the urinary bladder can be caused by bladder overdistention from bladder outlet obstruction, infection, inflammation, or, rarely, from malignancy [2]. We present a rare case of spontaneous urinary bladder rupture secondary to urothelial cell carcinoma. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000536581).

A 74-year-old man presented to the emergency department with abdominal pain of acute onset occurring in the context of 3 months of haematuria and melaena. These symptoms were associated with constitutional symptoms, worsening dyspnoea, and reduced exercise tolerance. He was previously well and lived alone independently. His only medical history was a right subclavian artery stent due to a crush injury many years prior to presentation. He was a smoker with a 90 pack year history and took aspirin.

On examination, he was afebrile and vital signs were noted with a blood pressure of 143/67 mm Hg, a pulse rate of 88 beats/minute, oxygen saturations of 93% on room air, and a respiration rate of 22/min. His abdomen was distended and generally tender without signs of peritonitis. Bowel sounds were present with bilateral pitting oedema to the knees.

Investigations revealed a white cell count of 5.9 × 109/L and a C-reactive protein of 586 mg/L. His blood film illustrated microcytic and hypochromic anaemia with haemoglobin of 79 g/L, a severe acute kidney injury with creatinine 426 μmol/L, an eGFR of 11 mL/min/1.73 m2 (there was no known prior renal failure), and urea 19.8 mmol/L. Lactate was 5.9 mmol/L.

Abdominal computed tomography without contrast revealed a proximal small bowel obstruction with free fluid and small volume free peritoneal gas in the abdomen suggestive of bowel perforation. The bladder wall was also thick and irregular, with calcified soft tissue projecting into the lumen highly suspicious for bladder cancer (Fig. 1). Bilateral hydronephrosis was also noted, with osteoblastic and osteolytic lesions in the lumbosacral spine.

Fig. 1.

Computed tomography scan of the patient. a Thick-walled and irregular bladder with internal calcified hyper-dense soft tissue material projecting into the bladder lumen suggestive of urothelial cell carcinoma. b Free gaseous material lying within the peritoneal cavity compatible with perforation.

Fig. 1.

Computed tomography scan of the patient. a Thick-walled and irregular bladder with internal calcified hyper-dense soft tissue material projecting into the bladder lumen suggestive of urothelial cell carcinoma. b Free gaseous material lying within the peritoneal cavity compatible with perforation.

Close modal

He underwent an emergency exploratory laparotomy, which revealed turbid intra-abdominal fluid without an obvious bladder or small bowel perforation. However, the peritoneum of the pelvis was inflamed, and macroscopically there was evidence of tumour infiltration. At this stage, an omental nodule was noted biopsied for histopathology (which did now show malignancy), and an extensive washout was performed and intraperitoneal surgical drains were placed. The intra-abdominal fluid was negative for cytology.

He was admitted to the intensive care unit and treated with piperacillin and tazobactam. He had a right-sided nephrostomy placed for hydronephrosis. However, the patient developed progressive sepsis and multi-organ failure. Urine culture returned with enterobacter cloacae (which was also later grown on intraperitoneal samples), and the patient’s antibiotic cover was changed to meropenem.

Four days after the initial laparotomy, a repeat computed tomography abdomen demonstrated an evolving abscess in the pre-peritoneal space that had developed despite adequate drainage with an IDC (Fig. 2). That night the patient returned to theatre for a re-look laparotomy to drain the collection along with rigid cystoscopy to endoscopically assess the bladder lesion. Intraoperatively, a purulent collection was washed out. Intraoperative cystoscopy revealed a large, fixed mass within the bladder. Three hundred millilitres of methylene blue was instilled into the bladder via an indwelling catheter (IDC), which revealed extravasation into the pre-peritoneal space. However, there was no leakage into the peritoneal cavity suggestive of extraperitoneal bladder perforation. Limited transurethral resection of the bladder tumour was performed to obtain tissue for histopathological diagnosis. To completely divert urine from draining into the bladder, a percutaneous left nephrostomy was performed 1 day after the second laparotomy.

Fig. 2.

Computed tomography scan of patient. a, b Large complex collection immediately underneath laparotomy scar inferiorly with multiple locules of gas measuring 7.1 × 10.1 × 6.3 cm.

Fig. 2.

Computed tomography scan of patient. a, b Large complex collection immediately underneath laparotomy scar inferiorly with multiple locules of gas measuring 7.1 × 10.1 × 6.3 cm.

Close modal

The histopathology returned muscle-invasive urothelial carcinoma (Fig. 3). This supported a diagnosis of metastatic urothelial carcinoma (cT4N2M1b). The patient was subsequently discussed at an uro-oncology multidisciplinary meeting and was managed with the consensus treatment of palliative radiotherapy for locoregional symptom control. He passed away in the community 2 months later.

Fig. 3.

Histopathology slides of biopsy showing urothelial carcinoma (×20 magnification, haematoxylin and eosin stain).

Fig. 3.

Histopathology slides of biopsy showing urothelial carcinoma (×20 magnification, haematoxylin and eosin stain).

Close modal

Spontaneous bladder rupture, intra or extraperitoneal, is a rare and life-threatening pathology usually associated with blunt or penetrating trauma or as an iatrogenic complication of urinary tract instrumentation [3, 4]. Risk factors for bladder rupture include diabetes, alcohol intoxication, and previous pelvic radiotherapy [5]. It is rare, however, for it to occur in the context of bladder cancer, with fewer than 30 cases described in the literature and is invariably associated with poor prognosis [6]. Mortality in spontaneous bladder perforation associated with bladder cancer has been reported to be up to 80% [2].

Presenting signs and symptoms of spontaneous bladder rupture are generally non-specific. The most common symptoms include abdominal pain, nausea and vomiting, abdominal distention, and urinary retention [5]. Most diagnoses are made intraoperatively rather than through imaging modalities, and rates of misdiagnosis are high [5]. Our case was similarly diagnosed at laparotomy, which was done to investigate a provisional diagnosis of small bowel perforation. In our case, free peritoneal gas led to this initial diagnosis, and this is not normally present in bladder perforation [7]. However, the urinary and intra-abdominal growth of Enterobacter Cloacae, a catalase positive normally bowel-dwelling organism, may have led to the production of peritoneal gas.

While the vast majority of bladder cancers diagnosed are urothelial cell subtype, when associated with spontaneous bladder rupture, there appears to be a higher proportion of squamous cell carcinomas [2]. This is reflective of the more aggressive clinicopathologic phenotype associated with squamous cell carcinoma of the bladder when compared to urothelial cell cancer [8]. While it is certainly theoretically possible for spontaneous bladder rupture from bladder cancer to occur in the context of non-muscle invasive disease, all reported cases are muscle-invasive disease [2].

Bladder perforation secondary to bladder cancer is a rare pathology associated with poor prognosis. Bladder perforation often has non-specific presenting symptoms including abdominal pain, distention. Doctors would benefit from awareness of it, however, as a differential diagnosis of abdominal pathology and have a particularly high index of suspicion in the context of clinical symptoms or radiological imaging preoperatively suggestive of bladder malignancy. Indeed, in the case presented, our patient was provisional diagnosis was a small bowel obstruction. Awareness of this will help facilitate prompt diagnosis, management, and appropriate counselling of patients and their family.

Written informed consent was obtained from the patient’s next of kin for publication of the details of their medical case and any accompanying images. Ethical approval is not required for this study in accordance with local or national guidelines.

There are no conflicts of interest to declare.

No funding was received for this paper.

J.D.H., E.X.S., A.N., C.M.T., and H.R. were involved in substantial contributions to the work, drafting the paper, reviewing it critically, and were involved with final approval of the version to be published.

All data generated or analysed during this study are included in this article and its online supplementary material files. Further enquiries can be directed to the corresponding author.

1.
Huang
JD
,
Shao
EX
,
Tham
CM
,
Chung
E
,
Rhee
H
.
Bladder malignancy as a cause of spontaneous bladder rupture: a systematic review
.
BJUI Compass
.
2024
;
5
(
1
):
12
6
. .
2.
Ahmed
J
,
Mallick
IH
,
Ahmad
SM
.
Rupture of urinary bladder: a case report and review of literature
.
Cases J
.
2009
;
2
(
5
):
7004
. .
3.
Oray
D
,
Limon
O
,
Ertan
C
,
Ugurhan
A
.
Spontaneous bladder rupture and pelvic fracture due to bladder cancer
.
Turk J Emerg Med
.
2014
;
14
(
3
):
139
41
. .
4.
Hadjipavlou
M
,
Tharakan
T
,
Khan
SAA
,
Swinn
M
.
Spontaneous bladder rupture of a urinary bladder with non-muscle invasive bladder cancer
.
BMJ Case Rep
.
2014
;
2014
:
bcr2013201972
. .
5.
Reddy
D
,
Laher
AE
,
Lawrentschuk
N
,
Adam
A
.
Spontaneous (idiopathic) rupture of the urinary bladder: a systematic review of case series and reports
.
BJU Int
.
2023
;
131
(
6
):
660
74
. .
6.
Jayathillake
A
,
Robinson
R
,
Al-Samarii
A
,
Manoharan
M
.
Spontaneous rupture of bladder presenting as peritonitis
.
N Z Med J
.
2002
;
115
(
1164
):
U222
.
7.
Merguerian
PA
,
Erturk
E
,
Hulbert
WC
,
Davis
RS
,
May
A
,
Cockett
ATK
.
Peritonitis and abdominal free air due to intraperitoneal bladder perforation associated with indwelling urethral catheter drainage
.
J Urol
.
1985
;
134
(
4
):
747
50
. .
8.
Patel
SG
,
Weiner
AB
,
Keegan
K
,
Morgan
T
.
Oncologic outcomes in patients with nonurothelial bladder cancer
.
Indian J Urol
.
2018
;
34
(
1
):
39
44
. .