In blunt trauma, probability of bladder rupture depends upon the degree of bladder distention. Pdf introduction urinary bladder ruptures are an uncommon injury, occurring in less than. Peritoneal lavage would reveal urinary ascitic fluid. Ecr 2019 c2071 urinary bladder rupture, our experience epos. This can occur with minimal trauma when the bladder is full. Bladder injuries can be categorized into several types. On the 18 positive examinations, 11 were extraperitoneal bladder rupture, five were intraperitoneal bladder rupture, and two were combined intraperitoneal and extraperitoneal bladder rupture. Conclusion a conservative treatment of a small intraperitoneal bladder perforation is possible under certain conditions. Extraperitoneal rupture of the bladder is uncommon. Mar 26, 2019 while most trauma patients with bladder perforation have multiple injuries and ct imaging is a regular part of the trauma evaluation, this does not preclude obtaining a separate cystogram if bladder findings on the ct scan are equivocal. Computed tomography ct cystogram demonstrating a complex extraperitoneal bladder rupture with contrast material extending through the.
Symptomatic extraperitoneal bladder perforation following. These are most often due to horizontal tear along dome of the bladder. In the past diagnosis of bladder rupture was often missed or delayed. Cross section of contrastenhanced computed tomography and cystography shows bladder rupture with massive ascites in the peritoneal space. Ct cystography with multiplanar reformation for suspected. It may be identified on plain films, contrast studies, and sectional imaging studies fig. Intraperitoneal bladder rupture can be handled by exploration and primary bladder closure or laparoscopic repair gunnarsson and heuman, 1997, while the extraperitoneal bladder injury is. It is more common with a full bladder and blunt abdominal trauma. Urinary bladder disease includes urinary bladder inflammation such as cystitis, bladder rupture and bladder obstruction tamponade. This report describes a rare case of an 86yearold man with an indwelling urethral catheter who developed severe abdominal pain and was diagnosed with intraperitoneal urinary bladder perforation.
Abdominal vessels trauma, intraperitoneal bladder rupture. In the setting of trauma to the bladder it is important to differentiate extraperitoneal from intraperitoneal rupture. Extraperitoneal bladder rupture is more common, with an 8090% frequency rate, whereas intraperitoneal bladder rupture occurs in 1520% of patients. Often, computed tomography ct is the first test performed in patients with blunt abdominal trauma. The small intraperitoneal bladder rupture was treated conservatively via continued urinary drainage under urinary antibiotic prophylaxis until closure. Intraperitoneal bladder rupture occurs in approximately 10%20% of major bladder injuries, 12.
Recent studies have described laparoscopic repair of intraperitoneal urinary bladder rupture. Laparoscopic repair of intraperitoneal bladder rupture. Diagnostic laparoscopy identified intraperitoneal bladder rupture, which required open surgical repair. Urinary bladder rupture radiology reference article. Finding for the evaluation of intraperitoneal bladder rupture following blunt trauma objective. Spontaneous bladder rupture is an extremely rare clinical event that is associated with urinary ascites and apparent acute renal failure. Sagittal and coronal multiplanar reformations may be helpful in identifying most sites of bladder rupture. Bladder rupture can be categorized into five types depending on the location and extent of the rupture. Axial contrastenhanced ct image of the pelvis demonstrates simple free fluid posterior to the bladder arrow. A urinary bladder that is full is more prone to rupture than an empty one.
Distinction between intraperitoneal and extraperitoneal. Other causes are spontaneous rupture intraperitoneal rupture of urinary bladder. Free intraperitoneal fluid was found on ultrasound and ct imaging. Laparoscopic repair of intraperitoneal bladder perforation was first described in 1994 and since then, a few cases of such approach have been reported to treat traumatic, spontaneous and iatrogenic bladder rupture, avoiding laparotomy. Bladder rupture is an uncommon injury, occurring in 10% of patients with pelvic fractures. The intraperitoneal investigation confirmed the presence of a large, transverse bladder rupture at the dome, measuring approximately 8 cm in length. To our knowledge, this is the first series of lrib reported secondary to blunt abdominal trauma. A large volume of contrast is demonstrated in the abdominal cavity consistent with an intraperitoneal urinary bladder rupture. Mortality with bladder rupture from external trauma can approach 20%. Intraperitoneal bladder rupture constitutes about 1040% of all bladder ruptures 12. Six retrospective studies were used to determine the incidence of urine leakage rates on initial followup imaging in low simple extraperitoneal or intraperitoneal ruptures that are surgically repaired, medium complex intraperitoneal ruptures that are surgically repaired, and high simple extraperitoneal bladder rupture managed by catheter. Spontaneous bladder rupture is rare and life threatening event, with a high mortality rate reaching up to 50%. Mar 18, 2011 the small intraperitoneal bladder rupture was treated conservatively via continued urinary drainage under urinary antibiotic prophylaxis until closure.
The laparoscopic approach is the best short recovery and less traumatic treatment allowing visualization of. Table 1 case series of nonoperative treatment for intraperitoneal bladder rupture. Highest morbidity and rupture mortality is associated with intraperitoneal rupture because of potential for development of chemical peritonitis imaging findings diagnostic evaluation of bladder rupture includes voiding cystourethrography vcug or ct scan. The diagnosis was suggested by abdominal ct scan and confirmed with a cystogram. While uncommon, late presentation of intraperitoneal bladder rupture following trauma may occur from masking of a primary laceration or development. In patients sustaining blunt abdominopelvic trauma with intraperitoneal bladder rupture p, should operative repair i versus nonoperative management c be used to decrease complications from the bladder injury o. Ct cystography in the evaluation of major bladder trauma. Intraperitoneal bladder rupture frequently occurs at the anatomically vulnerable bladder dome, the weakest and most mobile part of the bladder. Crosssectional images through the pelvis provide information on the status of both the pelvic organs and bony structures. This event is difficult to diagnose clinically, even with advanced techniques such as computed tomography. Cedarssinai imaging case of the month february 2018.
Intraperitoneal bladder rupturechildnonsurgical treatmentblunt traumapelvic. The final diagnosis in this case was a urinothorax occurring in conjunction with intraperitoneal bladder rupture of an acquired bladder dome diverticulum. A child with urine ascites as a delayed manifestation of posttraumatic intraperitoneal bladder rupture is presented. Delayed presentation of traumatic intraperitoneal rupture. Emergency urological care with celioscopic suture of the intraperitoneal bladder rupture. Ultrasound findings such as irregular posterior bladder wall, moderate amount of intraperitoneal free fluid, rent in bladder wall, and flow of fluid through the rent into the peritoneum while infusing saline through foleys catheter as shown in our case suggest ipr. A ct cystogram has been performed after approximately 400ml of urograffin contrast has been administered via a urinary catheter. To evaluate the frequency and relevance of the sentinel clot sign on ct for patients with traumatic intraperitoneal bladder rupture in a. On the 18 positive examinations, 11 were extraperitoneal bladder rupture, five were intraperitoneal bladder rupture, and two were combined intraperitoneal and. It typically follows significant trauma to the pelvis, for example following a rta, assualt or a fall from a height. Laparoscopic management of intraperitoneal bladder rupture. Urinary bladder rupture is generally caused by a direct blow or penetrating trauma to the urinary bladder the probability of bladder rupture is variable.
Intraperitoneal bladder rupture has to be repaired surgically, whereas extraperitoneal rupture can. Pdf management of blunt intraperitoneal bladder rupture. A, axial ct cystography image shows contrast extravasation into peritoneal space. Isolated bladder injury is a rare condition and on the other hand, delayed bladder perforation is an extremely rare entity.
No other posttraumatic lesions in the abdominal cavity. Two cases of intraperitoneal bladder rupture following. I versus no imaging study be used to diagnose bladder inju. The possible pathogenesis of bladder rupture in bladder cancer is precipitation of perforation on the weakened body wall by the tumour. Conservative treatment of an intraperitoneal bladder perforation. The common condition associated with pelvic fractures is intraperitoneal rupture of urinary bladder. Bladder perforations may be extraperitoneal or intraperitoneal and can be a consequence of inadvertent full. Coronal reformatted image of the pelvis from a ct cystogram showing hyperdense fluid in the bladder and in the intraperitoneal space. One image from an ivu shows a flameshaped density adjacent to right lateral wall. Pelvic fracture was present in essentially all patients with extraperitoneal bladder rupture, and hollow viscus injuries were present more often in patients with intraperitoneal bladder rupture. Delayed presentation of traumatic intraperitoneal bladder.
Gross hematuria is the classic sign of bladder rupture and is present in 90 % of the cases. Case report nonoperative treatment for intraperitoneal bladder rupture jiunhung genga, hsiaochun changb, shiudong chungb, peihwei chenb, bin chiub, chungyou tsaib, chinghwa yangb, shunfa hungb adepartment of urology, kaohsiung medical university hospital, kaohsiung, taiwan b department of surgery, far eastern memorial hospital, banciao, new taipei city, taiwan. The rupture is commonly intraperitoneal, usually at the dome, as this is the weakest point within the bladder wall. Highest morbidity and rupture mortality is associated with intraperitoneal rupture because of potential for development of chemical peritonitis. Patients usually present with vague symptoms, such as diffuse suprapubic pain and tenderness, mild shock, oliguria, and mildly raised renal function, mimicking other abdominal. Even in the absence of a clear history of trauma, the presence of a large volume of free fluid and acute renal impairment should raise suspicion of intraperitoneal bladder rupture. Intraperitoneal urinary bladder perforation observed in a. Distinction between intraperitoneal and extraperitoneal processes. Occurs in approximately 15% range 1020% of major bladder injuries, and typically is the result of a direct blow to the already distended bladder. While extraperitoneal bladder rupture can be treated conservatively, intraperitoneal bladder rupture requires surgical repair. Intraperitoneal bladder rupture is usually managed surgically because of the high probability of associated injuries and possibility of herniation of bowelloops through the tear, which causes adhesions 5,8.
Learningradiology bladder, rupture,intraperitoneal. Ct cystography is accurate for diagnosing bladder rupture. Exploratory laparotomy located an intraperitoneal rupture. Percutaneous peritoneal drainage for the management of. Mar 20, 2020 in this position, the appendix may be intraperitoneal or extraperitoneal fig. Cystitis is common, sometimes referred to as urinary tract infection uti caused by bacteria, bladder rupture occurs when the bladder is overfilled and not emptied while bladder tamponade is a result of blood clot formation near the bladder outlet. Complications of bladder injuries include urinary ascites free urine in the peritoneal cavity due to intraperitoneal rupture, infection including sepsis, persistent hematuria, incontinence, bladder instability, and fistula. Urotrauma guideline american urological association. We present a case of intraperitoneal bladder rupture in the setting of a blunt. The patients were studied for the demographic profile, inciting factors causing rupture of bladder, time to presentation, symptoms and signs at presentation, blood and imaging studies done, and management done for the patient.
Here, we report a case of a patient who experienced a spontaneous intraperitoneal bladder. They tend to be large and most commonly occur at the dome of the bladder. Given the rapid development of abdominal ascites and pleural effusion over the course of days, malignant related etiologies were felt unlikely. This is a true surgical emergency managed conventionally by open laparotomy with single or double layer repair. However, bladder irrigation could not subsequently be performed. Spontaneous bladder rupture diagnosis based on urinary. Ct cystography was applied to a classification scheme for bladder injury based on the degree of wall injury and anatomic location and demonstrated characteristic imaging features for each type of injury. Extraperitoneal bladder rupture is the most common type. Twenty of the 74 patients had intraperitoneal bladder rupture. To evaluate the frequency and relevance of the sentinel clot sign on ct for patients with traumatic intraperitoneal bladder rupture in a retrospective study. Schwartz clinical history 50yearold male with history of motor vehicle collision.
Management of blunt force bladder injuries the eastern. Urinary bladder rupture is usually seen in the context of significant trauma. The sudden increase in intravesicular pressure causes intraperitoneal rupture of the bladder dome. Learningradiology bladder rupture, intraperitoneal and. Blunt injury of the urinary bladder is well known and usually associates pelvic fractures.
In general, patients with intraperitoneal bladder ruptures should undergo operative repair. Nonoperative treatment for intraperitoneal bladder rupture. Intraperitoneal rupture shows contrast delineation of intraperitoneal organs such as bowel loops or liver edge. This injury is typically the result of a direct blow to the already distended bladder. Leakage of urine into perivesicular space tear drop shape on imaging. Trauma, education and training, technical aspects, cystography uretrography, contrast agentother, ultrasound, fluoroscopy, ct, urinary tract. Suad ali saleh alaghbari, md, general surgery resident level 3, omsb, sultanate of oman abstract. Pelvic fracture was present in 80%, hollow viscus injury in 34. Ct without opacification of the bladder may depict a sentinel clot sign abutting the bladder dome which indicates injury, with a. An important fact is that 85 % of bladder ruptures are the result of pelvic fractures, but that only 10 % of pelvic fractures are associated with bladder injuries. Aug 12, 2015 gross hematuria is the classic sign of bladder rupture and is present in 90 % of the cases.
Evidence for this mechanism is found in the fact that these injuries overwhelmingly involve the dome, suggesting. Mar 28, 2018 pelvic fracture was present in 80%, hollow viscus injury in 34. The differential diagnosis of bladder rupture includes urethral injury in males, during which extravasated urine. A defect is visible at the bladder dome, indicating the site of the bladder rupture with extravasation of intravesicular contrast from the bladder arrow into the peritoneal spaces along the. Contusion represents an intramural injury, with hematoma within the bladder wall. Bladder needs to be fully distended and evaluation of a. Herein, we described an unusual case of isolated delayed intraperitoneal bladder rupture that occurred on the third post injury day in a young male in the absence of free. Bi may be evaluated by conventionalcystography or ctcystography, with the latter having the additional benefit of evaluating pelvic fracture and other intraabdominal injuries. Delayed presentation of traumatic intraperitoneal rupture of. Diagnostic evaluation of bladder rupture includes voiding cystourethrography vcug or ct scan. An abdominal ct with a contrast media filled bladder can substitute all above mentioned imaging studies except for retrograde urethrography. Successful conservative treatment of traumatic intraperitoneal.
Imaging of gastrointestinal and abdominal emergencies in. For intraperitoneal rupture, the sensitivity and specificity were 100% and 99%, respectively. Bladder rupture in the puerperium is commonly associated with concomitant uterine rupture in the obstetric setting. Urine may also leak into the pouch of douglas, located midline and posterior to the bladder and anterior to rectosigmoid colon, or into the lateral pelvic recesses.
Laparoscopic repair of intraperitoneal bladder perforation. Ct cystography with multiplanar reformation for suspected bladder. All these injuries should be treated with prompt surgical exploration. Although the most frequent location for intraperitoneal perforation was the dome or the posterior wall of the bladder 6. Intraperitoneal associated with compressive force in presence of. For claims with a date of service on or after october 1, 2015, use an equivalent icd10cm code or codes. Bladder injuries are extraperitoneal in approximately 60%, intraperitoneal in approximately 30%, and the remaining injuries are both intraperitoneal and extraperitoneal ruptures. Axial ct image of the pelvis from a ct cystogram demonstrates hyperdense intraperitoneal.
Many complications of appendicitis are related to anatomic variations in the position of the appendix, refig. This is commonly seen but sometimes not classed as true rupture, since it involves an incomplete tear of the mucosa. A transverse unenhanced ct image shows a highattenuating hematoma. Management of blunt intraperitoneal bladder rupture. In the present case, we could not rule out perforation of the digestive tract.
From january of 2002 through june of 2006, a total of 9 patients were identified in our trauma registry with bladder ruptures secondary to abdominal blunt. In this position, the appendix may be intraperitoneal or extraperitoneal fig. Multiplanar reformation images were obtained by using a software package. However, 83% of patients with bladder rupture have a pelvic fracture. Intraperitoneal urinary bladder rupture diagnosed with. Laparoscopic repair of intraperitoneal bladder rupture secondary to blunt abdominal trauma dr. Bladder perforations may be extraperitoneal or intraperitoneal and can be a consequence of inadvertent full thickness bladder wall resection during surgery.
Voiding cystourethrography historically been preferred contrast enhanced study for diagnosis of bladder rupture. The bladder receives urine from the kidney via the ureters right and left, which enter the bladder inferiorly and posteriorly. The ct cystography results were compared with the findings at surgery, clinical followup, or both. However as mentioned before the intraperitoneal rupture is more common, bladder repair is indicated in the form of primary closure, partial cystectomy or radical cystectomy. Urinary bladder rupture is generally caused by a direct blow or penetrating trauma to the urinary bladder. Many complications of appendicitis are related to anatomic variations in. Laparoscopic repair of traumatic intraperitoneal bladder rupture. Conservative treatment of an intraperitoneal bladder. Intraperitoneal ruptures can lead to sepsis and carry a higher mortality than extraperitoneal injuries. It can occur as a direct or indirect consequence of other associated conditions such as urothelial carcinoma uc, the less common squamous cell carcinoma scc, pelvic radiotherapy, chronic cystitis, bladder outflow obstruction, alcohol intoxication and others. Oct 25, 2011 intraperitoneal rupture of the bladder is an uncommon condition that is usually caused by pelvic fractures. Intraperitoneal ruptures occur because rapidly rising intraperitoneal pressure causes the bladder to burst 5. Computed tomography ct scan of the abdomen and urinary cystogram can yield.
The peritoneal lining covers the bladder dome, which is the weakest part of the bladder and vulnerable to injury as the bladder distends with urine and rises into the peritoneal cavity. Extraperitoneal bladder rupture can be managed conservatively 8. The actual incidence of bladder perforation is difficult to estimate as small perforations remain unnoticed, however one series reports an incidence of 1. A homevisiting nurse suspected catheter obstruction and performed a catheter exchange.
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