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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 3  |  Page : 552-555
Bladder perforation in a peritoneal dialysis patient


1 Department of Internal Medicine A and Laboratory of Kidney Pathology LR 00 SP 01, Charles Nicolle's Hospital, Tunis, Tunisia
2 Department of Urology, Charles Nicolle's Hospital, Tunis, Tunisia

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Date of Web Publication7-May-2012
 

   Abstract 

The dysfunction of the catheter in peritoneal dialysis (PD) is a frequent compli­cation. However, perforation of organs are rare, particularly that of the urinary bladder. This re­quires an early diagnosis and prompt treatment of patients. We report here the case of a 38-year-old woman having end-stage renal disease due to autosomal-dominant polycystic kidney disease treated by PD since November 2000. Three years later, she was treated for Staphylococcal peritonitis. Four months later, she presented with a severe urge to urinate at the time of the fluid exchanges. The biochemical analysis of the fluid from the bladder showed that it was dialysis fluid. Injection of contrast through the catheter demonstrated the presence of a fistula between the bladder and the peritoneal cavity. She underwent cystoscopic closure of the fistulous tract and the PD catheter was removed. Subsequently, the patient was treated by hemodialysis. One month later, a second catheter was implanted surgically after confirming the closure of the fistula. Ten days later, she presented with pain at the catheter site and along the tunnel, which was found to be swollen along its track. The injection of contrast produced swelling of the subcutaneous tunnel but without extravasation of the dye. PD was withdrawn and the patient was put back on hemodialysis. Bladder fistula is a rare complication in PD and diagnosis should be suspected when patient complains of an urge to pass urine during the exchanges, which can be confirmed by contrast study showing presence of dye in the bladder. PD may be possible after the closure of the fistula, but recurrence may occur.

How to cite this article:
Ounissi M, Sfaxi M, Fayala H, Abderrahim E, Abdallah T B, Chebil M, Maiz H B, Kheder A. Bladder perforation in a peritoneal dialysis patient. Saudi J Kidney Dis Transpl 2012;23:552-5

How to cite this URL:
Ounissi M, Sfaxi M, Fayala H, Abderrahim E, Abdallah T B, Chebil M, Maiz H B, Kheder A. Bladder perforation in a peritoneal dialysis patient. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 Apr 25];23:552-5. Available from: http://www.sjkdt.org/text.asp?2012/23/3/552/95803

   Introduction Top


Mechanical complications of peritoneal dialysis catheters are frequent and often prevent the good daily exchanges. This results in poor-quality dialysis. The malfunctioning due to shifting of the catheter tip, kinking and obs­truction due to fibrin deposition or a clot in the catheter are the main mechanical complications reported in the literature. [1],[2] Perforations of the nearby organs are rare, and very few have been reported. We report a case of bladder perfora­tion in a patient on treatment with peritoneal dialysis (PD).


   Case Report Top


Mrs. M. H., 38-years old, is a known case of autosomal-dominant polycystic kidney disease (ADPKD) and hypertension discovered in 1994 during the exploration of an abscess of the right kidney. Family survey revealed that other family members also had ADPKD. In 1999, she was hospitalized for toxemia of pregnancy with renal insufficiency, with serum creatinine of 200 μmol/L. One year later, in April 2000, she reached end stage renal di­sease (ESRD) and, since then, the patient is on treatment with automated PD. In December 2003, she had recurrent peritonitis with methicillin-resistant Staphylococcus aureus (MRSA) requiring prolonged antibiotic therapy using vancomycin and a third-generation cephalosporin for ten weeks with complete resolution.

Two months later, she presented with urgency to urinate and "urine" leakage during the in­flow of PD fluid. Chemical analysis of the lea­kage fluid tested positive for glucose, thereby denoting that it was the dialysate. A peritoneo-vesical fistula was considered as the possibility and a contrast study through the catheter con­firmed the vesical leakage [Figure 1].
Figure 1: A peritoneo-vesical fistula.

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The PD was discontinued and cystoscopic repair of the fistula was done. Two months later, filling the bladder with contrast media showed occlusion of the fistula and, therefore, to continue with PD, a second catheter was inserted under general anesthesia. However, ten days later, she developed pain and swelling at the subcutaneous tunnel of the catheter. A contrast study done at this time demonstrated subcutaneous leakage of the fluid [Figure 2] necessitating stopping of PD and removal of the catheter. The patient was then transferred to hemodialysis.
Figure 2: Parietal extravasation of the contrast.

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   Discussion Top


Catheter dysfunction due to mechanical com­plications is frequent during the PD, causing poor inflow and/or outflow of the dialysate. The migration of the catheter tip catheter tip or blockage due to kinking is generally easy to solve by use of laxatives or by surgical manipulation.

The leakage of peritoneal fluid has been des­cribed by several authors. [1],[2] Mostly, it is the leakage around the catheter which occurs early, and can be recognized easily and without delay. [1] Leakages have been reported causing swelling of the penis and scrotum and, in females, that of the labia majora. [2]

Peripheral subcutaneous leakages have also been described, giving an orange-peel skin appearance of skin over the anterior abdominal wall and, sometimes, even extending poste­riorly. Some teams have reported peritoneopleural leakages in patients presenting with dyspnea, and extravasation of fluid could be confirmed radiologically. [3],[4]

The leakages are more common in the older age group and in those who are obese. The the­rapeutic approach consists of reducing the intra-peritoneal pressure, removal of the catheter and transferring the patient to hemodialysis. [5]

Occurrence of peritoneo-vesical fistula is rare. Our search revealed only 13 cases in the literature. [1] Most often, it is due to accidentally putting the catheter into the bladder if the bladder was not emptied prior to the procedure or when bladder sensations are poor in those with neurogenic bladder. The diagnosis may be delayed sometimes due to misinterpretation of the radiographs taken. Bamberger et al in 1993 reported bladder perforation during the insertion of PD catheter in a diabetic patient. [6] Moreiras et al also reported a similar incident in another diabetic patient. [7] The predisposing factors were a full bladder not verified before insertion of the catheter and presence of peri­toneal adhesions in a patient having surgical abdomino-pelvic antecedents. [7]

We report one case of the peritoneo-vesical fistula in a young and thin patient. She pre­sented 46 months after the beginning of PD with recurrent peritonitis with MRSA, which was resistant initially but responded to appro­priate antibiotic therapy with vancomycin and third-generation cephalosporin for a sufficient length of time.

The prolonged stasis of the infected liquid and the non-removal of the catheter could re­sult in alteration of the peritoneal structure, and may explain the appearance of the peritoneo-vesical fistula. The diagnosis should be strongly suspected from the history and should be con­firmed by chemical study of the extravasating fluid and by the demonstration of the fistula using contrast study.

Cystoscopy facilitates the removal of the ca­theter and also closure of the fistula. PD can be resumed later. The same therapeutic approach has been advocated by several authors. [6],[7] In high-risk patients, many also recommend obligatory checking of the bladder before insertion of the PD catheter as well as before doing pro­cedures such as a laparoscopy or a colonoscopy. [1],[5],[8]

The resumption of PD is possible after clo­sure of the fistula, like in our case, but a pa­rietal leakage appeared two weeks later, neces­sitating us to stop it again and transfer the patient to hemodialysis permanently. Several similar cases have been reported in the literature. [8] This second leakage testifies the altered state of the peritoneal membrane secondary to the prolonged peritonitis she had with drug-resistant germs.

The mechanical complications arising from catheter malfunctions during peritoneal dia­lysis are frequent and can generally be treated. The PD fluid leakages are rare and require a quick diagnosis and prompt treatment, inclu­ding temporary or permanent stopping of the procedure. The fistulas between the peritoneum and the nearby viscera are rare and are due to factors concerning the condition of the patient and the quality of the insertion technique. Improper treatment and extended period of peritonitis damage the peritoneal membrane and favor the formation of these fistulas. Because peritoneo-vesical fistulae are rare, and that too are commonly seen in the elderly and obese people, their occurrence in our well-dialyzed, non-obese young, female patient seem to favor the damage to the peritoneum from recurrent and prolonged peritonitis with re­sistant germs as the predisposing factor. The position of the catheter should by regularly checked with radiography and peritonitis should be prevented and effectively treated. It is advi­sable to remove the catheter at the end of one week if there is no improvement in the clinical condition of the patient.

 
   References Top

1.Ekart R, Horvat M, Hojs R, Pecovnik-Balon B. An accident with Tenckhoff catheter placement: Urinary bladder perforation. Nephrol Dial Transplant 2006;21:1738-9.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Allon M, Soucie JM, Maco EJ. Complications with permanent peritoneal dialysis catheters: experience with 154 percutaneously placed catheters. Nephron 1988;48:8-11.  Back to cited text no. 2
    
3.Bullmaster JR, Miller SF, Finley RK Jr, Jones LM. Surgical aspects of the Tenckhoff peritoneal dialysis catheter. A 7 year experience. Am J Surg 1985;149:339-42.  Back to cited text no. 3
[PUBMED]    
4.Francis DM, Donnelly PK, Veitch PS, et al. Surgical aspects of continuous ambulatory peritoneal dialysis - 3 years experience. Br J Surg 1984;71:225-9.  Back to cited text no. 4
[PUBMED]    
5.Sanderson MC, Swartzendruber DJ, Fenoglio ME, Moore JT, Haun WE. Surgical compli­cations of continuous ambulatory peritoneal dialysis. Am J Surg 1990;160:561-6.  Back to cited text no. 5
[PUBMED]    
6.Bamberger MH, Sullivan B, Padberg FT Jr, et al. Iatrogenic placement of a Tenckhoff catheter in the bladder of a diabetic patient after penectomy .J Urol 1993;150:1238-40.  Back to cited text no. 6
[PUBMED]    
7.Moreiras M, Cuina L, Rguez Goyanes G, Sobrado JA, Gil P. Inadvertent placement of a Tenckhoff catheter into the urinary bladder. Nephrol Dial Transplant 1997;12:818-20.  Back to cited text no. 7
    
8.Cronen PW, Moss JP, Simpson T, Rao M, Cowles L. Tenckhoff catheter placement sur­gical aspects. Am Surg 1985;51:627-9.  Back to cited text no. 8
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Correspondence Address:
M Ounissi
Department of Internal Medicine A, Charles Nicolle's Hospital, Boulevard du 9 Avril, 1006 BS-Tunis
Tunisia
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    Abstract
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