Urinary Ascites Mimicking Portal Hypertension in a Healthy Woman With Bladder Microperforation

Urinary ascites is a rare cause of ascites that can present with a high serum-ascites albumin gradient (SAAG), mimicking portal hypertension. Here we present a case of a 42-year-old woman with a history of cesarean section and a total laparoscopic hysterectomy (both remote and uncomplicated) that presented to the ED with abdominal ascites and pseudo-acute kidney injury after developing sudden, severe suprapubic pain during urination. Workup initially suggested a portal hypertension etiology due to a high SAAG; however, liver function and cardiac workup were normal. Her serum creatinine normalized after placing a Foley catheter; however, creatinine rebounded upon catheter removal, and urinary ascites was then confirmed by an elevated ascitic creatinine level. In follow-up, cystoscopy revealed a posterior bladder diverticulum with scar, demonstrating the likely culprit lesion of the bladder rupture. Urodynamics showed delayed bladder sensation due to dysfunctional voiding habits. The patient was advised to time voids, keeping volumes below 400-600 cc, and was scheduled for a six-month follow-up for uroflowmetry and post-void residual (PVR) measurement. This case highlights the importance of not overlooking urinary ascites in patients with unexplained ascites and concurrent apparent AKI, even in the absence of obvious risk factors such as this patient.