- Extravasation from the urinary bladder into the peritoneal cavity, with contrast extending into the paracolic gutters
- Metallic density in the left pelvis, consistent with shrapnel
- Unenhanced CT of the abdomen and pelvis, performed immediately after cystogram
- Large amount of intraperitoneal high-density fluid in the subhepatic space, paracolic gutters and within the peritoneal cavity, representing contrast from cystogram performed prior to the CT scan
- Intraperitoneal bladder rupture
- Extraperitoneal bladder rupture
- Ureteral injury
- Collecting system injury
- Bladder injury is most commonly seen in the setting of motor vehicle collisions.
- Bladder trauma occurs from blunt injury and penetrating or iatrogenic trauma.
- Often associated with pelvic fractures.
- Classification of bladder injury
- Type 1: Simple bladder contusion is a
mucosal injury and does not have detectable abnormalities on imaging
- Type 2: Intraperitoneal rupture is the
result of a direct blow to an already distended bladder, which increases
intraluminal pressure and causes rupture of the dome of the bladder.
Intraperitoneal bladder injury accounts for about one-third of all major
- Type 3: Interstitial injury is an
intramural or partial thickness laceration with an intact serosa. This
type of injury is rare and would be difficult to recognize on imaging
- Type 4: Extraperitoneal rupture is the most
common type of bladder injury, and accounts for approximately 60% of
major bladder injuries.
- Type 4A: Simple extraperitoneal rupture has extravasation limited to the perivesical space.
- Type 4B: Complicated
extraperitoneal rupture has extravasation beyond the perivesical space.
- Type 5: Combined injury is a combination of
intraperitoneal and extraperitoneal injury, and accounts for 5% of all
- Clinical presentation
- Gross hematuria
- Suprapubic pain
- Decreased bowel sounds (with intraperitoneal injury)
- Acute abdomen (with intraperitoneal
- Laboratory findings
- Urinanalysis will demonstrate hematuria.
- Peritoneal lavage fluid will be
consistent with urine.
- Imaging recommendations
- Cystography -- CT or conventional (equal sensitivity).
- Exclude urethral injury in males before performing cystography.
- Check postdrainage films to identify
extravasation that was hidden by contrast.
- Radiographic findings
- Bladder contusion: Usually not recognized by imaging, but may have teardrop appearance of bladder due to extrinsic compression of bladder by bladder hematoma.
- Intraperitoneal: Extravasation of contrast around bowel loops, paracolic gutters, pouch of Douglas, and intraperitoneal viscera.
- Interstitial injury: Focal defect along the wall of the bladder may be seen, but is difficult to recognize on imaging.
- Simple: Extravasation around the bladder.
- Complex: Extravasation extends beyond the pelvis.
- Combined: Findings of both intraperitoneal and extraperitoneal rupture.
- CT cystography
- Contusion: Normal appearance.
- Intraperitoneal: Same findings as conventional cystogram.
- Interstitial: Extravasation of contrast intramurally and submucosally without transmural extension, but difficult to recognize on imaging.
- Extraperitoneal rupture:
- Simple: Contrast is confined to perivesical space.
- Complex: Contrast extends beyond the perivesical space.
- "Molar tooth" sign -- rounded superiorly with pointed inferior contours.
- Fluid around the bladder
- Hematoma within bladder wall
- Complications include fistulas, abscess,
sepsis, hematoma, and hemorrhage.
- Management is determined by classification of injury.
- Contusions and interstitial injuries are managed conservatively with Foley catheterization.
- Intraperitoneal injury requires laparotomy and surgical repair of bladder injury.
- Extraperitoneal injury is usually treated
with catheter drainage. If there is complicated extraperitoneal rupture,
then surgical repair may be necessary.
- Follow-up: Perform cystography 10 days after initiation of treatment.