Bladder Rupture

Morning Report

Written by: Jackie Shibata MD

(Reviewed by deSouza)

Here’s the scene… It’s Sunday and you get a transfer from an outside hospital for a young guy with constant abdominal pain and mild distention since falling off his bicycle the night before. He was drunk, swerved to miss a pothole and fell. This morning he urinated normally, but he now cannot urinate. There was no hematuria.

Exam:

Normal vital signs

Abdomen is distended, diffusely tender with guarding; no ecchymosis

No scrotal or peritoneal hematoma or blood at the urethral meatus.

Pelvis is stable and nontender.

FAST: Free fluid everywhere!

Labs: Creatinine 3

CT: Opacity in the bladder concerning for bladder rupture. Diffuse ascites.

Course:

Patient is kidnapped from the CT scanner by the surgeons and taken directly to the OR.

You think, of course he should go to the OR, he has a belly full of free fluid after a trauma, but then you think back to a case of a pelvis fracture who had a positive retrograde cystogram, and you recall the surgeons saying, “nah, no OR, just leave a foley in.”

Why the difference in management?

Intraperitoneal bladder rupture goes emergently to the OR and ALWAYS require repair.

(Why the OR? Urinary ascites, abscess, peritonitis, sepsis, electrolyte abnormalities)

Extraperitoneal bladder injuries get better with a foley for 10-14 days in up to 90% of cases (1).

Quick anatomy review:

The bladder is mostly extraperitoneal sitting just posterior to the pelvic rami. Pelvis fractures can cause shearing forces to injure the bladder. Bony spicules can also lacerate the bladder.

Bladder injuries associated with pelvic fractures are almost always extraperitoneal.

Only the dome of the bladder is covered by peritoneum. This is also the weakest part of the bladder and as it distends, muscle fibers here are stretched thin. A direct blow to the abdomen can cause the distended bladder* to rupture at the dome causing intraperitoneal leakage.

*This is commonly associated with acute alcohol consumption.

Presentation:

Abdominal bruising
Abdominal swelling
Perineal or scrotal edema
Inability to void
95% have gross hematuria (in the case above, hematuria was not observed until foley was placed)

Diagnosis

Retrograde cystogram or Stress cystogram is considered the gold standard. It is important to distend the bladder with contrast otherwise it may not extravasate to reveal the defect. This can be done with CT or plain films. Note that the cystogram should be performed only after the abdomen/pelvis CT; any potential visceral and vascular injuries may otherwise be obscured by the bladder infused during the cystography (4).

How to do it:

Place a foley (if no urethral injury suspected).
Attach a 60cc catheter syringe to the drainage tubing.
Elevate the apparatus so that the contrast is infused by gravity.
Add 350-400cc of diluted contrast*
If the bladder contracts, the meniscus in the tubing will increase in height; at this point you know the bladder is distended; inject 50cc more.
Clamp the foley and take a KUB XR or CT pelvis.
Allow the bladder to empty and repeat the XR (since it may be difficult to see contrast extravasation when the bladder is distended) (3).

*Note: use less contrast in pediatric patients (mL = (age in years + 2) x 30).

Intraperitoneal rupture: contrast will be seen surrounding loops of bowel and in the paracolic gutters.

Fun fact: The abdominal urinary ascites can act like peritoneal dialysis causing electrolyte and BUN/Cr reabsorption (this is probably why our healthy young guy had a creatinine of 3). Watch out for electrolyte abnormalities (2).

Extraperitoneal rupture: “Flame shaped” areas of contrast are generally confined to perivesical soft tissue, but it may extravasate into scrotum or retroperitoneal space.

Fun fact: take these extraperitoneal guys to the OR if: the catheter is not draining, bladder neck injured, open fixation of pelvis w/ hardware (to avoid infection), associated rectal or vaginal injuries (to avoid fistulas) (2).

Take Home Points:

If gross hematuria in trauma -> do a stress cystogram.
If intraperitoneal rupture -> send to OR
If extraperitoneal rupture -> leave a foley and admit anyway (they probably have a pelvis fracture).

References:

1. McManus J, Gratton MC, Cuenca PJ. Chapter 262. Genitourinary Trauma. In:Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.

2. Gomez RG, Ceballos L, Coburn M, et al: Consensus statement on bladder injuries. BJU Int 94: 27, 2004. [PubMed: 15217426]

3. Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radiographics 2000; 20:1373. [PubMed: 10992026]

4. Wah et al. The role of CT in the management of adult urinary tract trauma. Clin Radiol. 2001 Apr;56(4):268-77.