Vesna Ivancic

Gillian Lieberman, MD
July 2001

BLADDER RUPTURE
vesna ivancic
Harvard Medical School Year IV
Gillian Lieberman, MD
 Vesna Ivancic
Gillian Lieberman, MD

FRIDAY NIGHT IN THE READING RM

TWO TRAUMA PATIENTS JUST CAME IN
• Patient 1:
– 38 yo female Pedestrian struck by 30 mph car, hit
windshield, thrown 30 ft with 30 seconds LOC
– AVSS, Drunk, Abrasions to face and arms
– Abdomen distended but soft, Nontender, Normal DRE
– Gross Hematuria
• Patient 2:
– 25 yo male unrestrained Passenger in high speed MVC,
LOC and Hypotensive during 10 minute extraction
– AVSS, agitated, Abdomen Nontender, Normal DRE
– Unstable Pelvis and Microscopic Hematuria
2
Vesna Ivancic
Gillian Lieberman, MD

ANATOMY: PELVIS

Associated with Bladder Rupture:

Diastasis of Pubic Symphysis or SI joint 3
Fractures of Ilium, Pubic Rami, Sacrum
Vesna Ivancic
Gillian Lieberman, MD

Patient 1: AP Pelvis

Left Sacral
Ala Fractured

Left Pubic
Rami Fractured

BIDMC 2001
4
Vesna Ivancic
Gillian Lieberman, MD

Patient 1: Axial pelvis CT

Rib Fracture

Superior Pubic
Ramus Fracture

BIDMC 2001

Left Inferior Pubic

Ramus Fracture
5
 Vesna Ivancic
Gillian Lieberman, MD

Patient 2: Ap pelvis

Diastasis of
Right SI joint

Diastasis of
Pubic Symphysis

BIDMC 2000 6
Vesna Ivancic
Gillian Lieberman, MD

Patient 2: Axial pelvic CT

Left Inferior Pubic

Ramus Fracture

BIDMC 2000

Right Sacroiliac
Diastasis
BIDMC 2000
7
Vesna Ivancic
Gillian Lieberman, MD

? Bladder Rupture (BR)

INTRAPERITONEAL? EXTRAPERITONEAL?
(IPBR) (EPBR)

8
 Vesna Ivancic
Gillian Lieberman, MD

RADIOLOGIC
CLASSIFICATION
BLADDER TRAUMA
CONTUSION Intramural injury/hematoma Conservative
NO ESCAPE of urine or contrast management
INTRA Tear in bladder dome Surgical
Peritoneal Fluids ESCAPE PERITONEUM management!
Rupture
EXTRA Tear in bladder wall Conservative
Peritoneal Fluids ESCAPE SOFT TISSUES management
Rupture

9
 Vesna Ivancic
Gillian Lieberman, MD

QUICK ANATOMY REVIEW

Bladder is EXTRAPERITONEAL!

Male Female Gray’s Anatomy www.barbtleby.com

Note relationship between Bladder & Pubic Symphysis 10

Vesna Ivancic
Gillian Lieberman, MD

INCREASED RISK
FOR BLADDER RUPTURE!

11
Extremes of life: Elderly and babies
 Vesna Ivancic
Gillian Lieberman, MD

Because bladder projects above

pubic symphysis:

Baby Gray’s Anatomy www.barbtleby.com

BPH: Any patient with a full distended
12
bladder eg s/p ETOH at higher risk
Vesna Ivancic
Gillian Lieberman, MD

Patients who need

a bladder evaluation:

• HISTORY:
– Trauma patients
– With abdominal pain
• PHYSICAL:
– Hematuria
• TRAUMA SERIES:
– Pelvic fractures
13
 Vesna Ivancic
Gillian Lieberman, MD

FIRST DECISION:
? Obtain RUG
Rule out urethral tear!
RISK FACTORS
Male
Scrotal hematoma
Blood at meatus
High-riding prostate
Unable to void

TEAR

Seminars Roent, 1983 Chong, eMedicine.com

RUG: Retrograde UrethroGram 14

 Vesna Ivancic
Gillian Lieberman, MD

SECOND DECISION:
?Obtain CYSTOGRAM
Cystogram
Fluoroscopic or CT
If BR suspected
can’t rely on I+ CT!
No extravasation of
contrast on I + CT

Contrast extravasates
with CT Cystogram
I.e. need a CT Cystogram Radiol Clin North Am 1999 15
 Vesna Ivancic
Gillian Lieberman, MD

IPBR vs EPBR
INTRAPERITONEAL EXTRAPERITONEAL
PROPORTION 10-20% 80-90%
MOST HAVE PELVIC FX
CAUSATIVE Blunt (seat belt) Shearing
FORCES To Lower abdomen To bladder base
URINE = NONCOMPRESSIBLE FLUID! Full Bladder Or Injury via bone fragments
DISTENDED BLADDER = THIN WALL!
Extends into prevesical soft
EXTENSION Ruptures at dome tissues, perineum, scrotum,
Extends into peritoneal thigh, anterior abdominal
cavity wall, retrorectal/presacral sp.

MANAGEMENT Surgical Conservative

16
 Vesna Ivancic
Gillian Lieberman, MD

IPBR PATTERN
ON CYSTOGRAPHY
GENERAL FEATURES
• Smooth, regular contours
• Contrast accumulates near
dome and extends laterally
filling peritoneal cavity
• Surrounds bowel, forming
gas-filled defects
surrounded by circular
segments of contrast
• Scalloped effect near
paracolic recesses, haustra
• May outline liver margin
Ney and Fiedenberg, 1981 17
 Vesna Ivancic
Gillian Lieberman, MD

OUTLINING LOOPS

Ney and Fiedenberg, 1981 Brian Camozzi www.weather.com

Outline of liver margin and peritoneal reflection

18
Vesna Ivancic
Gillian Lieberman, MD

IPBR PATTERN
CT CYSTOGRAPHY
GENERAL FEATURES
• Smooth contours
• Contrast material
around bowel loops
• Flows between
mesenteric folds
• Accumulates in
paracolic gutters,
rectouterine & Radiol Clin North Am 1999
rectovesical pouches
19
Vesna Ivancic
Gillian Lieberman, MD

EPBR PATTERN
ON CYSTOGRAPHY
GENERAL FEATURES
• Often over lower half
of bladder
• Streaky, patchy
• Irregular patterns
• Spreads along fascial
planes and spaces
Seminars in Roentgenology, 1983

20
Vesna Ivancic
Gillian Lieberman, MD

“…like rays of sun bursting

through a breaking cloud…”
Friedland,1983

Jason Boggs www.weather.com 21

 Vesna Ivancic
Gillian Lieberman, MD

SUNBURST PATTERN

James Lucas www.weather.com

Ney and Fiedenberg, 1981

Seen with Extraperitoneal bladder ruptures 22

 Vesna Ivancic
Gillian Lieberman, MD

EPBR PATTERN
CT CYSTOGRAPHY
GENERAL FEATURES
• Variable path of
contrast spread
• Dense, flame-shaped
• Often into perivesical
and prevesical space
(Space of Retzius)
• May flow into
presacral space Radiol Clin North Am, 1999

• Dissects fascial planes

23
Vesna Ivancic
Gillian Lieberman, MD

TEARDROP PATTERN
ON CYSTOGRAPHY
GENERAL FEATURES
• Bladder looks high
and elongated
• Compression by
pelvic hematoma
• Can impair voiding
• Not necessarily
ruptured Ney and Fiedenberg, 1981

24
 Vesna Ivancic
Gillian Lieberman, MD

TEARDROP BLADDER

Extravasation of contrast from Teardrop bladder associated with

teardrop bladder associated with
extraperitoneal rupture.
This patient had a teardrop
bladder with rupture
extraperitoneal rupture and
bladder neck fracture.
Ney and Fiedenberg, 1981
25
 Vesna Ivancic
Gillian Lieberman, MD

PATIENT 1
I+ AbdominoPelvic CT SCAN

BIDMC 2001

Hematoma
Intraperitoneal fluid: 4 HU Bladder with Foley
Uterus
26
Rectum
 Vesna Ivancic
Gillian Lieberman, MD

PATIENT 2
I+ AbdominoPelvic CT SCAN

BIDMC 2000

SI diastasis with bone fragment

27
Intraperitoneal fluid: 4 HU
Vesna Ivancic
Gillian Lieberman, MD

DDX for FREE

INTRAPERITONEAL FLUID
# 1: THINK BLOOD (35-70 HU)
OUR PATIENTS: LOW ATTENUATION (4 HU)!
BILE LEAK? URINE LEAK? BOWEL PERF?
ASCITES? CHYLOPERITONEUM?

I+ CT CYSTOGRAM SHOWED EXTRAVASATION:

BLADDER RUPTURE?
URINE LEAK FROM UPPER TRACT?
(ENTEROVESICAL FISTULA WITH BOWEL PERF?)
28
 Vesna Ivancic
Gillian Lieberman, MD

PATIENT 1
CT CYSTOGRAM
?

Air in bladder
due to
instrumentation

BIDMC 2001

INTRAPERITONEAL EXTRAVASATION OF CONTRAST

?AREA OF HIGH ATTENUATION?
Extraperitoneal BR? Hematoma? 29
Vesna Ivancic
Gillian Lieberman, MD

PATIENT 2
I+ CT SCAN & CT CYSTOGRAM

Air in Subcutaneous Tissues

BIDMC 2000

INTRAPERITONEAL EXTRAVASATION OF CONTRAST

Note: No Ureteral disruption
30
 Vesna Ivancic
Gillian Lieberman, MD

FOLLOW-UP: PATIENT 1
I+ CT: 5 days later

Anterior pelvic clot

Intraluminal air
indenting bladder
not yet resolved

BIDMC 2001

After Conservative (!) Management,

NO CONTRAST LEAK 31
 Vesna Ivancic
Gillian Lieberman, MD

FOLLOW UP: PATIENT 1

Fluoroscopic Retrograde Cystogram: 12 d. later

NO LEAK

BIDMC 2001
AP Oblique
32
 Vesna Ivancic
Gillian Lieberman, MD

FOLLOW-UP: PATIENT 2
POSTOPERATIVE PELVIC CT: 3 days later

BIDMC 2000
• Closed Reduction of Right Hemipelvis
• Percutaneous Fixation of Posterior SI joint Dislocation
• Intraoperative Bladder Repair 33
Vesna Ivancic
Gillian Lieberman, MD

BLADDER RUPTURE
Translation:
• ETIOLOGY: Trauma Urologic surgeons sleep
– 67-86% Blunt through 98% of traumas
• 90% MVC ☺
– Rarely ruptures due to
Malignancy, Obstruction, Drugs
– HOWEVER, of abdominal injuries that require
surgery, only 2% are Bladder Ruptures!
• IF EQUIVOCAL IMAGING:
– Flexible cystoscopy
34
 Vesna Ivancic
Gillian Lieberman, MD

SUMMARY part one

•TRAUMA (MVC, Fall)
HISTORY
•PAIN (Abdominopelvic)
PHYSICAL EXAM •HEMATURIA (90% of IPBR) Gross
more likely but can have major GU
injury with only Microscopic (DEGREE
DOESN’T correlate with SEVERITY)
•UNSTABLE PELVIS
TRAUMA SERIES •PELVIC FRACTURES
Plain films: Pelvic Scout XRAY (>95% of EPBR) (Scott et al, 1997)

•Less accurate than Retrograde

I+ CT Cystography (Haas et al, 1999)
Often done to R/O other injuries •PELVIC FLUID is a significant
predictor of BR (Morgan et al, 2000)
35
 Vesna Ivancic
Gillian Lieberman, MD

SUMMARY part two

Routine:
CYSTOGRAM
AP, Both Obliques, Postvoid
Study of choice
IF BLOOD at MEATUS RUG
CT CYSTO:
Recent studies show EQUAL
NOTE: MUST TRULY
DISTEND BLADDER accuracy to plain cystography
Accuracy 85-100% if use
400 ml (Dubinsky et al, 1999)
300 ml (Morey et al, 1999)
•Transabdominal Sonogram: showed
ULTRASOUND? intraperitoneal fluid adjacent to dome of
If doing Sonography already, bladder, confirmed with CT cystogram
look at bladder!? (Dubinsky et al, 1999)
36
 Vesna Ivancic
Gillian Lieberman, MD
MANAGEMENT
• EXPLORE IN O.R. IF
– Penetrating Trauma
– Urethra, Bladder neck,
Vagina, or Rectum
damaged
• MOST IPBR O.R.
– “IPBR occurring after blunt
trauma should always be
reconstructed emergently”
(Morey et al, 1999)
– Risk peritonitis and
absorption of electrolytes
• MOST EXBR MANAGED
CONSERVATIVELY
–1 wk broad-spectrum Abx
–Decompress bladder with
catheter until heals (2 wks)
–Then repeat Cystography
–Repair if pt going to OR
anyway
• DIVERT URINE OUTPUT IF
–Emergent surgery needed before
bladder repair
–Ex: can Externalize Stents
37
 Vesna Ivancic
Gillian Lieberman, MD

TAKE HOME MESSAGES

• PELVIC FRACTURE
1. THINK: Possible Bladder Rupture
2. DO: Cystogram—not just I+ CT
• MEN
1. Must do RUG FIRST if any RF for Urethral Injury
• INTRAPERITONEAL SURGICAL
EXTRAPERITONEAL CONSERVATIVE
• Empty bladder
– Before any road trip
– Never ever drink & drive
38
Vesna Ivancic
Gillian Lieberman, MD

ACKNOWLEDGEMENTS
• Our Webmasters:
– Larry Barbaras THANK YOU
– Cara Lyn D’amour FOR
the CASES &
• Residents:
the TEACHING!
– Ann McNamara, MD
– Dan Saurborn, MD
• The Presentation Fiasco Disaster Team:
– Michael, Sam, Dr. Lieberman and Pamela
– My Classmates, My Parents, and My Roommate
– Andrew and Lynda
39
 Vesna Ivancic
Gillian Lieberman, MD

REFERENCES
TEXTS
• Friedland GW, et al. Uroradiology: An Integrated Approach. Volume I. Churchill Livingstone
Inc., New York 1983; 639-672.
• Ney C, Fiedenberg RM. Radiographic Atlas of the Genitourinary System. 2nd Edition, Volume II.
J.B. Lippincott Co., Philadelphia 1981; 1445-1550.
ARTICLES• Anh JH, Morey AF, McAninch JW. Workup and Management of Traumatic Hematuria. Emer Med
Clin North Am 1998; 16(1): 145-164.
• Dubinsky TJ. Sonographic diagnosis of a traumatic intraperitoneal bladder rupture. AJR Am J
Roentgenol 1999; 172(3): 770.
• Haas CA, Brown SL, Spirnak JP. Limitations of routine spiral computerized tomography in the
evaluation of bladder trauma. J Urol 1999; 162(1): 51-2.
• Mirvis SE. Trauma. Radiologic Clinics of North America 1996; 34 (6): 1225-1258.
• Morey, AF, Hernandex J, McAninch JW. Reconstructive Surgery for Trauma of the Lower Urinary
Tract. Urol Clin North Am 1999; 26(1): 49-60.
• Morgan DE. CT cystography: radiographic and clinical predictors of bladder rupture. AJR Am J
Roentgenol 2000; 174(1): 89-95.
• Novelline, RA, Rhea JT, Bell T. Helical CT of Abdominal Trauma. Radiologic Clinics of North
America 1999; 37 (3): 608-612.
• Peng MY, Parisky YR, Cornwell EE. CT cystography versus conventional cystography in evaluation
of bladder injury. AJR Am J Roentgenol 1999; 173(5): 1269-72.
• Scott MH. Extraperitoneal bladder rupture: pitfall in CT cystography. AJR Am J Roentgenol 1997;
168(5): 1232.
WEBSITES• www.vesalius.com; www.netmedicine.com; www.bartlebys.com; www.weather.com; AJEM 2000;
18(4); Emer Med Clin North Am 1998 16(1).
40