Intraperitoneal Urinary Extravasation Associated with Infected Urachal Cyst

A 68-year-old man presented to the emergency department with diffuse abdominal pain, fevers, chills, anorexia and anuria. Abdominal pain began 3 days before presentation with fevers on the following day. He had noticed no urinary output for the previous 72 hours. Diet for the last 6 months had consisted primarily of alcohol. On physical examination the patient was cachectic and in moderate distress with rebound abdominal tenderness and no evidence of blunt or penetrating trauma. Urinary catheterization yielded 30 cc of dark urine. Blood urea nitrogen and creatinine were 14 mg./dl. (normal 7 to 21) and 0.7 mgJdl. (normal 0.6 to 1.4), respectively, and serum albumin was 1.9 gm./dl. (normal 3.8 to 5). Due to possible rupture of the bladder a cystogram was performed, which demonstrated dif€uae intraperitoneal extravasation (see figure). The patient underwent immediate exploratory lapamtomy. At surgery the urachus was noted to be increasingly dilated from 4 cm. below the umbilicus to the level of the bladder dome. "he caudal aspect of the urachus and bladder dome was necrotic with communication between the bladder lumen and peritoneum a t this level. The necrotic bladder dome was excised and closed in layers aRer a suprapubic catheter was placed. The peritoneum was explored and was otherwise unremarkable for intraperitoneal processes except for significant collections of pus. It was copiouely irrigated, drained and closed. Despite the administration of antibiotics and fluids, and ventilatory and hemodynamic support the patient died 3 days postoperatively of overwhelming sepsis and multisystem failure. Histological evaluation of the removed bladder dome and urachus as well as a postmortem examination were consistent with an infected urachal cyst with necrosis of the bladder dome and intraperitoneal urinary extravasation with peritonitis. disease (such as radiation cystitis, bladder cancer, amyloidosis, tuberculosis and infection), instrumentation, pregnancy and alcohol consumption. Intrinsic bladder disease predisposes the bladder to rupture. Alcohol consumption, which predisposes to trauma and chronic consumption resulting in nutritional depletion, may weaken bladder resistance to rupture. Our patient presented with an acute abdomen and no history or clinical evidence of blunt or penetrating trauma. On a cystogram intraperitoneal contrast material and several bladder diverticula were seen. Intraoperatively the bladder dome WBB found to be necrotic. Histologically there was no evidence of intrinsic bladder disease except for focal acute and chronic inflammatory changes. Our patient was nutritionally depleted and had a urachal cyst that became infected, resulting in peritonitis and intraperitoneal bladder rupture. The urachus is an embryonic tubular structure that connects the developing bladder with the allantois at the umbi-