Spontaneous rupture of tuberculous bladder

　　The main reasons for the spontaneous rupture of tuberculous bladder are that the lesions of tuberculous bladder often involve the entire bladder wall. If there are factors such as lower urinary tract obstruction and sudden increase in intra-abdominal pressure, rupture can occur. Spontaneous rupture of tuberculous bladder almost always belongs to the intraperitoneal type. The site of rupture is often at the top or posterior wall of the bladder. According to foreign literature, in 7 reported cases, 6 were located at the top and 1 at the bottom. In 15 reported cases in China, 10 were located at the top, 4 at the posterior wall, and only 1 at the bottom. This may be related to the lack of support from surrounding tissues in this area and it being the weakest point when the bladder swells. The size of the rupture varies from needle-thin to cup-shaped.

　　After the rupture of the bladder, severe pelvic infection can occur. Secondly, hypoalbuminemia, edema, weight loss, hypokalemia, hyponatremia, metabolic acidosis, and other conditions may occur. As the condition progresses, diffuse peritonitis and sepsis may also occur. There may also be some diseases with similar manifestations to spontaneous rupture of tuberculous bladder, such as gastrointestinal tumors, intestinal adhesions, inflammatory bowel disease, severe pancreatitis, and multiple trauma. Therefore, it is necessary to be cautious and differentiate from these diseases.

　　1. This disease is characterized by acute onset, severe condition, and complexity, and is often misdiagnosed as other acute abdominal conditions. Abdominal pain occurs suddenly without trauma, with no history of urination or only a small amount of hematuria after onset. Patients with peritoneal irritation signs in the abdomen should consider this disease and inquire about a history of urinary tuberculosis. Peritoneal irritation signs may be observed during physical examination, but they are usually not severe, often evident in the lower abdomen, and bowel sounds are usually not absent. These characteristics may be related to the bladder being a pelvic organ, and the stimulation of the peritoneum and intestines after rupture is lighter than that of general purulent peritonitis, and the extent of involvement is from the bottom up. Since the urine from the bladder tuberculosis keeps flowing into the abdominal cavity after rupture, the sign of ascites is often positive, and a large amount of yellow fluid can usually be aspirated through abdominal puncture. During diagnostic catheterization, there is often no urine output, or only a small amount of bloody urine is discharged. The amount of fluid aspirated during bladder lavage is significantly less than the amount injected, but if the catheter enters the abdominal cavity, the amount of fluid aspirated is significantly increased. Bladder造影 may be used for diagnosis when necessary. If the diagnosis cannot be confirmed, an early laparotomy should be performed to avoid missing the opportunity for rescue.

　　2. Spontaneous rupture of the tuberculous bladder is a severe late complication of renal tuberculosis. In order to further clarify the upper urinary tract lesions, it is necessary to perform upper urinary tract examination. Since late renal tuberculosis often encounters many difficulties during urography, if the condition permits, the bladder lesions should be explored simultaneously with the exploration of both kidneys during emergency surgery, and indocyanine green test should be performed, which is of important reference value for etiological diagnosis and subsequent treatment.

　　There is evidence that in addition to tuberculosis, other factors that increase intraperitoneal pressure can also cause spontaneous rupture of the bladder, such as constipation, lower urinary tract obstruction, tumors, alcoholism, etc. Therefore, early onset and early treatment, avoiding other complications and secondary diseases are also important preventive health measures. And for factors that can be avoided, such as alcoholism, they should be avoided as much as possible. If there is tuberculosis in other parts, active anti-tuberculosis treatment should be carried out to avoid triggering bladder tuberculosis infection and leading to bladder rupture.

　　A low-fat, low-fiber diet should be adopted with frequent small meals and a liquid-based diet to facilitate gastric emptying. Since smoking can slow gastric emptying, smoking should be avoided, and drugs that can delay gastric emptying should be avoided as much as possible.

　　The timing of surgery in patients with spontaneous rupture of the tuberculous bladder has a decisive significance for the prognosis. Therefore, while actively rehydrating, blood transfusing to correct shock, and early surgery to repair bladder perforation and perform bladder fistulization, it is also necessary to perform systemic anti-infection therapy and simultaneously carry out anti-tuberculosis treatment. Further treatment should be based on the changes of renal tuberculosis.