Q J Med 2003; 96: 542-543
© 2003 Association of Physicians
Correspondence |
Bladder rupture: a rare complication of tonic-clonic seizures
Department of Neurology
Department of Urology
Department of Nephrology
Sanjay Gandhi PGIMS
Lucknow
India
e-mail: ukmisra{at}sgpgi.ac.in
ukmisra{at}indiatimes.com
Sir,
A 52-year-old man taking flufenazine, resperidone and trihexyphenydil for schizophrenia had two generalized tonic-clonic seizures within an hour. During the second, he was incontinent of faeces but not urine. In a nearby hospital, he was treated with iv phenytoin and a urinary catheter was inserted which drained 10 ml of bloodstained urine. The patient was subsequently transferred to our care because of continuing coma and anuria.
At the time of transfer, he was apyrexial and normotensive. His abdomen was distended and the sign of shifting dullness could be elicited. Abdominal ultrasonography showed an empty bladder and confirmed the presence of ascites. The ascitic fluid contained 700 mg/dl protein, 135 mg/dl sugar, and 850 cells/mm3 (90% neutrophils); smear was negative for acid-fast bacilli and malignant cells.He was treated with phenytoin, ceftriaxone, metronidazole and iv fluids. Haemodialysis was carried out on days 3 and 5 after admission because of a rising serum creatinine and continuing anuria. On day 6, following a hypotensive episode, a cystogram was performed, which showed extravasation of dye into the peritoneal cavity (Figure 1). Rupture of of the urinary bladder was diagnosed and surgical repair considered but not implemented because of the patient's improving general condition. Seven days later, both repeat cystogram and serum creatinine were normal, and he was discharged.
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In our patient, presence of haematuria, absence of urinary output and increasing abdominal distension were highly suggestive of a ruptured urinary bladder. Following grand mal seizure, urinary incontinence is common, whereas our patient had faecal incontinence only, suggesting that bladder rupture might have occurred during one of the convulsions. Our patient had a seizure in the morning after overnight retention of urine. The anticholinergic effects of his drug treatment for schizophrenia may have been a contributing factor. Moreover, schizophrenic patients have been reported to have detrusor hypereflexia.1 Full bladder with possible outflow obstruction in presence of raised intraabdominal pressure during convulsions could have resulted in a ruptured bladder in our patient. The cystogram in our patient revealed the rent in the dome of the diaphragm. The bladder is protected anteriorly by pubic bone, inferolaterally by the urogenital diaphragm and obturator internus, leaving the dome unprotected, covered only by peritoneum. Our patient may have some similarity with two patients who developed bladder rupture following electroconvulsive therapy.1,2 In these patients, bladder rupture was attributed to powerful abdominal muscle contraction during an unmodified seizure on a distended bladder on a background of anticholinergic medication.
Acknowledgments
We gratefully acknowledge Mr Rakesh Kumar Nigam for secretarial help.
References
1. Irving AD, Drayson AM. Bladder rupture during ECT. Br J Psychiat 1984; 144:670.[Medline]
2. O’Brien PD, Morgan DH. Bladder rupture during ECT. Convuls Ther 1991; 7:56–9.[Medline]
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