Uroperitoneum as an Atypical Source of Ascites: A Case Report

Uroperitoneum secondary to spontaneous bladder rupture is a rare cause of ascites associated with significant morbidity and mortality. It can be difficult to detect and is often initially mistaken for other, more common etiologies. We present the case of a 56-year-old female with a history of cervical cancer treated with chemotherapy and radiation, radiation proctitis, and diabetes mellitus who presented with subacute onset abdominal pain and distension, urinary retention, and nausea. She had been diagnosed with cervical squamous cell cancer 12 years prior to presentation and was successfully treated with two months of chemotherapy and radiation, and a presumed recurrence five years later was treated to remission with chemotherapy. The golden-yellow appearance of her ascitic fluid during diagnostic paracentesis raised suspicion for urinary ascites that was confirmed by an elevated ascites-to-serum creatinine ratio and computed tomography (CT) cystography. Subsequent CT cystogram demonstrated leakage of contrast from the bladder with a 0.5 cm irregularity noted at the bladder dome, potentially representing the site of extravasation. A Foley catheter was placed at the time of admission with an immediate output of 1 L of fluid. Subsequently, her abdominal distension significantly improved, and her creatinine began to downtrend. Gynecologic oncology and urology were consulted and determined that she was not a candidate for surgical intervention given the significance of her bladder scarring. Positron emission tomography (PET)/CT was performed and revealed no active cancer. At the time of discharge, she had no episodes of emesis. Additionally, her creatinine had fallen to 1.0 mg/dl. She was discharged with a Foley catheter with plans to follow up with outpatient urology. While relatively uncommon, uroperitoneum should be suspected in patients presenting with new-onset ascites who have risk factors for spontaneous bladder rupture such as pelvic irradiation. Uroperitoneum has a significant rate of mortality and morbidity. Ascites urea and creatinine studies, followed by a CT cystogram if these studies are abnormal, should be performed in any patient with risk factors for uroperitoneum. Patients should be managed with the placement of a Foley catheter and urology consultation for surgical evaluation.