Case of the Month

Our Imaging Case of the Month is presented as a part of the Imaging Department's residency teaching program. Each month a resident collaborates with one of our attending imaging physicians to present an interesting case to the Cedars-Sinai medical community. The case is used to teach both imaging and other residents at Cedars-Sinai. Below is the current Case of the Month.

Submitted by Joseph Kallini, MD and Thomas Learch, MD.

Presentation

44-year-old man with diffuse abdominal pain after motor vehicle collision.

Allergies and Relevant Past Medical and Surgical Histories:

  • No known drug allergies
  • Hepatitis C

Initial Physical Exam

  • BP: 121/70
  • HR: 102
  • Tmax: 99.5
  • RR: 16
  • SpO2: 99% on 2L/min flow via NC
  • Constitutional: Lethargic.
  • Pulses: Symmetric and equal.
  • Abdominal: Diffuse tenderness to palpation.
  • Neurological: GCS eye, verbal, and motor subscores are 3, 4, and 6, respectively.

 Relevant Laboratory Analysis:

  • Blood alcohol level: 0.267 g/dL
  • Potassium: 3.3 mmol/L (normal 3.5 - 5.0 mmol/L)
  • Hemoglobin 17.5 g/dL (within normal limits)
  • All other components within normal limits
Initial Imaging

 

Figure 1 

Figure 2

Figures 1 and 2: Axial [Fig. 1] and coronal [Fig. 2] venous-phase contrast-enhanced CT images show a linear focus of contrast at the dome of the bladder [yellow cursor].

Differential Diagnosis
  • Intraperitoneal Bladder Rupture
  • Urethral injury
  • Active pelvic or abdominal hemorrhage
  • Blood clot in bladder
Next Step – CT cystography

 

Figure 3

Figure 3. After 300 mL of water-soluble contrast administration through a Foley catheter inserted into the urinary bladder, axial CT demonstrates extraluminal contrast extending into peritoneal space between mesenteric folds and bowel loops.

Figure 4

Figure 4. After 300 mL of water-soluble contrast administered through a Foley catheter inserted into the urinary bladder, sagittal CT demonstrates contrast extending into the paracolic gutters.

Diagnosis

Intraperitoneal Bladder Rupture

Discussion

Five types of urinary bladder rupture have been described, which depend on location and extent. Cystography (either CT or conventional) is the preferred method of diagnosis, which is performed by instilling water-soluble contrast into the bladder through a Foley catheter. CT provides the additional benefit of analyzing the upper urinary tracts. Type 1 is a bladder contusion, which involves an incomplete tear of the bladder wall mucosa. This is common and considered by some not to be a true rupture. CT cystography is often normal. A “pear-shaped bladder” has been described, due to extrinsic, symmetrical bladder compression by extraperitoneal hematoma. Type 2 is intraperitoneal rupture, as illustrated by this case. Type 3 is subserosal / interstitial bladder rupture, which is a tear in the serosal surface and a rare occurrence. Cystography demonstrates elliptical extravasation of contrast around the bladder. Extraperitoneal (type 4) bladder rupture is the most common type of bladder injury and occurs in 80-90% of cases. It is usually the result of pelvic fractures or penetrating trauma. Cystographic findings are often variable. Contrast usually pools at bladder base anterolaterally. Contrast may also pool into the prevesical space (space of Retzius), known as the ‘molar tooth’ sign. Sometimes, contrast may extend to the thigh, scrotum or perineum. Conservative treatment with an indwelling catheter is performed. Type 5, combined bladder rupture, is simultaneous intraperitoneal and extraperitoneal rupture.

Intraperitoneal (type 2) bladder rupture occurs in 10-20% of major bladder injuries. It is usually iatrogenic or secondary to penetrating injury. Blunt trauma is more likely to result in intraperitoneal rupture in children than in adults owing to the fact that the pediatric bladder is more intraperitoneal in location. The dome of the bladder in an adult is predominantly extraperitoneal; thus, adult intraperitoneal bladder rupture usually occurs when the bladder is full. CT cystography demonstrates extraluminal contrast extending into peritoneal spaces (paracolic gutters, pouch of Douglas, Morrison's pouch), between mesenteric folds, and outlining bowel loops.

The most common presenting signs/symptoms of bladder rupture include gross hematuria, suprapubic pain and tenderness, anuria, and fever. Intraperitoneal rupture may present with paucity of bowel sounds and acute abdomen (in the setting of urine-induced chemical peritonitis). Urinalysis demonstrates hematuria. Chemistry panel may reveal hypernatremia, hyperkalemia, uremia, and acidosis (secondary to reabsorption of urine). Peritoneal lavage would reveal urinary ascitic fluid.

The differential diagnosis of bladder rupture includes urethral injury (in males), during which extravasated urine can extend into the prevesical spaces. Active pelvic or abdominal hemorrhage may simulate bladder rupture. Intravesicle blood clot is also a consideration.

Complications of intraperitoneal bladder rupture include fistula, abscess, sepsis, bladder calculi, hematoma, hemorrhage, and shock. High morbidity and mortality is associated with intraperitoneal rupture because of the potential for development of chemical peritonitis. As a result, intraperitoneal bladder rupture requires surgical repair, differentiating it from extraperitoneal rupture, which is managed expectantly.

References
  • Heller MT, Federle MP. Bladder Trauma. In: STATdx (2018) [online] Available at: http://www.statdx.com [Accessed 2 Apr. 2018].
  • Jones J et al. Urinary bladder rupture. In: radiopedia.org (2018) [online] Available at: https://radiopaedia.org/articles/urinary-bladder-rupture [Accessed 2 Apr. 2018].
  • Patel BN et al: Imaging of iatrogenic complications of the urinary tract: kidneys, ureters, and bladder. Radiol Clin North Am. 52(5):1101-16, 2014.
  • Ishak C et al: Bladder trauma: multidetector computed tomography cystography. Emerg Radiol. 18(4):321-7, 2011

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