Traumatic intraperitoneal bladder rupture in a toddler: a case report

¹Faculty of Surgery, University of Health and Allied Sciences, School of Medicine, Ho, Ghana, ²Department of Surgery, Ho Teaching Hospital, Ho, Ghana

^&Corresponding author
Frank Obeng, Faculty of Surgery, University of Health and Allied Sciences, School of Medicine, Department of Surgery, Urology Unit, Ho Teaching Hospital, Ho, Ghana

Introduction    

Intraperitoneal bladder rupture is a rare but significant complication of blunt abdominal trauma, accounting for 15-30% of bladder injuries [1]. In pediatric patients, this condition is even rarer due to the unique anatomical and physiological characteristics of children. Bladder rupture is often associated with high-energy trauma, such as road traffic accidents (RTAs), and its diagnosis requires a high index of suspicion. The occurrence of intraperitoneal bladder rupture in the pediatric population is even more uncommon. Early recognition and prompt surgical intervention are crucial to achieving optimal outcomes for these patients [2,3]. While the existing literature provides valuable insights into bladder injuries, rare injury mechanisms such as the one presented in this case require increased clinical awareness to ensure accurate diagnosis and timely treatment. This case is particularly notable due to the unusual mechanism of injury a high-speed side-impact collision followed by vehicular somersault- which resulted in intraperitoneal bladder rupture. The violent nature of the crash, combined with the child potentially having a full bladder after two hours of travel, may have increased the likelihood of such an injury. Literature suggests that 80-90% of intraperitoneal bladder ruptures occur when the bladder is full during blunt abdominal trauma [4-7]. This case also highlights the severity of the trauma, with the child sustaining a femoral shaft fracture while the other adult passengers tragically lost their lives. Here, we present a case of a 2-year-old girl who sustained an intraperitoneal bladder rupture following a severe RTA. This report highlights the diagnostic challenges and emphasizes the importance of prompt surgical intervention in managing such injuries [6,7]. We report a case of traumatic intraperitoneal bladder rupture in a toddler following an RTA to raise awareness of this rare condition and its management.

Patient and observation     

Patient information: a 2-year-old girl of African descent presented to the emergency department following a high-speed RTA. She had been an unrestrained passenger in a cargo vehicle that somersaulted after a side-impact collision. Tragically, all other passengers died on site. The child was ejected during the crash.

Clinical findings: the child presented with a distended abdomen, everted umbilicus and generalized abdominal tenderness. Additional findings included a sutured forehead laceration and a deformed right thigh, consistent with a left femoral shaft fracture. Vital signs were pulse 148 bpm, respiratory rate 52 cycles per minute, SpO2 99% on room air and temperature 37.8°C. Bowel sounds were present.

Timeline of current episode: Day 0: RTA and emergency presentation; Day 1: stabilization and diagnostic evaluation; Day 2: emergency laparotomy for bladder repair; Day 14: discharge following recovery.

Diagnostic assessment: laboratory tests revealed anemia (Hb 6.4 g/dL), elevated creatinine (180.12 μmol/L), and hyponatremia (131 mmol/L). Abdominopelvic ultrasound showed intra-abdominal free fluid and a poorly filled bladder. Paracentesis confirmed urine ascites. Diagnosis of traumatic intraperitoneal bladder rupture was made.

Therapeutic interventions: initial management included intravenous fluids, antibiotics (ceftriaxone and metronidazole) and analgesics. Laparotomy revealed a 5 cm fundal bladder rupture. The bladder was repaired in two layers using absorbable sutures and the abdominal cavity was irrigated. Post-operatively (Table 1), the patient received supportive care, including catheter drainage and close monitoring (Figure 1, Figure 2, Figure 3).

Follow-up and outcome of interventions: the child had an uneventful recovery and was discharged home on post-operative day 14. Follow-up evaluations confirmed normal bladder function and resolution of associated injuries (Figure 4, Figure 5, Figure 6).

Patient perspective: the patient's family expressed gratitude for the care provided, highlighting the timely diagnosis and successful surgical outcome.

Informed consent: informed consent was obtained from the patient's guardian for publication of this case report.

Discussion     

Bladder rupture in children is rare, accounting for less than 1% of pediatric trauma cases. Intraperitoneal rupture is associated with significant trauma, particularly when the bladder is full. In this case, the child's distended bladder likely predisposed her to rupture during the RTA [1]. Diagnostic challenges arise due to nonspecific symptoms such as abdominal distension and a reduced urinary drainage. Imaging, including ultrasound and cystography, is crucial. However, in hemodynamically unstable patients, early surgical exploration may be necessary as in this case. Surgical repair of bladder rupture involves meticulous closure to prevent leakage and ensure healing. Post-operative care focuses on preventing infection and monitoring bladder function. Multidisciplinary management is essential for optimal outcomes.

In the tabular summary of pre-existing literature (Table 2), we reviewed various studies on pediatric intraperitoneal bladder injuries, highlighting key demographic and clinical details. Osman et al. (2005) reported outcomes for 8 patients with differing management strategies [8,9]. Bakal et al. (2014) noted a mean recovery of 15 days among 10 patients with pelvic injuries managed by laparotomy [10]. Yogo et al. (2019) successfully managed a patient with intraperitoneal bladder rupture, nonoperatively [7]. Zhang et al. (2021) discussed complications related to misdiagnosis [2], while Shah and Shah (2022) documented a successful laparoscopic repair in a 1-year-old [5]. Lautz et al. (2009) reported a bladder rupture with unspecified outcomes [7]. These findings underscore the variability in presentations and management of pediatric bladder injuries across studies. The findings in Table 2 also underscore how uncommon intraperitoneal bladder ruptures are; as from the table, between 2005 and 2022 the total number of reported cases were 23. Again, from the table [2,7,9,10], the sex distribution of these injuries suggests a probable female preponderance (13 females (56.52%), versus 10 males (43.48%, Table 2). The unique anatomical and physiological characteristics of children, such as a more pliable abdominal wall and relatively larger, but less distensible bladder relative to body size, can predispose them to bladder injuries during trauma [10]. The index case underscores the importance of considering bladder rupture in the differential diagnosis of pediatric patients presenting with signs of intra-abdominal injury and femoral shaft fracture, following blunt trauma [3] in an RTA.

The clinical presentation of bladder rupture can be subtle and easily missed if not considered early. Symptoms may include abdominal distension, reduced urinary drainage, haematuria and signs of peritonitis [3]. In the index case, the increasing abdominal size, generalized (mild) tenderness, and minimal urine output despite adequate hydration were key indicators. Imaging plays a crucial role in diagnosing bladder rupture. Abdominopelvic ultrasound can reveal free fluid in the abdomen, although it may not always pinpoint the exact source. In the index case, the ultrasound showed significant intra-abdominal fluid but an underfilled bladder, raising suspicion for bladder injury. Further diagnostic procedures, such as cystography, and computed tomography scan are essential to confirm the diagnosis and plan surgical intervention, but in our case, even though we acknowledge cystography as the gold-standard diagnostic modality for bladder rupture [7], by the end of the second abdominopelvic ultrasound scan, the diagnosis had been firmed-up. So, we rather focused on proceeding urgently to surgery. By this, we spared precious time, since the index patient was not stable [7]. We also spared this pediatric patient an exposure to radiation by precluding an initial cystography. Surgical repair of bladder rupture involves identifying and closing the ruptured site [5]. Intra-operative findings in this case included a completely ruptured bladder fundus with the urethral catheter displaced into the abdominal cavity. Repair was achieved using a two-layer closure technique, which is standard practice to ensure watertight closure and promote healing [3].

Post-operative management focuses on preventing infection, ensuring adequate pain control, and monitoring the patient for complications such as urinary leakage or infection. The use of broad-spectrum antibiotics, regular monitoring of vital signs, and maintaining a strict input-output chart are critical components of care [2]. Despite an initial postoperative fever and catheter blockage, timely interventions and continued care led to a successful recovery of the index case. Comparing this index case with others in the literature, we observe varying mechanisms, management approaches and outcomes. For instance, Yogo et al. (2019) documented a successful conservative management approach for an intraperitoneal bladder rupture, highlighting that non-operative treatment can be effective under certain conditions of isolated intraperitoneal bladder rupture [5]. In contrast, our case necessitated immediate surgical intervention due to the nature of the injury and the child's hemodynamic status. Further literature, including the findings from Zhang et al. (2021) and Lautz et al. (2009), indicates that such injuries can frequently be misdiagnosed due to nonspecific symptoms [2]. This underlines the importance of a high index of suspicion in pediatric patients, particularly following significant trauma. Recognizing the signs of bladder injury such as gross haematuria and abdominal tenderness can be crucial for timely diagnosis and management [2].

Overall, this case not only illustrates the complexities of pediatric trauma but also serves as a reminder of the critical importance of seatbelt and appropriate restraint systems for children in vehicles. Enhanced awareness among caregivers and clinicians can lead to better prevention strategies and improved management outcomes in similar traumatic events. This case also highlights the importance of multidisciplinary care in managing complex pediatric trauma cases. Collaboration between pediatric surgeons, radiologists, and nursing staff is vital for comprehensive care and optimal outcomes. The successful management of this client was a result of such a collaborative approach, ensuring timely diagnosis, appropriate surgical intervention and meticulous postoperative care [3]. The management of bladder rupture in pediatric patients also requires consideration of long-term outcomes [7]. Potential complications include bladder dysfunction, recurrent urinary tract infections and renal impairment. Long-term follow-up with a pediatric urologist is recommended to monitor and address any sequelae.

Conclusion     

This case highlights the rarity of intraperitoneal bladder rupture in pediatric patients and underscores the importance of high clinical suspicion, prompt diagnosis and surgical intervention. Public health measures, including appropriate child restraints in vehicles, are crucial in preventing similar injuries.

Competing interests     

The authors declare no competing interests.

Funding     

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions     

Frank Obeng and Aishah Fadila Adamu contributed to the conception and drafting of the manuscript. Samuel Edudzi Gavor provided clinical oversight and first draft of the manuscript. All authors approved the final version of the manuscript.

Acknowledgements     

We thank the medical and nursing staff at the Ho Teaching Hospital for their exceptional care. We also appreciate the patient's family for their consent and cooperation.

Tables and figures     

Table 1: post-operative management summary

Table 2: literature review on pediatric intraperitoneal bladder rupture

Figure 1: bladder rupture at the fundus with the urethral catheter displaced into the peritoneal cavity

Figure 2: bladder rupture site and the displaced urethral catheter

Figure 3: bladder rupture demonstrated between two surgical clamps, providing a clear view of the rupture margins and the extruded tip of the urethral catheter

Figure 4: normal bladder contours with no evidence of contrast leakage, confirming successful repair

Figure 5: absence of contrast extravasation, confirming bladder integrity post-repair

Figure 6: absence of contrast leakage, indicating a well-healed bladder repair

References