BLADDER RUPTURE

BLADDER RUPTURE BLADDER RUPTURE

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Vesna Ivancic Gillian Lieberman, MD July 2001 BLADDER RUPTURE vesna ivancic Harvard Medical School Year IV Gillian Lieberman, MD

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

Vesna Ivancic

Gillian Lieberman, MD

ANATOMY: PELVIS

Associated with Bladder Rupture:

Diastasis of Pubic Symphysis or SI joint

Fractures of Ilium, Pubic Rami, Sacrum

Vesna Ivancic

Gillian Lieberman, MD

Patient 1: AP Pelvis

BIDMC 2001

Left Sacral

Ala Fractured

Left Pubic

Rami Fractured

Vesna Ivancic

Gillian Lieberman, MD

Patient 1: Axial pelvis CT

Rib Fracture

Superior Pubic

Ramus Fracture

Left Inferior Pubic

Ramus Fracture

BIDMC 2001

Vesna Ivancic

Gillian Lieberman, MD

Diastasis of

Right SI joint

Patient 2: Ap pelvis

BIDMC 2000

Diastasis of

Pubic Symphysis

Vesna Ivancic

Gillian Lieberman, MD

Patient 2: Axial pelvic CT

BIDMC 2000

Right Sacroiliac

Diastasis

Left Inferior Pubic

Ramus Fracture

BIDMC 2000

Vesna Ivancic

Gillian Lieberman, MD

? Bladder Rupture (BR)

INTRAPERITONEAL?

(IPBR)

EXTRAPERITONEAL?

(EPBR)

Vesna Ivancic

Gillian Lieberman, MD

RADIOLOGIC

CLASSIFICATION

BLADDER TRAUMA

CONTUSION Intramural injury/hematoma

NO ESCAPE of urine or contrast

INTRA Tear in bladder dome

Peritoneal

Rupture

Fluids ESCAPEPERITONEUM

EXTRA Tear in bladder wall

Peritoneal

Rupture

Fluids ESCAPESOFT TISSUES

Conservative

management

Surgical

management!

Conservative

management

Vesna Ivancic

Gillian Lieberman, MD

QUICK ANATOMY REVIEW

Bladder is EXTRAPERITONEAL!

Male Female

Note relationship between Bladder & Pubic Symphysis

Gray’s Anatomy www.barbtleby.com

Vesna Ivancic

Gillian Lieberman, MD

INCREASED RISK

FOR BLADDER RUPTURE!

Extremes of life: Elderly and babies

Vesna Ivancic

Gillian Lieberman, MD

Because bladder projects above

BPH: Any patient with a full distended

bladder eg s/p ETOH at higher risk

pubic symphysis:

Baby

Gray’s Anatomy www.barbtleby.com

Vesna Ivancic

Gillian Lieberman, MD

Patients who need

a bladder evaluation:

• HISTORY:

– Trauma patients

– With abdominal pain

• PHYSICAL:

– Hematuria

• TRAUMA SERIES:

– Pelvic fractures

Vesna Ivancic

Gillian Lieberman, MD

Rule out urethral tear!

Seminars Roent, 1983

FIRST DECISION:

? Obtain RUG

RISK FACTORS

Male

Scrotal hematoma

Blood at meatus

High-riding prostate

Unable to void

TEAR

Chong, eMedicine.com

RUG: Retrograde UrethroGram

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

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

Full Bladder Or Injury via bone fragments

URINE = NONCOMPRESSIBLE FLUID!

DISTENDED BLADDER = THIN WALL!

EXTENSION Ruptures at dome

Extends into peritoneal

cavity

MANAGEMENT Surgical Conservative

Extends into prevesical soft

tissues, perineum, scrotum,

thigh, anterior abdominal

wall, retrorectal/presacral sp.

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

Vesna Ivancic

Gillian Lieberman, MD

OUTLINING LOOPS

Ney and Fiedenberg, 1981

Outline of liver margin and peritoneal reflection

Brian Camozzi www.weather.com

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 &

rectovesical pouches

Radiol Clin North Am 1999

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

Vesna Ivancic

Gillian Lieberman, MD

“…like rays of sun bursting

through a breaking cloud…”

Jason Boggs www.weather.com

Friedland,1983

Vesna Ivancic

Gillian Lieberman, MD

Ney and Fiedenberg, 1981

SUNBURST PATTERN

Seen with Extraperitoneal bladder ruptures

James Lucas www.weather.com

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

• Dissects fascial planes

Radiol Clin North Am, 1999

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

Vesna Ivancic

Gillian Lieberman, MD

TEARDROP BLADDER

Extravasation of contrast from

teardrop bladder associated with

extraperitoneal rupture.

This patient had a teardrop

bladder with rupture

Teardrop bladder associated with

extraperitoneal rupture and

bladder neck fracture.

Ney and Fiedenberg, 1981

Vesna Ivancic

Gillian Lieberman, MD

PATIENT 1

I+ AbdominoPelvic CT SCAN

Intraperitoneal fluid: 4 HU

BIDMC 2001

Hematoma

Bladder with Foley

Uterus

26

Rectum

Vesna Ivancic

Gillian Lieberman, MD

PATIENT 2

I+ AbdominoPelvic CT SCAN

Intraperitoneal fluid: 4 HU

BIDMC 2000

SI diastasis with bone fragment

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?)

Vesna Ivancic

Gillian Lieberman, MD

Air in bladder

due to

instrumentation

PATIENT 1

CT CYSTOGRAM

INTRAPERITONEAL EXTRAVASATION OF CONTRAST

?AREA OF HIGH ATTENUATION?

Extraperitoneal BR? Hematoma?

BIDMC 2001

29

Vesna Ivancic

Gillian Lieberman, MD

PATIENT 2

I+ CT SCAN & CT CYSTOGRAM

Air in Subcutaneous Tissues

INTRAPERITONEAL EXTRAVASATION OF CONTRAST

Note: No Ureteral disruption

BIDMC 2000

Vesna Ivancic

Gillian Lieberman, MD

Intraluminal air

not yet resolved

FOLLOW-UP: PATIENT 1

I+ CT: 5 days later

After Conservative (!) Management,

NO CONTRAST LEAK

BIDMC 2001

Anterior pelvic clot

indenting bladder

Vesna Ivancic

Gillian Lieberman, MD

FOLLOW UP: PATIENT 1

Fluoroscopic Retrograde Cystogram: 12 d. later

NO LEAK

AP Oblique BIDMC 2001

Vesna Ivancic

Gillian Lieberman, MD

FOLLOW-UP: PATIENT 2

POSTOPERATIVE PELVIC CT: 3 days later

• Closed Reduction of Right Hemipelvis

• Percutaneous Fixation of Posterior SI joint Dislocation

• Intraoperative Bladder Repair

BIDMC 2000

Vesna Ivancic

Gillian Lieberman, MD

BLADDER RUPTURE

• ETIOLOGY: Trauma

– 67-86% Blunt

• 90% MVC

– Rarely ruptures due to

Malignancy, Obstruction, Drugs

Translation:

Urologic surgeons sleep

through 98% of traumas

☺

– HOWEVER, of abdominal injuries that require

surgery, only 2% are Bladder Ruptures!

• IF EQUIVOCAL IMAGING:

– Flexible cystoscopy

Vesna Ivancic

Gillian Lieberman, MD

HISTORY

PHYSICAL EXAM

TRAUMA SERIES

SUMMARY part one

Plain films: Pelvic Scout XRAY

I+ CT

Often done to R/O other injuries

•TRAUMA (MVC, Fall)

•PAIN (Abdominopelvic)

•HEMATURIA (90% of IPBR) Gross

more likely but can have major GU

injury with only Microscopic (DEGREE

DOESN’T correlate with SEVERITY)

•UNSTABLE PELVIS

•PELVIC FRACTURES

(>95% of EPBR) (Scott et al, 1997)

•Less accurate than Retrograde

Cystography (Haas et al, 1999)

•PELVIC FLUID is a significant

predictor of BR (Morgan et al, 2000)

Vesna Ivancic

Gillian Lieberman, MD

CYSTOGRAM

SUMMARY part two

Study of choice

IF BLOOD at MEATUS RUG

NOTE: MUST TRULY

DISTEND BLADDER

Accuracy 85-100% if use

400 ml (Dubinsky et al, 1999)

300 ml (Morey et al, 1999)

ULTRASOUND?

If doing Sonography already,

look at bladder!?

Routine:

AP, Both Obliques, Postvoid

CT CYSTO:

Recent studies show EQUAL

accuracy to plain cystography

•Transabdominal Sonogram: showed

intraperitoneal fluid adjacent to dome of

bladder, confirmed with CT cystogram

(Dubinsky et al, 1999)

Vesna Ivancic

Gillian Lieberman, MD

• 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

MANAGEMENT

• 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

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

Vesna Ivancic

Gillian Lieberman, MD

ACKNOWLEDGEMENTS

• Our Webmasters:

– Larry Barbaras

– Cara Lyn D’amour

• Residents:

– Ann McNamara, MD

– Dan Saurborn, MD

THANK YOU

FOR

the CASES &

the TEACHING!

• The Presentation Fiasco Disaster Team:

– Michael, Sam, Dr. Lieberman and Pamela

– My Classmates, My Parents, and My Roommate

– Andrew and Lynda

Vesna Ivancic

Gillian Lieberman, MD

REFERENCES

• 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. 2

40

nd TEXTS

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).

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