a 56-year - old man with hepatic steatosis secondary to excessive alcohol consumption was diagnosed with a low - grade invasive rectosigmoid adenocarcinoma stage 2b ( pt4pn0m0 ) .
a laparoscopically assisted anterior rectum resection with partial cystectomy was performed to remove the tumor that had infiltrated the bladder .
six months postoperatively a control colonoscopy showed an intact colorectal anastomosis with no pathological findings on control ct ( computed tomography ) imaging .
one year later the patient presented twice , with a three - month interval , to the emergency department of our hospital because of abdominal pain .
the first time the patient presented with diffuse abdominal pain and watery non - bloody diarrhea .
blood analysis showed signs of acute kidney insufficiency , hyponatremia , and increased inflammatory parameters ( table 1 ) . 
 
blood analysis showing acute kidney insufficiency , hyponatriemia , and increased inflammatory parameters on admission , with complete remission of his kidney insufficiency and hyponatriemia after aspiration of ascites fluid . 
 
his acute kidney insufficiency was blamed on dehydration secondary to noninfectious diarrhea , with hyponatremia due to increased gastrointestinal losses .
postrenal causes of acute kidney insufficiency were ruled out using ultrasonography ; urinary and coprocultures were negative .
three months later the patient was readmitted with abdominal pain , which started abruptly during forceful micturition after a night of heavy drinking .
the onset was intense , non - crampoid , and initially located in the lower abdomen . on physical examination the abdomen was distended .
the presence of elevated creatinine levels ( 56 mg / dl compared to a normal serum level of 1.41 mg / dl ) and urea levels ( 545 mg / dl compared to a normal serum level of 25 mg / dl ) was suggestive of urinary ascites .
2 ) . a conservative approach with indwelling catheter and prophylactic urinary antiseptics ( nitrofurantoin 100 mg od ) was initiated .
ct cystography with 3-dimensional reconstruction three weeks later showed no more leakage and complete closure of the bladder perforation ( fig .
ct cystography showing the bladder with indwelling catheter and no signs of urinary leakage ( november 2010 ) .
urodynamic evaluation showed bladder instability during the filling phase with an obstructive voiding pattern characterized by high pressures intravesically and a weak urinary flow . after starting the patient on a combined alpha - blocker ( tamsulosin 0.4 mg ) and anticholinergic ( solifenacin 5 mg ) therapy , voiding was good with no post - void residual
traumatic bladder perforations are known complications from gastrointestinal and urogynecological interventions , trauma ( blunt or penetrating ) to the lower abdominal wall , pelvic irradiation [ 26 ] , and delivery - related interventions such as forceful forceps , vacuum device , and cesarean section .
but also long - term catheterization in the presence of urinary tract infections can lead to chronic irritation with weakening of the bladder wall integrity and spontaneous rupture as a result .
non - traumatic causes are mostly the result of cancerous invasion from surrounding structures such as recto - sigmoid and cervical cancers . in our case ,
first of all , the laparoscopic closure of the partial cystectomy one year before led to a zone of smaller resistance . secondly , the presence of obstructive voiding worsened by obsessive alcohol consumption led to high intravesical pressure in an overdistended bladder . the combination led to a rupture at the  fragile  bladder wall , resulting in urinary ascites .
patients with urinary ascites , as in our case - report , present with a diffusely tender , distended abdomen without evidence of sepsis .
their urological symptoms may range from normal micturition to dysuria and hematuria [ 3 , 7 , 10 ] . in the absence of a traumatic event ,
it is important to educate patients who have had bladder repair of the possibility of sutures releasing with bladder perforation as a consequence .
possibly the acute renal failure was a misdiagnosed case of  reverse self - dialysis  of the peritoneal membrane [ 2 , 12 , . instead of diffusion of metabolic waste products into a dialysis solution , the peritoneum re - absorbs urea and creatinine from the leaked urine with a subsequent rise in serum levels
moreover , in extreme conditions there may exist a physiological attempt to dilute the hypertonic uroperitoneum at the expense of extracellular fluid .
in this situation , serum values of urea , creatinine , and potassium will be high , while sodium and chloride concentrations will be low [ 15 , 16 ] . in order to maintain osmolar equilibrium , water and sodium diffuse into the peritoneal cavity leading to an increase in ascites fluid .
work - up of urinary ascites includes a combination of serum and ascites biochemistry , cystoscopy , conventional cystography , or ct cystography to pinpoint the diagnosis .
urine cytology or biopsies taken at the rupture site can be used to exclude malignant perforation .
carroll and mcaninch diagnosed 100% of cases , while sandler et al . diagnosed 19 of 21 intraperitoneal bladder perforations with a conventional cystogram [ 17 , 18 ] . today
some trauma centers rely exclusively on ct cystograms to evaluate suspected bladder rupture with equally good results .
the management of bladder perforations has been a controversial issue . in the beginning , all bladder perforations used to be treated by open repair .
publications by hayes and corriere [ 20 , 21 ] supported a conservative management with temporary bladder drainage in extraperitoneal perforations .
intraperitoneal ruptures on the other hand , are usually still managed primarily by open repair , mostly because of concern about communication between the environment and peritoneal cavity .
our case illustrates that even a conservative approach in the treatment of small intraperitoneal ruptures may be considered if a number of conditions are maintained : urinary antibiotic prophylaxis and continued urinary drainage through an indwelling catheter for a minimum of two weeks until closure of the perforation is evident on ct cystogram .
patients should be warned however that an unsuccessful result with persistent communication to the peritoneal cavity is possible and more typical .
urinary ascites should be considered in the differential diagnosis of ascites in patients who have had bladder surgery in their past surgical history .
our case illustrates that a conservative approach is possible , even in cases with intraperitoneal rupture .
nevertheless , we recommend urinary prophylaxis until urinary drainage via an indwelling catheter has allowed the lesion to heal .
 introductionthe management of bladder rupture depends on its anatomical location.material and methodscase report and review of the pertinent english language literature.resultsa 56-year - old man with history of an anterior rectum resection with partial cystectomy presented with signs of acute renal failure , and later with a tender , distended abdomen . 
 work - up including serum and ascites biochemistry , cystoscopy , and ct cystography diagnosed urinary ascites . 
 the small intraperitoneal bladder rupture was treated conservatively via continued urinary drainage under urinary antibiotic prophylaxis until closure.conclusiona conservative treatment of a small intraperitoneal bladder perforation is possible under certain conditions . 
INTRODUCTION
MATERIAL AND METHODS
CASE REPORT
DISCUSSION
CONCLUSION