Rare case of spontaneous extraperitoneal bladder rupture in an elderly bedbound female: a case report

Introduction

Elderly patients with extensive comorbidities often present atypically, requiring a high index of suspicion to diagnose serious conditions. Spontaneous bladder rupture (SBR) is a rare and serious urological emergency associated with trauma or underlying bladder pathology, and carries significant morbidity and mortality (1-3). In non-traumatic settings, such as in elderly, immobile, or neurologically impaired patients, SBR is exceedingly uncommon and presents unique diagnostic and management challenges.

Candiduria is typically seen in patients with urinary tract instrumentation, prior surgical procedures, recent antibiotic use, advanced age, female sex, diabetes mellitus, immunosuppressive therapy, and prolonged hospital stays (4). While Candida infections have been implicated in urinary tract complications, their direct role in bladder wall rupture remains unclear (5,6). To our knowledge, this is the first reported case of SBR in which Candida dubliniensis was isolated from the urine culture, raising the possibility of its contribution to bladder wall fragility rather than definitively establishing it as the primary cause.

Additionally, the patient was found to have an occipital infarct, raising concern for undiagnosed neurogenic bladder potentially contributing to chronic urinary retention and increased intravesical pressure, leading to overdistention and eventual rupture.

This case highlights the clinical relevance of early imaging, multidisciplinary care, and tailored management strategies in optimizing outcomes for vulnerable populations. This case further adds to the limited literature on spontaneous extraperitoneal bladder rupture, underlining the importance of recognizing fungal infections and neurological dysfunction as potential contributing factors. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-25-11/rc).

Case presentation

A 78-year-old Hispanic female with a complex medical history, including hypertension, coronary artery disease status post-coronary artery bypass graft, hyperlipidemia, chronic kidney disease (CKD), congestive heart failure, and osteoarthritis (on prednisone 10 mg daily for the past two years) presented to the emergency department with progressive abdominal pain and lethargy. Over the preceding three days, her symptoms had worsened. Her daughter reported brown-colored fluid discharge from both the urethral meatus and the anus. The patient had been bedbound for 12 months, unable to self-feed for the past two months, and fully dependent for all activities of daily living. She voided spontaneously using adult diapers and had no history of urinary catheterization.

She had a history of recurrent urinary tract infections (UTIs), most recently six months prior. At that time, a computed tomography (CT) scan of the abdomen and pelvis showed moderate diffuse inflammatory changes surrounding the bladder, highly suspicious for cystitis, without hydronephrosis or obstructing urolithiasis. An 8-mm non-obstructing stone was noted in the left renal collecting system. She was empirically treated with meropenem for five days due to a history of extended-spectrum beta-lactamase (ESBL)-producing UTIs, though urine culture showed no growth. That hospitalization was complicated by acute kidney injury (AKI), which improved with supportive management.

On current presentation, physical examination revealed diffuse abdominal tenderness. A CT scan of the abdomen and pelvis (Figure 1) revealed a bladder wall rupture with bilateral hydronephrosis, in the absence of obstructing urolithiasis. Surgical consultation recommended conservative management, including intravenous fluids, broad-spectrum antibiotics (meropenem and vancomycin), and Foley catheter placement. Urology advised close monitoring of urine output and deferred potential nephrostomy tube placement based on clinical progression. Additional findings included an occipital infarct on CT head and laboratory evidence of leukocytosis, lactic acidosis, and AKI superimposed on her pre-existing CKD.

Figure 1 Computed tomography of the abdomen and pelvis in (A) coronal, (B) sagittal and (C) axial views demonstrates mild, diffuse thickening of the urinary bladder wall with adjacent ill-defined hazy densities, extensive perivesical fat stranding, and a small to moderate fluid collection (yellow arrows). A small free air loculus (red arrows) is noted posterior to the bladder, raising concern for urinary bladder rupture with associated secondary changes. Additionally, there is evidence of mild to moderate bilateral hydroureteronephrosis with distal ureteric transitions, likely related to vesicoureteric reflux, with no ureteric calculi identified.

The patient was admitted to the medical intensive care unit for septic shock management. She received aggressive fluid resuscitation, which improved her mean arterial pressures. Given her chronic steroid use, stress-dose steroids were initiated. Infectious disease and nephrology were consulted. Hemodialysis was not immediately required, and the patient maintained adequate urine output via the indwelling Foley catheter. Urine culture later grew Candida dubliniensis, prompting initiation of micafungin.

On hospital day 16, the patient developed hypotension (blood pressure 67/40 mmHg) and tachycardia (heart rate 124 bpm). Electrocardiogram showed sinus tachycardia with right bundle branch block. A fluid bolus and metoprolol were administered. Repeat imaging revealed loculated air collections above the bladder. Labs showed worsening leukocytosis and bandemia. Blood cultures were obtained, and antimicrobial regimen was broadened to meropenem and linezolid to cover vancomycin-resistant Enterobacteriaceae faecium. Vasopressor support (phenylephrine and vasopressin) was initiated for persistent hypotension.

On hospital day 17, a repeat CT imaging revealed worsening bladder leak with an adjacent fluid collection, a fistulous tract between the sigmoid colon and vaginal cuff, and findings consistent with proctocolitis. Interventional radiology placed a 10-French pigtail suprapubic catheter under CT guidance, draining 125 mL of purulent fluid. Cultures grew Candida dubliniensis and Pseudomonas aeruginosa. Antimicrobials were continued. Table 1 provides the timeline of events.

Surgical intervention was deferred after consultation with colorectal surgery and gynecology due to the patient’s poor functional status, significant comorbidities, and high perioperative risk. Her hospital course was further complicated by refractory septic shock, worsening renal function requiring dialysis, and overall clinical decline. After thorough discussion with the care team and palliative care, the family opted for comfort-focused care. The patient subsequently passed away.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardian for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal upon request.

Discussion

SBR is a rare but life-threatening condition, typically presenting with nonspecific abdominal symptoms that delay diagnosis and intervention. While most cases involve intraperitoneal urinary leakage (1-3), this case developed an extraperitoneal rupture in the absence of trauma, likely due to a confluence of predisposing factors—chronic immobility, advanced age, chronic steroid use, and recurrent urinary tract infections.

Bladder rupture is anatomically defined based on the location of the rupture and urine extravasation in relation to the peritoneum. Intraperitoneal ruptures generally involve the bladder dome, while extraperitoneal ruptures affect the bladder base and are often linked to increased intravesical pressure or weakened bladder walls (7-9). In the majority of cases, there is an underlying bladder pathology as an etiology for SBR (Table 2), although idiopathic SBR may occur, as it appears to be in this case (10).

The vague presentation, abdominal pain, lethargy and sepsis, can mimic other abdominal pathologies, delaying recognition (11,12). In addition to physical signs like suprapubic pain and urinary leakage, laboratory findings may include elevations in creatinine and blood urea nitrogen, mimicking renal failure but lacking specificity (13).

CT cystography remains the diagnostic gold-standard, with sensitivity of 87–100% and a specificity of 64–100% for detecting bladder rupture (14). However, small or incompletely filled bladder perforations may elude initial detection, necessitating repeat imaging if suspicion persists (15).

Extraperitoneal ruptures typically require conservative management, with bladder drainage and antibiotics, reserving surgical intervention for patients with worsening infection, abscess formation, or persistent leaks (13,16). This patient initially improved with conservative measures, but developed worsening sepsis and bladder leak, ultimately requiring suprapubic catheter placement by interventional radiology. Surgery was deferred due to poor functional status and high perioperative risk.

The incidental occipital stroke raises a potential neurological etiology for chronic urinary retention. Although occipital strokes are not classically associated with micturition control, in elderly, bedbound individuals with global neurological compromise, the risk of functional or neurogenic bladder dysfunction may be underestimated. This, combined with increased intravesical pressure and an impaired immune response, may have set the stage for rupture.

The role of infection, particularly fungal, remains unclear. Candida dubliniensis was isolated from both urine and suprapubic fluid aspirate. While candiduria is often a benign colonization in hospitalized or immunocompromised patients, its presence alongside Pseudomos aeruginosa raises concern for chronic infectious cystitis contributing to bladder wall compromise. However, given the absence of candidemia and lack of invasive fungal disease, it is more plausible that Candida may be a secondary colonizer rather than a primary cause of rupture.

Conservative management was aligned with American Urological Association guidelines, and nephrostomy was considered as a backup should further deterioration occur (17). Unfortunately, despite multidisciplinary efforts, the patient succumbed to complications of refractory septic shock and multiorgan failure.

Conclusions

This case illustrates the diagnostic challenges of SBR in medically complex, immobilized elderly patients. Clinicians should maintain a high index of suspicion for SBR in individuals presenting with nonspecific symptoms such as abdominal pain and lethargy, particularly those with multiple comorbidities, a history of recurrent UTIs, and immunosuppression. The potential contribution of fungal cystitis, particularly involving Candida dubliniensis, to bladder wall compromise remains unclear but warrants further study. The concurrent finding of an occipital stroke also raises consideration for neurogenic bladder dysfunction as a silent contributor to urinary retention and overdistension. Timely imaging with CT cystography, close multidisciplinary collaboration, and invidualized management plans are vital to optimizing outcomes. This report contributes to the limited literature on spontaneous extraperitoneal bladder rupture, emphasizing the need for vigilance, and early intervention in high-risk, medically fragile populations.

Acknowledgments

We express our gratitude to Dr. Daniel Rabinowitz for his invaluable contributions to the urological management of this case and for his critical insights during the preparation of this manuscript.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-25-11/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-25-11/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-25-11/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardian for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal upon request.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Simon LV, Sajjad H, Lopez RA, et al. Bladder rupture. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
2. Sholklapper T, Elmahdy S. Delayed diagnosis of atraumatic urinary bladder rupture. Urol Case Rep 2021;38:101723. [Crossref] [PubMed]
3. Al-Qassim Z, Mohammed A, England R, Khan Z. Idiopathic spontaneous rupture of the urinary bladder (SRUB): a case report and review of literature. Cent Eur J Urol 2012;65:235-7. [Crossref] [PubMed]
4. Bukhary ZA. Candiduria: a review of clinical significance and management. Saudi J Kidney Dis Transpl 2008;19:350-60.
5. Mardani M, Shahzadi M, Rakhshani N, et al. Spontaneous perforation of urinary bladder secondary to Candida cystitis: acute abdomen of urologic origin. Surg Infect (Larchmt) 2008;9:525-7. [Crossref] [PubMed]
6. Polacheck I, Strahilevitz J, Sullivan D, et al. Recovery of Candida dubliniensis from non-HIV-infected patients in Israel. J Clin Microbiol 2000;38:170-4. [Crossref] [PubMed]
7. Jenkinson LR. Spontaneous intraperitoneal rupture of the urinary bladder. Postgrad Med J 1981;57:269-70. [Crossref] [PubMed]
8. Loganathan A, Wood J, Pridgeon S. Idiopathic spontaneous rupture of the urinary bladder: An unusual presentation of intraperitoneal bladder rupture managed conservatively. Urol Case Rep 2019;24:100873. [Crossref] [PubMed]
9. Gomez RG, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int 2004;94:27-32. [Crossref] [PubMed]
10. Bakhshi GD, Siddique M, Jadhav KV, et al. Spontaneous rupture of the urinary bladder: a case report and review of literature. J Med Sci Clin Res 2016;4:12562-4.
11. Anderson RE, Keihani S, Moses RA, et al. Current Management of Extraperitoneal Bladder Injuries: Results from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS). J Urol 2020;204:538-44. [Crossref] [PubMed]
12. Reddy D, Laher AE, Lawrentschuk N, et al. Spontaneous (idiopathic) rupture of the urinary bladder: a systematic review of case series and reports. BJU Int 2023;131:660-74. [Crossref] [PubMed]
13. Zhao S, Duan H, Wang Y, et al. Spontaneous rupture of the urinary bladder: A rare case report. Heliyon 2023;9:e17129. [Crossref] [PubMed]
14. Devlies W, de Jong JJ, Hofmann F, et al. The Diagnostic Accuracy of Cystoscopy for Detecting Bladder Cancer in Adults Presenting with Haematuria: A Systematic Review from the European Association of Urology Guidelines Office. Eur Urol Focus 2024;10:115-22. [Crossref] [PubMed]
15. Zhang Y, Yuan S, Alshayyah RWA, et al. Spontaneous Rupture of Urinary Bladder: Two Case Reports and Review of Literature. Front Surg 2021;8:721705. [Crossref] [PubMed]
16. Rodríguez Rodríguez A, Vendrell R, Luque P, et al. Spontaneous bladder perforation secondary to bacterial cystitis. Cause of acute abdomen in diabetic elderly. Actas Urol Esp 1995;19:393-7.
17. Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol 2014;192:327-35. [Crossref] [PubMed]