Unsuspected intraperitoneal perforation of the urinary bladder as an iatrogenic disorder

Perforation of the urinary bladder associated with long-term indwelling catheter drainage is a rare and lethal iatrogenic disorder. Moreover, bladder perforation can occur in a variety of surgical settings. We report here several unusual situations: one in which a fibroid uterus probably played a role in pressure necrosis of a bladder with an indwelling catheter, one in which carcinoma of the prostate and faulty catheter drainage was present, and one in which pelvic radiation therapy was followed by bladder perforation. These three cases illustrate the clinical acumen required to recognize intraperitoneal perforation. The variety of presentations is suggested by the fact that one case was diagnosed preoperatively by cystogram, one was unexpectedly found at laparotomy for acute peritonitis, and one was discovered only at autopsy. One of the patients was diabetic, two had been treated for miliary tuberculosis, and all had a history of long-term urinary bladder catheterization. Bladder perforation can be prevented by several alternative methods of chronic bladder drainage. The diagnosis of the problem requires a high degree of clinical suspicion, aided by definitive cystograms. The treatment is surgical, including prompt repair of the perforation and drainage of the bladder.