Diagnostic dilemma: Shingles popped a hole in a man's bladder

The patient: A 77-year-old man in China

The symptoms: Seven hours before being admitted to a hospital, the patient developed shortness of breath, abdominal pain and "obvious" abdominal distension, meaning his belly appeared very bloated and stretched out, doctors wrote in a report of the case. He'd had trouble urinating and defecating for about four days, and one week prior to admission, he'd been given antiviral and pain-relieving medicines for a case of shingles that was affecting his lower back, around the sacrum, or the base of the spine.

What happened next: At the emergency department, doctors found that the patient's abdomen was "distended and painful," especially beneath the stomach, and there were signs of "massive" fluid buildup. Around the base of the spine, there was visible skin damage from shingles, which causes painful rashes of fluid-filled blisters. The man's heart rate, blood pressure and breathing rate were high, but he had no fever. The amount of oxygen circulating in his blood was low, while markers of inflammation and acid levels in the blood were elevated.

A CT scan of the abdomen confirmed a large amount of fluid in the man's pelvis and abdomen. After being transferred to the intensive care unit, the patient had a catheter placed, allowing bloody urine to pour out of his body for three hours straight. The doctors, who had already suspected that the man's bladder may have ruptured, then introduced blue dye to the catheter to see if it ended up in the abdomen.

The diagnosis: This dye test also pointed to a bladder rupture, so the doctors performed surgery to both confirm the problem and repair it. During the operation, they found a nearly 0.8-inch (2 centimeters) tear in the bladder wall.

The treatment: The medical team repaired the tear in the man's bladder during the surgery. They also placed a catheter and performed a cystostomy, which allows urine to exit the bladder through a temporary opening in the abdominal wall. While recovering from surgery, the patient also got antiviral medications for several weeks to treat his shingles.

"The patient regained complete bladder function after undergoing surgery to repair the bladder and treatment with antiviral drugs," his doctors reported.

What makes the case unique: "Spontaneous bladder rupture is an extremely rare urological emergency that can be life-threatening," the patient's doctors wrote in their report. Common causes include chronic bladder infections, bladder obstructions, cancerous tumors and cancer treatments designed to kill tumors in the pelvic area.

In this case, however, the rupture appeared to be triggered by shingles, which is caused by the varicella zoster virus. The same virus causes chickenpox, and after a chickenpox infection, it can go dormant, hide in the body's nerves, and reactivate later to cause shingles. (The reactivated virus is known as herpes zoster.)

A rare complication of shingles is urinary retention, in which the bladder doesn't empty enough or at all when someone urinates. But the man's doctors believe this is the first known time that the infection has led to bladder rupture.

Although urinary retention occurs in roughly 4% of shingles cases, it happens at a higher rate in patients whose shingles affects their lower spine and sacrum. It's thought that the complication can arise from inflammation of the bladder, of the nerves that connect to the bladder, or of the nearby nerves of the spinal cord. This inflammation makes it harder for the bladder wall to contract and thus empty urine

In this patient's case, a history of diabetes may have complicated the picture, as both diabetes and shingles may have contributed to nerve issues that decreased the man's ability to sense that his bladder was full. This may have kept him from seeking treatment early on, raising the likelihood that his bladder would rupture when it got too full, the doctors wrote.

"The risk of herpes zoster-associated urinary system dysfunction cannot be ignored," they concluded. "Urgent intervention is required."