An independent 99-year-old community-dwelling man was admitted after being found on the floor, confused and complaining of diffuse abdominal pain and difficulty voiding.
His past medical history included obesity, diabetes, hypertension, and benign prostatic hyperplasia.
Examination showed a stuporous patient, abdominal distention, and diffuse abdominal tenderness. Bladder catheterization yielded 600 mL of bloody urine. Laboratory tests revealed serum creatinine 13.7 mg/dL (6 days prior: 1.15 mg/dL), blood urea nitrogen 96 mg/dL, sodium 123 mEq/L (glucose 225 mg/dL), potassium 7.8 mEq/L, phosphorus 12.2 mEq/L, calcium 8.7 mEq/L, and pH 7.15 (base excess −6.5). Serum proteins, muscle and liver enzymes, and blood counts were normal. Cultures were negative.
X-ray studies and head computed tomography (CT) were unremarkable. Abdominal CT revealed some free fluid. Hyperkalemia was treated. Catheter irrigation with 400 mL normal saline yielded back only 200 mL. CT cystography with retrograde contrast demonstrated intraperitoneal extravasation (Figures 1 and 2). He was successfully operated on and made a slow recovery, and was discharged with creatinine 1.2 mg/dL.
Our patient had perforated his urinary bladder after a low, “simple” same-level fall, without pelvic fracture—an extremely rare occurrence.
The bladder is usually well protected by the anterior bony pelvis. Bladder perforation seen in blunt trauma is associated with pelvic fracture in almost all cases.1
The incidence of urinary retention in men increases with age, likely >30% octogenarian men have urinary retention. In our patient, the bladder was full when he fell, probably associated with his benign prostatic hyperplasia and possibly neurogenic weak detrusor contractility due to the diabetes and diabetic autonomic neuropathy. Thus, the dome—the weakest part of the bladder—was susceptible to intraperitoneal rupture.1Difficulty voiding, gross hematuria (sensitivity >90% in rupture of the bladder), abdominal tenderness, and seemingly “severe renal failure” were the presenting findings. Actually, the elevated serum creatinine and hyperkalemia in this case are likely the result of transperitoneal absorption of the extravasated urine, following his intraperitoneal rupture of the urinary bladder.2
Ground-level falls are highly prevalent in the elderly and trigger an evaluation for bone fractures and brain injury—the most common serious sequela.3 Internal organ contusion, severe enough to cause rupture, is often not considered, although reported in up to 0.8%,4 a substantial number given the frequency of falls in the elderly. Myriad such injuries have been reported for isolated patients, including ruptured spleen, bowel, and gallbladder.5
Physicians evaluating elderly patients who have sustained a “minor” fall should be aware of the potential for occult serious internal organ injuries, including rarely reported rupture of the urinary bladder without pelvic fracture.
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-Ami Schattner, MD, Ina Dubin, MD, Yair Glick, MD
This article originally appeared in the January issue of The American Journal of Medicine.
