Women! Know your limits! Or exploding bladder highjinks

Until now, certainly, doctors expected to see bladder rupture only in people with abnormal or previously damaged bladders, or in men - who were more likely to be hardcore alcoholics. In fact, alcohol-induced bladder rupture was considered an exclusively male problem. However, women are now catching up with men when it comes to drinking: 86% of women, compared with 91% of men, consume alcohol regularly. This drunken equality is starting to produce some serious side effects in women too.

In the BMJ report, urologist Dr Mohantha Dooldeniya and colleagues at Pinderfields Hospital in Wakefield, describe the cases of three young women who came into the hospital during the course of a year, initially confusing the doctors with their symptoms. Each woman arrived at casualty the day after a bender, feeling significantly more unwell than they might expect to feel, even with the mother of all hangovers. All complained of lower abdominal pain.

The doctors initially diagnosed a urinary infection in two of these cases, and prescribed antibiotics and rehydration. However, on further investigation using abdominal scans, they were shocked to discover that the sickness was down to bladder rupture. With the third case, they first suspected appendicitis because the woman's pain was quite localised. However, recalling the two previous cases, they ordered a laparoscopy, which showed that the suspected appendicitis was, indeed, another torn bladder. In the end, all three women needed to have their bladders sewn back together by surgeons.

The mechanics of this gruesome problem are relatively straightforward. Alcohol is diuretic - it makes you urinate more - hence the sight of drunk people urinating in the streets on a Saturday night. Alcohol is also an anaesthetic: it dulls the urge to go. The combination of large volumes of urine, and a dimmed, possibly non-existent urge to pee can result in a seriously over-full bladder.

While most people will just let the urine out one way or another (possibly in their sleep), some will be so "dulled" that they will not feel the urge to "void". If it is not emptied, the bladder will eventually be unable to contain the volume, and - like any over-full bag - can burst apart under the pressure. A minor trauma - say, falling down and bumping your over-full bladder during a drunken binge - can also increase the likelihood of this happening.

Men and women have different plumbing, and this, along with the fact that until now women have tended to drink much less than men, explains why alcohol-related bladder rupture has historically been a male-only phenomenon. "Men have a longer urethra than women [the tube that urine travels down to get out via the normal route]," explains Dooldeniya. "You therefore need a lot more pressure to force the urine out of the bladder through the male urethra. "We previously thought that women were more likely to leak than to rupture because they have a shorter urethra than men, and therefore it is easier for the urine to be forced out by the pressure, rather than to rupture."

But this may no longer hold true: only one of the women who came to Pinderfields was a diagnosed alcoholic. The other two had just been on a heavy night out. All three were in their 20s to early 30s. All had previously normal bladders. "Everyone is different, so it is impossible to put a figure on exactly what volume you would have to consume to rupture your bladder," says Dooldeniya, "But you would basically have to be so drunk that you can't remember anything, and have lost control over your body."

The ruptures tend to be about 3-4cm long, and are usually found at the dome, or top of the bladder, the part in women that is not connected to the pelvic bone. This sounds agonising but, says Dooldeniya, "the bladder itself does not have a good 'nerve' - so the pain tends not to be localised." There may be nausea, vomiting, general lower abdominal pain, fever, a failure to urinate, or urinating only tiny amounts and there may be blood in the urine. But the symptoms are often general, and can be similar to those of a urinary tract infection (a common problem for women).

The reason people with a ruptured bladder feel so ill is that they are literally being poisoned from the inside: "The urine leaks out and sits in the abdominal cavity," says Dooldeniya. "Urine contains toxins excreted by the kidneys. These toxins are reabsorbed into the bloodstream via the lining of the abdomen, and this causes people to feel very ill, a condition known as uraemia."

Since most doctors consider bladder rupture to be a very rare male-only catastrophe, it is possible that faced with a woman presenting these symptoms, they may initially misdiagnose the problem. "We wanted to alert A&E doctors that bladder rupture might be something to consider in younger women presenting with lower abdominal pain," says Dooldeniya. Studies of men with burst bladders show a significant mortality rate - 1-5% die of sepsis (blood poisoning). "We know that the earlier you get treatment for a ruptured bladder, the easier and faster your recovery will be."

So, how do you know if your hangover is more than just a hangover? "The symptoms can be very non-specific, but you'd know something was wrong, because your hangover would feel different from a normal hangover," he says. "The paracetamol or the fry-ups would have no impact."

Dooldeniya continues: "we did not publish the report to alarm the public. Though we don't know the exact numbers, it's important to remember that ruptured bladders are rare - these are the first documented cases in women in the world." It seems safe to say, though, that as the binge-drinking population grows, A&E departments will be seeing more women - and possibly men - in this sorry state.

"It is certainly not an epidemic," agrees Frank Soodeen, spokesman for Alcohol Concern. "It seems to be more about a few unlucky people who got completely smashed. But this new development certainly highlights the fact that the risks of heavy drinking go way beyond liver cirrhosis. There are any number of ways you can damage your body by drinking too much: this is just one more that most people have never considered".

OUCH!