AJR 2005; 184:S99-S101
© American Roentgen Ray Society
Delayed Traumatic Bladder Rupture
Martin Laufik,
Darren Buono,
Giovanna Casola and
Claude Sirlin
University of California, San Diego, 200 W Arbor Dr., San Diego, CA
92103-8756.
Received February 6, 2004;
accepted after revision June 30, 2004.
Address correspondence to C. Sirlin
(csirlin{at}ucsd.edu).
Introduction
Delayed injury to the bladder after blunt abdominal trauma is rare.
Two cases of delayed traumatic bladder hematoma without documented bladder
rupture were reported in the 1970s
[1,
2] before CT was available. To
our knowledge, delayed bladder rupture has not been reported in the
literature. We present the case of a 17-year-old girl with delayed traumatic
bladder rupture and massive bladder hematoma diagnosed on CT cystography.
Case Report
A 17-year-old girl was a restrained backseat passenger in a high-velocity
motor vehicle accident and was admitted to the trauma service at a level 1
trauma center. She had gross hematuria on initial presentation. Nonenhanced
pelvic CT revealed displaced bilateral inferior and superior pubic rami
fractures and bilateral sacral alar fractures with extension into the left
acetabulum and neural foramina. Multiple bony spicules were in close proximity
to the bladder neck, with one bone spicule contiguous with the bladder neck
serosa (Fig. 1A). Follow-up
contrast-enhanced abdominopelvic CT performed immediately afterward showed no
evidence of bladder injury. The kidneys and other abdominal organs were normal
(images not shown). No extraabdominal injuries were seen.
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Fig. 1A. —17-year-old girl after motor vehicle accident. Admission
unenhanced pelvic CT reconstructed with bone algorithm shows bone spicule
(arrow) contiguous with bladder neck (note Foley catheter in bladder
neck). Numerous other pelvic fractures were present (not shown). No evidence
of injury to urinary tract was seen on follow-up contrast-enhanced
abdominopelvic CT (not shown).
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Because of the gross hematuria and multiple pelvic fractures, CT
cystography was performed by the attending radiologist at the time of the
examination. The CT cystogram was done by manually injecting 300 mL of
nonionic 10% iodinated contrast material into the bladder through an
indwelling urethral catheter to the limit of patient comfort; CT images of the
bladder were obtained at peak distention and after bladder drainage on a
4-MDCT scanner. Images were reconstructed at 2.5-mm overlapping increments.
The CT cystogram confirmed that the bladder was intact; there was no
intraluminal filling defect, bladder wall thickening, or other evidence of
bladder injury (Fig. 1B). There
was a small amount of extraperitoneal fluid and soft-tissue infiltration but
no focal perivesicular collections (Fig.
1C). Laboratory studies were within normal limits, with no
evidence of coagulopathy. The patient's hematuria resolved spontaneously by
the second hospital day. The orthopedic service placed a left sacroiliac screw
1 day after admission. The patient's other pelvic fractures were considered
stable and were managed conservatively. The patient was discharged on day 4
with an indwelling urethral catheter and, because of her orthopedic injuries,
was instructed to not bear weight.
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Fig. 1B. —17-year-old girl after motor vehicle accident. CT cystogram
with 300 mL of 10% nonionic contrast agent (ioversol injection USP 68%, 320 mg
I/mL, Optiray 320, Mallinckrodt). Distended bladder is intact; no evidence of
extravasation or intraluminal filling defects is seen.
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Four days after discharge (8 days after initial presentation), the patient
returned to the emergency department with 2 days of recurrent gross hematuria,
12 hours of urinary retention, and symptomatic anemia. Her radiologic
evaluation included IV contrastenhanced abdominopelvic CT (images not shown)
and CT cystography (Figs. 1D,
1E and
1F) using the same technique as
before. The imaging studies revealed focal extravasation of contrast material
from the bladder neck at the site of the abutting bony spuicule
(Fig. 1D), a 6-cm hematoma
within the bladder lumen (Fig.
1E), and a 3-cm extraperitoneal collection containing fluid and
gas anterior and to the right of the urinary bladder superior to the bony
spicules (Fig. 1F). The focal
extravasation, intraluminal hematoma, and perivesical collection were new
compared with the CT studies performed during the first admission. The gas-
and fluid-containing collection was physically remote from the bowel, no
overlying soft-tissue or skin injury was seen, and no clinical or laboratory
evidence of abscess was present. The remainder of the abdomen, including the
kidneys, was normal.
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Fig. 1D. —17-year-old girl after motor vehicle accident. CT cystogram
with 150 mL of dilute 10% ioversol performed 8 days after initial presentation
shows new extraperitoneal extravasation from bladder neck. Note close
proximity of bony spicule (arrow) to area of extravasation.
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Fig. 1F. —17-year-old girl after motor vehicle accident. CT image
through level of acetabulum shows new 3-cm perivesicular collection
(arrows) containing gas and fluid. Gas within collection is
presumably related to air introduced into bladder via catheterization. On
subsequent CT cystograms (not shown), this collection communicated with
bladder neck.
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The urology service performed cystoscopy and evacuated a large blood clot,
thought to be the cause of the patient's urinary retention. The bladder mucosa
was unremarkable; no clear sources of bleeding were identified, and the focal
rupture documented on CT cystography was not apparent on direct visualization.
The patient received a transfusion for her anemia.
After cystoscopic hematoma evacuation, the patient's hematuria was
successfully managed nonoperatively with continuous bladder irrigation via a
large-bore urethral catheter, first as an inpatient and later as an
outpatient. The patient underwent three follow-up CT cystograms as an
outpatient, performed 2, 3, and 4 weeks after initial presentation (images not
shown). These follow-up studies documented gradual resolution of the
extravasation, bladder hematoma, and extraperitoneal collection. Repeat
cystoscopy 8 weeks after initial presentation identified a posttraumatic
diverticulum in the right anterolateral bladder neck but no active injury.
Discussion
We present a rare case of delayed traumatic bladder rupture. The patient
discussed in this report presented with gross hematuria after a motor vehicle
accident. However, abdominopelvic CT and dedicated CT cystography during
initial admission were negative for bladder injury. The likelihood of a missed
bladder rupture or hematoma is low, as the sensitivity of CT cystography for
the diagnosis of clinically important bladder injury approaches 100%
[3]. No evidence of renal
contusion, other abdominal injury, or coagulopathy was seen. Her hematuria
resolved rapidly and was attributed to a minor bladder mucosal injury that
healed spontaneously.
After initial discharge, the patient's bladder neck spontaneously ruptured
into the extraperitoneal space, presumably because of laceration by contiguous
bony spicules. An extraperitoneal gas- and liquid-containing collection
adjacent to the bladder developed. Gas within the collection was likely
related to air in the bladder introduced by urethral catheterization. Abscess
related to occult enteric injury was unlikely, as the collection was
physically remote from the bowel and no clinical or laboratory evidence of
abscess was present. A massive hematoma developed within the bladder lumen and
manifested with gross hematuria, urinary retention, and symptomatic
anemia.
Patients with traumatic bladder rupture typically present at the time of
initial evaluation [3]. Only
two cases of delayed bladder hematoma have been reported
[1,
2]. In those cases, the cause
of the delayed hematoma was unclear, possibly because of technological
limitations in the pre-CT era, and no rupture was documented. Thus, our
patient's delayed bladder rupture was highly unusual.
Ultimately, this patient's perforation healed with a posttraumatic
diverticulum after conservative management. This is not surprising, as almost
all extraperitoneal bladder ruptures close spontaneously within a few weeks
[4].
Several suggestions can be proposed about future management of similar
patients. First, radiologists should be aware that patients presenting with
pelvic fractures and hematuria may develop delayed bladder rupture, even if
initial evaluation is negative. Based on our observations from the present
case, we speculate that bony spicules in close proximity to the bladder wall
may increase the risk for delayed bladder injury. In this case, one of the
bone spicules was contiguous with the bladder neck serosa. Thus, it may be
prudent to report and call attention to bony spicules adjacent to the bladder
wall in patients with pelvic fractures. Conceivably, this could influence
patient management by restricting patient movement at discharge and
establishing a lower threshold for further workup if hematuria recurs.
References
- Turnbull AR, Smart CJ, Jenkins JD. Delayed rupture of the bladder.
Br J Urol 1978;50:162
-163[Medline]
- Turner AR. Delayed post-traumatic rupture of the bladder.
J R Coll Surg Edinb1974; 19:247
-248[Medline]
- Vaccaro JP, Brody JM. CT cystography in the evaluation of major
bladder trauma. RadioGraphics2000; 20:1373
-1381[Abstract/Free Full Text]
- Corriere JN, Sandler CM. Bladder rupture from external trauma:
diagnosis and management. World J Urol1999; 17:84
-89[Medline]
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Introduction
Case Report
