AJR 2003; 181:1379-1380
© American Roentgen Ray Society
Imaging of Traumatic Bladder Perforation That Spontaneously Sealed After Omental Herniation
U. K. Sharma1,
R. K. Rauniyar1,
C. S. Agrawal2,
J. S. Rao1,
D. B. Karki1 and
M. H. Naik1
1 Department of Radiodiagnosis and Medical Imaging, B. P. Koirala Institute of
Health Sciences, Dharan, Nepal.
2 Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan,
Nepal.
Received October 2, 2002;
accepted after revision March 11, 2003.
Address correspondence to U. K. Sharma.
Introduction
Bladder injuries occur as a result of blunt or penetrating trauma.
Spontaneous sealing of bladder perforation is rare, and presenting findings
may be quite diverse. We present an unusual case of intraperitoneal urinary
bladder perforation spontaneously sealed with a herniated omentum that was
diagnosed with imaging.
Case Report
An 11-year-old boy presented to the outpatient department with complaints
of pain in the perineal and suprapubic regions. When he had fallen from a tree
6 weeks earlier he sustained injury to his lower abdomen and pelvis.
Immediately after trauma there was transient bleeding of the rectum. He had
also experienced two episodes of painless terminal hematuria. He was examined
because of persistent suprapubic pain and hematuria. Physical examination
results were normal except for minimal tenderness in the suprapubic region.
Perineal examination did not reveal any external sign of injury. The results
of rectal examination were normal. Laboratory examination showed a hemoglobin
level of 12.6 g/dL, total leukocyte count of 15.9 x
103/µL, and a blood urea level of 25 g/dL; urine showed RBC and
pus cells. Radiography of the pelvis did not reveal any fracture.
Sonography of the pelvis showed an echogenic polypoid mass measuring
approximately 2 x 3 cm in the anterosuperior wall of the urinary bladder
(Figs. 1A and
1B). Findings of abdominal
sonography were normal. Color Doppler sonography of the mass showed a large
vessel arising from outside the bladder. Findings of subsequent conventional
cystography showed a rounded filling defect in the anterosuperior position of
the bladder. Later findings of CT cystography showed a fat-density mass
continuous with the omentum with a rent in the bladder dome, which confirmed
the sonographic diagnosis (Figs.
1C and
1D). Bladder distensibility was
maintained, and no leakage of contrast material could be seen. A tear in the
dome of the bladder and the omentum adherent and protruding through it were
found during surgery. The omentum was extracted, and the tear was closed. The
postoperative period was uneventful, and the child was doing well in follow-up
care.
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Fig. 1A. —11-year-old boy with complaints of suprapubic pain and
hematuria 6 weeks after trauma. Transverse (A) and sagittal (B)
sonograms show echogenic polypoidal mass arising from anterosuperior wall of
urinary bladder.
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Fig. 1B. —11-year-old boy with complaints of suprapubic pain and
hematuria 6 weeks after trauma. Transverse (A) and sagittal (B)
sonograms show echogenic polypoidal mass arising from anterosuperior wall of
urinary bladder.
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Fig. 1C. —11-year-old boy with complaints of suprapubic pain and
hematuria 6 weeks after trauma. Axial CT cystogram (C) and multiplanar
reformatted image (D) show fat-density mass (arrow) continuous
with omentum. Note tear in bladder dome.
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Fig. 1D. —11-year-old boy with complaints of suprapubic pain and
hematuria 6 weeks after trauma. Axial CT cystogram (C) and multiplanar
reformatted image (D) show fat-density mass (arrow) continuous
with omentum. Note tear in bladder dome.
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Discussion
The urinary bladder is located such that rupture or perforation of the
bladder may result in either intraperitoneal or extraperitoneal extravasation
of urine. In adults, extraperitoneal bladder perforation is more common,
accounting for 80–90% of cases
[1]. Intraperitoneal
perforation occurs in 15–20% of cases, whereas combined perforation
occurs in up to 12% of bladder ruptures
[1]. The incidence of an
intraperitoneal bladder rupture is higher in children because of the
predominantly intraabdominal location of the bladder before puberty.
Intraperitoneal bladder rupture typically occurs at the anatomically weak
dome, and the mechanism of injury is a sudden, severe increase in intravesical
pressure in a full bladder. In this condition, patients may present with
urinary ascites, anuria, electrolyte abnormalities (hyperkalemia,
hypernatremia, or uremic acidosis), or hematuria
[1–3].
The initial diagnostic technique for bladder injury is retrograde
cystography or, if available, CT cystography. For bladder injuries,
cystography has an 85–100% accuracy, and CT cystography has a
sensitivity of 95% and a specificity of 100%
[4]. The diagnosis in this case
was made using color Doppler sonography and confirmed by CT cystography, which
showed a fat-density structure herniating through the dome of the bladder that
was continuous with omentum.
References
- Novelline RA, Rhea JT, Bell T. Helical CT of abdominal trauma.
Radiol Clin North Am1999; 37:608
–609
- Corriere JN, Sandler CM. Mechanisms of injury, patterns of
extravasation and management of extraperitoneal bladder rupture due to blunt
trauma. J Urol1987; 139:43
–44
- Cass AS, Luxenberg M. Features of 164 bladder ruptures.
J Urol 1987;138:743
–745[Medline]
- Deck AJ, Shaves S, Talner L, Porter JR. Computerized tomography
cystography for the diagnosis of traumatic bladder rupture. J
Urol 2000;164:43
–46[Medline]
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Introduction
Case Report
