Perforation of continent caecal reservoir for urine twice in one patient

Perforation of a continent caecal reservoir, presumably during catheterization, occurred twice in a 64-year-old woman, 52 and 59 months after urinary diversion, during hyperglycemic confusion. Acute overdistension of the reservoir, creating high tension in its wall, with resulting weakness, could have been an underlying cause of the perforation. Awareness of this potentially lethal complication in patients with augmented bladder or continent urinary reservoir is necessary.