# Urinary Ascites Mimicking Portal Hypertension in a Healthy Woman With Bladder Microperforation

## TL;DR

A healthy woman developed urinary ascites mimicking portal hypertension due to a bladder microperforation, highlighting the need to consider this rare condition in unexplained cases.

## Contribution

This case report highlights urinary ascites as a rare but important differential diagnosis in patients with unexplained ascites and acute kidney injury.

## Key findings

- Urinary ascites was confirmed by elevated ascitic creatinine levels despite normal liver and cardiac workup.
- Cystoscopy revealed a posterior bladder diverticulum with scarring, likely causing the bladder rupture.
- The patient was advised to manage voiding habits to prevent recurrence and scheduled for follow-up assessments.

## Abstract

Urinary ascites is a rare cause of ascites that can present with a high serum-ascites albumin gradient (SAAG), mimicking portal hypertension. Here we present a case of a 42-year-old woman with a history of cesarean section and a total laparoscopic hysterectomy (both remote and uncomplicated) that presented to the ED with abdominal ascites and pseudo-acute kidney injury after developing sudden, severe suprapubic pain during urination. Workup initially suggested a portal hypertension etiology due to a high SAAG; however, liver function and cardiac workup were normal. Her serum creatinine normalized after placing a Foley catheter; however, creatinine rebounded upon catheter removal, and urinary ascites was then confirmed by an elevated ascitic creatinine level. In follow-up, cystoscopy revealed a posterior bladder diverticulum with scar, demonstrating the likely culprit lesion of the bladder rupture. Urodynamics showed delayed bladder sensation due to dysfunctional voiding habits. The patient was advised to time voids, keeping volumes below 400-600 cc, and was scheduled for a six-month follow-up for uroflowmetry and post-void residual (PVR) measurement. This case highlights the importance of not overlooking urinary ascites in patients with unexplained ascites and concurrent apparent AKI, even in the absence of obvious risk factors such as this patient.