Rupture during delivery is very unlikely, as she was catheterized two hours prior to delivery. It is possible that the patient had voiding difficulties in the immediate postpartum period, which went unnoticed. This would be expected, especially in the presence of a painful episiotomy which might discourage voiding and lead to urinary retention. In addition, the nulliparous patient might confuse hematuria with lochia. The late onset of peritonitis may be explained by the fact that the initial urine sample was sterile.
Patients tend to remain well with minimal peritonitis if the urine remains uninfected.
Full urological investigation of all patients with spontaneous rupture of the bladder is imperative to identify possible underlying bladder disease, which might lead to recurrent bladder rupture. Although urological investigation in this case did not show any evidence of underlying bladder pathology, unrecognized neurologic bladder dysfunction cannot be completely ruled out. A tissue sample taken intraoperatively from the bladder may have shown up any underlying pathology which might not be apparent on visual examination of the traumatized bladder wall. Postpartum patients who have had episiotomy or perineal repair frquently experience voiding difficulties which may lead to urinary retention. Retention may not be recognized since these patients pass small amounts of urine frequently.