Spontaneous bladder rupture diagnosed by pleural fluid analysis.

Urinothorax, defined by urine in the pleural space classically migrating from the retroperitoneum, has rarely been described. We present a unique case of spontaneous bladder rupture producing urine ascites, leading to a large pleural effusion with subsequent respiratory symptoms. CASE PRESENTATION: A 45 year old female presented to the emergency department (ED) with pelvic pain after straining during a bowel movement. Acute abdominal series was unremarkable, and Computed Tomography (CT) of the abdomen and pelvis with contrast revealed a small amount of fluid anterior to the uterine fundus and in Morrison\u27s pouch. She described a surgery two years prior in which she had a leiomyoma removed from her bladder, causing similar pain, and was discharged home to follow up with Urology. She returned to the ED 72 hours later with worsening pelvic pain, infrequent urination and new dyspnea. Labs were consistent with acute kidney injury. Imaging revealed a new large right pleural effusion and worsening ascites. Thoracentesis was performed with 2250 mL of clear yellow fluid removed, which was transudative with pleural creatinine greater than serum. The bladder was catheterized, and her serum creatinine decreased. CT cystogram was performed, with contrast extravasation into the peritoneum. She was taken to the operating room for repair of the bladder defect. DISCUSSION: At present, less than 70 cases of urinothorax have been reported, and are associated with obstructive uropathy, surgery or trauma to the ureter1. Urine collects in the retroperitoneal space and dissects superiorly into the pleura. Pleural effusions are most often transudative and pleural: serum creatinine greater than 1 is specific for diagnosis; low pH and glucose are usually found2. Our patient had a unique presentation, with a suspected bladder defect causing urine ascites ascending into the right pleural space, similar to hepatic hydrothorax. The large diffusion space of the peritoneum altered her fluid chemistry to produce both typical and atypical findings of a urine effusion. Although her pleural: serum creatinine ratio was greater than 1, pleural fluid glucose and pH were elevated to near serum levels. CONCLUSIONS: Diagnosis of urinothorax requires a high index of suspicion and should be considered when genitourinary trauma coexists with pleural effusion