CASE PRESENTATION: A 45 year old female presented to the emergency department (ED) with pelvic pain after straining during a bowel movement. Acute abdominal series was unremarkable, and Computed Tomography (CT) of the abdomen and pelvis with contrast revealed a small amount of fluid anterior to the uterine fundus and in Morrison's pouch. She described a surgery two years prior in which she had a leiomyoma removed from her bladder, causing similar pain, and was discharged home to follow up with Urology. She returned to the ED 72 hours later with worsening pelvic pain, infrequent urination and new dyspnea. Labs were consistent with acute kidney injury. Imaging revealed a new large right pleural effusion and worsening ascites. Thoracentesis was performed with 2250 mL of clear yellow fluid removed, which was transudative with pleural creatinine greater than serum. The bladder was catheterized, and her serum creatinine decreased. CT cystogram was performed, with contrast extravasation into the peritoneum. She was taken to the operating room for repair of the bladder defect.