Perforation of the bladder may occur during TURP. The incidence of perforation is estimated at 1.1%. Perforations are most often made by the cutting loop or the knife electrode, although the tip of the resectoscope is sometimes responsible. Overdistension of the bladder with irrigating fluid can also result in a perforation. Most perforations are extraperitoneal. In the awake patient, pain may occur in the periumbilical, inguinal, or suprapubic region. If the
irrigation fluid fails to return as it normally does, perforation of the prostatic capsule is suspected. Occasionally, damage to the wall of the bladder may cause an intraperitoneal perforation, or a large extraperitoneal perforation may extend into the peritoneum. In such cases, pain might be referred from the diaphragm to the precordial region or the shoulder, or may be more generalized to the upper abdomen. Additional warning signs or symptoms may include pallor, diaphoresis دوخة, abdominal rigidity, nausea, vomiting, hypotension, or hypertension. Hiccups and shortness of breath may result from subdiaphragmatic irritation. Intraperitoneal
fluid will usually be extruded by the kidney although catheter drainage may be necessary. Significant extravasation may need to be drained suprapubically.