Emerg Radiol (2006) 13: 155–156DOI 10.1007/s10140-006-0520-x

CLINICAL QUIZ

Andrew Gelbman

Clinical quiz: combined intraperitoneal and extraperitonealbladder rupture

Received: 4 April 2006 / Accepted: 9 June 2006 / Published online: 19 October 2006# Am Soc Emergency Radiol 2006

Clinical history

The patient is a 39-year-old man who was a restrained frontseat passenger in a motor vehicle collision. The vehicle inwhich he was riding was T-boned on the drivers side,resulting in the death of the driver. CT scans of theabdomen and pelvis were obtained. Axial images throughthe neck and base of the bladder are shown.

A. Gelbman (*)Department of Radiology,Creighton University Medical Center,601 N. 30th St.,Omaha, NE 68131, USAe-mail: dockandy@cox.netTel.: +1-402-4494540

Diagnosis

Combined intraperitoneal and extraperitoneal bladderrupture

The initial CT scan through the pelvis demonstrates IVcontrast around the bladder neck and a small defect in thebladder dome. A small amount of free fluid is noted in thepelvis. Right pubic and iliac wing fractures are also seen.Delayed imaging of the abdomen and pelvis with multi-planar reformatting (right) was later performed. Thedelayed images demonstrate extraperitoneal extravasationof IV contrast into the space of Retzius and a rent in thebladder dome with intraperitoneal extravasation of IVcontrast.

Discussion

Trauma to the genitourinary system occurs in approxi-mately 5–10% of all patients with trauma [1]. Bladdertrauma is the second most common genitourinary injuryafter renal trauma. Fifty to 85% of ruptures are extraper-itoneal (many of which have associated pelvic fractures),while 15–45% are intraperitoneal and only 1–10% are both[1–4].

Five grades of bladder injuries are recognized [2].

Type IPartial tears of the mucosa. This is the most commontype of bladder injury. Cystogram is normal.

Type IIIntraperitoneal bladder rupture. Most commonly theresult of a direct blow to the distended organ.Intraperitoneal contrast will be seen.

Type IIIPartial tear of the serosa. Mural defect withoutextravasation will be seen.

Type IVExtraperitoneal bladder rupture. Laceration to thelower bladder anterolaterally from pelvic fragments.Extravasation into the prevesical space (simple),perineum, thigh, or scrotum (complex).

Type VCombined rupture. Results from penetrating and blunttrauma.

Retrograde cystograms have long been used for detect-ing bladder ruptures, and are nearly 100% sensitive. CTcystography, with washout after filling the bladder with400 cm3 of dilute contrast, has been shown to be assensitive as retrograde cystography [2, 4]. With extraperi-toneal bladder rupture, a Foley catheter is placed, and mostheal without intervention or complication. With intraperi-toneal rupture, operative repair is required. Morbidity andmortality are greatly influenced by preexisting urinary tractinfection as sepsis can ensue within 24 h. When intraperi-toneal bladder rupture is treated properly, few long-termcomplications occur in the patients [1–3].

References

1. Choe J et al (2004) Bladder trauma. Available @ http://www.arabmedmag.com/issue-30-04-2005/urology/main04.htm

2. Platter D et al (2004) Bladder, trauma. Available @ http://www.emedicine.com/radio/topic81.htm

3. Mattox K et al (2000) Trauma, 4th edn. McGraw-Hill, NewYork, pp. 163–164, 860–862

4. Mirvis S et al (2003) Imaging in trauma and critical care, 2ndedn. Saunders, Philadelphia, pp. 496–504

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