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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 November 10; 335(7627): 992–993.
PMCID: PMC2072017
Lesson of the Week

Lower abdominal pain in women after binge drinking

M D Dooldeniya, specialist registrar in urology, R Khafagy, specialist registrar in urology, H Mashaly, staff grade in general surgery, A J Browning, urology consultant, S K Sundaram, urology consultant, and C S Biyani, urology consultant

Consider alcohol related pathology in women who present with lower abdominal pain

Alcohol misuse is costing the NHS up to £3bn (€4.4bn; $5.9bn) a year—with over 28 000 hospital admissions caused by alcohol dependence or poisoning.1 This is small compared with the annual cost to employers, which is estimated at £6.4bn, but it excludes the hidden costs in terms of alcohol related crime and social problems. The resulting use of hospital facilities places a considerable financial burden on the NHS; inpatient costs alone accounting for 2-12% of total NHS expenditure on hospitals.1 In terms of pathology it is estimated that there are 22 000 premature deaths each year caused by problems related to alcohol. The heaviest burden is on accident and emergency departments. Around 40% of such admissions are alcohol related, and this increases to 70% after midnight.2

Women have now caught up with men in their alcohol consumption, with 86% of women compared with 91% of men consuming alcohol regularly.3 Health concerns that were initially raised about drinking habits in men now seem to affect women as well.

Case reports

The table gives the clinical details of three women in whom we ultimately diagnosed “idiopathic” rupture of the bladder.bladder. The first two patients presented with symptoms consistent with urinary sepsis and as such were initially treated with antibiotics and rehydration. The second woman was catheterised on admission because of symptoms consistent with urinary retention. The diagnosis was initially made on the basis of the findings of free pelvic fluid on ultrasonography and, in the case of the second women, an inability to fill the bladder. Bladder rupture was confirmed with cystography and ultimately at surgical exploration. All women underwent repair of the bladder.

Case summaries in three women presenting with lower abdominal pain

The third women presented to the general surgery department with pain in the right iliac fossa. They suspected either ovarian pathology or appendicitis because of the localisation of the pain and the mildly raised white cell count. Bladder rupture was diagnosed at exploratory laparoscopy and the defect repaired laparoscopically.


Bladder rupture has previously been reported in women, but usually in association with other pathologies, such as the 83-90% related to pelvic trauma.4 5 In all our cases, there was no history of pelvic injury to explain the diagnosis. Our patients did not undergo formal radiological examination of the pelvis, though all had normal results on abdominal radiology and were mobile before presentation as well as postoperatively. The other common cause of rupture is neuropathic bladder. Although a well recognised complication in patients who undergo bladder augmentation for relief of symptoms, it is rare in patients with “untreated” bladders.6 As the women's symptoms before presentation and postoperatively did not suggest this diagnosis, we did not carry out formal urodynamic assessment. Routine bedside screening excluded diabetes, which is the next most common cause for “spontaneous” rupture of the bladder.


The symptoms of this condition are vague, and a definite diagnosis is generally made only after surgical exploration. Symptoms include diffuse suprapubic pain and tenderness, evidence of mild shock (raised heart rate, reduction in mean arterial pressure), oliguria (the bladder drains into the abdominal cavity and so gives this impression), and mildly raised renal function (caused by re-absorption of urine through the peritoneum). Ultrasonography might show fluid within the pelvis. Cystography can show the defect in the bladder as jet of contrast (figure).(figure).

figure doom414367.f1
Preoperative cystogram showing intraperitoneal leak (arrow) No arrow on fig!!

Bladder rupture after alcohol consumption is a rare but well described phenomenon. A few cases have been reported of spontaneous or idiopathic rupture in men associated with alcohol consumption.5 7 The condition was first described in postmortem reports in patients who regularly ingested large quantities of alcohol.8 9 Bennett and Delrio reported a case of bladder rupture in an 18 year old man resulting from a combination of alcohol ingestion and a self administered intravenous injection of methamphetamine.10 Mardones et al also described spontaneous bladder rupture in a 53 year old man with alcoholic abuse.11

The rupture is commonly intraperitoneal and at the dome as this is the weakest point within the bladder wall. Early recognition of this condition is crucial as it does have considerable implications on survival as well as morbidity.5 6


In all the reported cases, diuresis and the dulling effect of alcohol,8 without the relief of bladder voiding, was thought to be the cause, although others have speculated about the role of bladder infarction.9 Alcohol consumption increases the volume of urine held within the bladder and dulls the senses such that the patient has a reduced urge to void despite the increased bladder volume. Minor trauma, such as from a fall, will further increase the pressure and can cause rupture.8 It has been thought that women, because of the short length of the urethra and the less pronounced sphincter mechanism, would have a tendency to leak rather than rupture.

We suggest that with the increase in alcohol consumption in women today, the complications previously seen only in men should now also be considered.


Contributors: MDD wrote paper, RK contributed to the last case report. HM AJB SKS, and CSB provided clinical details of the case reports. CSB is guarantor.

Funding: None.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.


1. Working party of the Royal College of Physicians. Alcohol—can the NHS afford it? London: Royal College of Physicians, Feb 2001.
2. Prime Minister's Strategy Unit. Alcohol misuse: how much does it cost? London: Cabinet Office, Sept 2003.
3. National Statistics. Focus on health: drinking London: Office for National Statistics, July 2004.
4. Gomez RG, Ceballos L, Coburn M, Corriere JN Jr, Dixon CM, Lobel B, et al. Consensus statement on bladder injuries. BJU Int 2004;94:27-32. [PubMed]
5. Herd AM, Crofts NG, Lee LM, Girard JV, Sweetland RJ. Isolated bladder rupture after minor trauma in a patient with alcohol intoxication. J Emerg Med 1994;12:409-11. [PubMed]
6. Neel KF. Spontaneous bladder rupture in a non-augmented neuropathic bladder. Saudi Med J 2004;25:220-1. [PubMed]
7. Festini G, Gregorutti S, Reina G, Bellis GB. Isolated intraperitoneal bladder rupture in patients with alcohol intoxication and minor abdominal trauma. Ann Emerg Med 1991;20:1371-2. [PubMed]
8. Mokoena T, Naidu AG. Diagnostic difficulties in patients with a ruptured bladder. Br J Surg 1995;82:69-70. [PubMed]
9. Haddad FS, Wattle TL. Spontaneous intraperitoneal rupture of the bladder. Urol Int 1987;42:467-9. [PubMed]
10. Bennett AH, Delrio. Idiopathic rupture of the bladder: association with methamphetamine and alcohol. J Urol 1979;124:429-30.
11. Mardones GB, Fúnez FA, Montoiro PA, BP Mengual, DG Flórez, AE Barrilero. Ruptura espontánea vesical recidivante asociada a abuso de alcohol: presentación de un nuevo caso. Arch Esp Urol 2002;55:849-52. [PubMed]

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