Emerg Radiol DOI 10.1007/s10140-015-1323-8
CASE REPORT
BWH emergency radiology-surgical correlation: intraperitoneal urinary bladder rupture Wendy Landman 1 & Bharti Khurana 1 & Alexandra Briggs 2 & Mark Fairweather 2 & Zara Cooper 2 & Robert Riviello 2 & Aaron D. Sodickson 1
Received: 8 May 2015 / Accepted: 15 May 2015 # American Society of Emergency Radiology 2015
Abstract We describe the radiological and intraoperative correlation of two cases of intraperitoneal bladder rupture: a 23year-old man involved in a high-speed motor vehicle collision and a 49-year-old man with hematuria and abdominal pain after a night of heavy alcohol ingestion. Both patients underwent urgent exploratory laparotomies and repair of their bladder injuries. The purpose of this article is to emphasize the importance of understanding the different etiologies of bladder rupture and recognizing the imaging findings on computed tomography (CT) and CT cystography to help guide the surgeons in the patient’s management. Keywords Bladder rupture . Intraperitoneal . Blunt trauma . Cystography
Case presentation 1 Following prolonged extrication from a motor vehicle collision with one fatality, a 23-year-old male unrestrained backseat passenger was intubated at the scene and transported by ambulance to our Emergency Department (ED). In the ED, his vital signs were normal. On physical exam, his abdomen was soft and nondistended. Notable laboratory values included an elevated white blood cell count (WBC) of 13,700 cells/mL. * Wendy Landman [email protected] 1
Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
2
Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Contrast-enhanced multi-detector computed tomography (MDCT) of the abdomen and pelvis demonstrated a large volume of free intraperitoneal fluid, mostly measuring simple fluid attenuation. There was a focal defect at the bladder dome with adjacent hematoma and active arterial extravasation of contrast indicating active bleeding (Fig. 1a). The patient underwent urgent exploratory laparotomy. Intraoperative findings included an approximately 6 cm long and 2 cm wide, full-thickness vertical defect at the dome of the bladder extending inferiorly towards the bladder neck (Fig. 1b). There was evidence of intraluminal bleeding. The bladder was repaired with a two-layer closure. A Foley catheter remained in place until a conventional cystogram 11 days later demonstrated no evidence of leak.
Case presentation 2 A 49-year-old male presented to our ED with acute abdominal pain and hematuria, the morning after a night of heavy drinking with friends. Past medical history is notable for alcohol abuse, type 2 diabetes mellitus, and hypertension. He denied any history of trauma. In the ED, his vital signs were normal. Physical exam revealed a distended abdomen which was diffusely tender with rebound and guarding. Notable laboratory values included an elevated creatinine of 1.5 mg/dL. Bedside ultrasound demonstrated a large amount of free intraperitoneal fluid in all four quadrants. MDCT of the abdomen and pelvis revealed a large volume of free intraperitoneal fluid, mostly of simple fluid attenuation, along with pelvic hematoma, and asymmetric thickening of the left side of the bladder dome. The patient subsequently underwent a CT cystogram following the administration of 350 mL of dilute water soluble-contrast through the indwelling Foley catheter.
Emerg Radiol Fig. 1 a Coronal contrastenhanced CT scan shows intraperitoneal bladder rupture with a focal defect in the bladder dome (black arrow) and adjacent bladder wall hematoma with active intravenous contrast extravasation (white arrow) indicating active bleeding. Note large volume of intraperitoneal free fluid (asterisk) around the liver and small bowel loops. b Intraoperative photo with the head beyond the top of the photo, demonstrating a large fullthickness laceration in the bladder dome (bracket), with adjacent hematoma (white arrow) corresponding to that seen on CT
This revealed a large defect at the bladder dome with leakage of cystographic contrast into the peritoneum (Fig. 2a). The patient underwent urgent exploratory laparotomy. Intraoperative findings included approximately 300 ml of blood clot in the intraperitoneal cavity, a large thick-walled bladder, and a 5-cm laceration of the dome of the bladder (Fig. 2b). The bladder was repaired with a double layer suture and subsequently distended with 750 mL of methylene blue stained saline to assess for any leak at the suture line. A drain was placed in the pelvis. The post operative course was notable for increased bleeding from the drain and hematuria after resuming aspirin which resolved when the aspirin was held. His creatinine returned to baseline at 0.6 mg/dL. The patient was Fig. 2 a Sagittal CT cystogram shows intraperitoneal bladder rupture with a defect in the bladder dome (arrow) and large amount of contrast material outlining small bowel loops and mesenteric folds (black asterisk). Pelvic hematoma (H) is also seen posterior to the bladder. b Intraoperative photo with the head beyond the top of the photo, showing a large full-thickness laceration in the bladder dome (bracket) with the Foley catheter visible through the defect (white asterisk)
discharged 4 days later with his Foley catheter in situ for follow up. Three weeks later, the Foley catheter was removed following conventional cystography with no evidence of leak.
Discussion Urinary bladder injuries may result from either blunt or penetrating trauma. The most frequent causes are motor vehicle accidents, which account for approximately 90 % of the cases—often from seat belt compression of the full bladder or ejection- or from falls, crush injuries, and blows to the lower abdomen [1]. The risk of bladder rupture increases with
Emerg Radiol
the degree of bladder distention. Sixty to 90 % of patients with bladder injuries due to blunt trauma have associated pelvic fractures while only 6 % of patients with pelvic fractures have bladder rupture [1]. Iatrogenic causes also contribute to bladder injuries, with the bladder as the most commonly injured organ during pelvic surgery [1]. In the absence of trauma or instrumentation, urinary bladder rupture can occur spontaneously secondary to underlying diseases of the bladder wall or bladder outflow with some of the underlying causes including acute or chronic inflammation, pelvic or bladder malignancy, radiation, and neurogenic bladder [2]. Idiopathic bladder rupture has been increasingly reported in non-diseased bladders secondary to alcohol intoxication [3], which increases the risk of bladder rupture due to the large volume of ingested alcohol and its diuretic effect leading to bladder overdistention in a patient with decreased sensation to bladder filling. Intoxicated patients are also more susceptible to minor trauma which may be forgotten or unnoticed. Bladder injuries were initially classified into five types using conventional cystography by Sandler et al. [4]. Type 1 is a simple bladder contusion which is an incomplete or partial tear of the bladder mucosa. Patients present with hematuria with normal findings at cystography. Although bladder contusion is considered the most common bladder injury in trauma patients, it is not considered a major injury, and the true incidence is unknown [4, 5]. Type 2 is an intraperitoneal (IP) bladder rupture accounting for 10–20 % of major bladder injuries and usually caused by a direct blow to a distended bladder creating a sudden increase in intravesicular pressure causing intraperitoneal rupture of the bladder dome which is the weakest and most mobile part of the bladder. On cystography, extravasated contrast material surrounds bowel loops and pools between mesenteric folds and in the paracolic gutters [4–6]. Type 3 is an interstitial bladder injury which is an intramural or partial-thickness laceration with intact serosa. This is a rare injury. On cystography, contrast may be seen in the bladder wall. Type 4 is an extraperitoneal bladder (EP) rupture which is the most common type representing 80–90 % of major bladder injuries. Extraperitoneal bladder rupture is typically associated with pelvic fractures, and the mechanism of injury is direct due to laceration from bone fragments or indirect related to contra-coup injury from traction or breakdown of the adjacent ligaments. On cystography, the rupture can be simple with contrast extravasation confined to the pelvic and perivesical space (a molar tooth appearance of extra vasated con trast an d h ematoma within the extraperitoneal space of Retzius) or can be complex with contrast extending beyond the perivesical space into the retroperitoneal space, perineum, and anterior abdominal wall [4, 5]. Type 5 bladder injuries are combined IP and EP bladder rupture with a prevalence of 5–12 % [4, 5].
Bladder injuries can also be classified by the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) into five grades based on severity of injury [7]; grade 1 is contusion, intramural hematoma, and partial-thickness laceration; grade 2, EP wall lacerations or=2 cm and IP laceration or = 2 cm; and grade 5, IP or EP lacerations that extend into the bladder neck or trigone. The most common sign associated with bladder rupture is gross hematuria. Other clinical findings include history of trauma to the lower abdomen, suprapubic pain, inability to pass urine, oliguria or anuria, and distention of the abdomen from increasing ascites (in the case of intraperitoneal bladder rupture). Peritonitis and sepsis can be present with delayed diagnosis of intraperitoneal bladder ruptures [1]. Peritoneal resorption of urea and creatinine can present as acute renal failure on laboratory studies, as in our second patient [8]. Absolute indications for dedicated bladder imaging are gross hematuria with pelvic fractures. Relative indications for cystography after blunt trauma include gross hematuria without pelvic fracture, microhematuria with pelvic fracture, and isolated microhematuria, with imaging recommended in patients with clinical symptoms as described above or with altered mental status including intoxication [9]. Most patients with bladder rupture are high-energy blunt trauma patients who routinely undergo contrastenhanced abdominal and pelvic CT scans first to investigate other injuries. The absence of pelvic fluid is a strong negative predictor for bladder rupture, and follow-up cystography is not recommended [10]. Imaging findings however which can be seen in bladder rupture include pelvic fluid, abnormal location of Foley catheter, defect in the bladder wall, or pelvic/bladder wall hematoma [10, 11]. Passive distention of the bladder during routine abdominal and pelvic CT scan cannot exclude bladder rupture, and dedicated bladder imaging should be performed when indicated [12]. CT cystography and conventional cystography are equivalent for detecting bladder injury with high sensitivity and specificity of 95 and 100 %, respectively [13]. In the emergent setting, CT cystography with retrograde distention using 350–400 mL of dilute contrast is the modality of choice. Adequate distention is achieved by instilling contrast by gravity with the bag held 4 ft above the patient, and stopping due to patient discomfort (a sign of bladder distention), or when the flow stops or the bag has been fully instilled. Coronal and sagittal multiplanar reformations can help identify bladder rupture sites, especially in intraperitoneal bladder ruptures where the bladder dome is parallel to the axial scan plane [14]. Post drainage imaging is not typically necessary [10]. Of note, patients with suspected urethral
Emerg Radiol
injuries (i.e., blood at the meatus) should undergo retrograde urethrography prior to insertion of the Foley catheter or pericatheter retrograde urethrography after CT cystogram if the Foley has already been placed [10]. Treatment ranges from conservative management to surgical intervention. Bladder contusions and interstitial injuries may only require observation or catheter drainage alone. Most extraperitoneal bladder ruptures are treated with catheter drainage alone with follow-up cystogram 10 days later; 85 % of bladders will be healed by then with most healed by 3 weeks [1]. Complicated extraperitoneal ruptures with presence of bone fragments in the bladder or concurrent vaginal or rectal injury require early surgical treatment to prevent fistula formation. Involvement of the bladder neck can lead to incontinence, also requiring surgical intervention. If the patient is undergoing laparotomy for orthopedic or other intraabdominal injuries, bladder repair is advised [1, 15]. Intraperitoneal bladder ruptures from blunt trauma usually result in a large defect at the bladder dome necessitating surgical repair. Penetrating injuries must also be repaired. Delay in treatment of intraperitoneal bladder ruptures can result in urinary extravasation leading to sepsis and peritonitis [1, 15]. In conclusion, we have shown radiological and surgical correlation of two patients with intraperitoneal bladder rupture from different causes. Although uncommon, it is important to consider bladder rupture in patients with acute alcohol intoxication with hematuria or vague abdominal symptoms. Early diagnosis and definitive management are critical to reduce morbidity and mortality.
References 1. 2. 3.
4. 5. 6. 7.
8.
9. 10.
11. 12. 13.
14. Conflict of interest The authors declare that they have no conflict of interest.
15.
Gomez RG, Ceballos L, Coburn M et al (2004) Consensus statement on bladder injuries. BJU 94:27–32 Huffman JL, Schraut W, Bagley D et al (1983) Atraumatic perforation of bladder. Urology 22(1):30–35 Parker H, Hoonpongsimanont W, Vaca F et al (2007) Spontaneous bladder rupture in association with alcoholic binge: a case report and review of the literature. J Emerg Med 37(4):386–389 Sandler CM, Hall JT, Rodriguez M et al (1986) Bladder injury in blunt pelvic trauma. Radiology 158:633–638 Vacarro JP, Brody JM (2000) CT cystography in the evaluation of major bladder trauma. Radiographics 20:1373–1381 Corriere JN, Sandler CM (1999) Bladder rupture from external trauma: diagnosis and management. World J Urol 17:84–89 Moore EE, Cogbill TH, Jurkovich GJ et al (1992) Organ Injury scaling. III: Chest wall, abdominal vascular, ureter, bladder, and urethra. J Trauma 33(3):337–339 Daignault MC, Saul T, Lewiss R (2012) Bedside ultrasound diagnosis of atraumatic bladder rupture in an alcohol-intoxicated patient: a case report. Crit Ultrasound J 4(1):9 Morey AF, Iverson AJ, Swan A et al (2001) Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma 51:683–686 Morgan DE, Nallamala LK, Kenney PJ (2000) CT cystography: radiographic and clinical predictors of bladder rupture. AJR Am J Roentgenol 174:89–95 Gross JS, Rotenberg S, Horrow M (2014) Bladder injury: types, mechanisms, and diagnostic imaging. Radiographics 34(3):802–803 Pao DM, Ellis JH, Cohan R et al (2000) Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol 7:317–324 Quagliano PV, Delari SM, Malhotra AK (2006) Diagnosis of blunt bladder injury: a prospective comparative study of computed tomography cystography and conventional retrograde cystography. J Trauma 61(2):410–421 Ishak C, Kanth N (2011) Bladder trauma: multidetector computed tomography cystography. Emerg Radiol 18:321–327 Morey AF, Brandes S, Dugi DD 3rd et al (2014) Urotrauma: AUA guideline. J Urol Aug 192(2):327–335
CASE REPORT
BWH emergency radiology-surgical correlation: intraperitoneal urinary bladder rupture Wendy Landman 1 & Bharti Khurana 1 & Alexandra Briggs 2 & Mark Fairweather 2 & Zara Cooper 2 & Robert Riviello 2 & Aaron D. Sodickson 1
Received: 8 May 2015 / Accepted: 15 May 2015 # American Society of Emergency Radiology 2015
Abstract We describe the radiological and intraoperative correlation of two cases of intraperitoneal bladder rupture: a 23year-old man involved in a high-speed motor vehicle collision and a 49-year-old man with hematuria and abdominal pain after a night of heavy alcohol ingestion. Both patients underwent urgent exploratory laparotomies and repair of their bladder injuries. The purpose of this article is to emphasize the importance of understanding the different etiologies of bladder rupture and recognizing the imaging findings on computed tomography (CT) and CT cystography to help guide the surgeons in the patient’s management. Keywords Bladder rupture . Intraperitoneal . Blunt trauma . Cystography
Case presentation 1 Following prolonged extrication from a motor vehicle collision with one fatality, a 23-year-old male unrestrained backseat passenger was intubated at the scene and transported by ambulance to our Emergency Department (ED). In the ED, his vital signs were normal. On physical exam, his abdomen was soft and nondistended. Notable laboratory values included an elevated white blood cell count (WBC) of 13,700 cells/mL. * Wendy Landman [email protected] 1
Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
2
Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Contrast-enhanced multi-detector computed tomography (MDCT) of the abdomen and pelvis demonstrated a large volume of free intraperitoneal fluid, mostly measuring simple fluid attenuation. There was a focal defect at the bladder dome with adjacent hematoma and active arterial extravasation of contrast indicating active bleeding (Fig. 1a). The patient underwent urgent exploratory laparotomy. Intraoperative findings included an approximately 6 cm long and 2 cm wide, full-thickness vertical defect at the dome of the bladder extending inferiorly towards the bladder neck (Fig. 1b). There was evidence of intraluminal bleeding. The bladder was repaired with a two-layer closure. A Foley catheter remained in place until a conventional cystogram 11 days later demonstrated no evidence of leak.
Case presentation 2 A 49-year-old male presented to our ED with acute abdominal pain and hematuria, the morning after a night of heavy drinking with friends. Past medical history is notable for alcohol abuse, type 2 diabetes mellitus, and hypertension. He denied any history of trauma. In the ED, his vital signs were normal. Physical exam revealed a distended abdomen which was diffusely tender with rebound and guarding. Notable laboratory values included an elevated creatinine of 1.5 mg/dL. Bedside ultrasound demonstrated a large amount of free intraperitoneal fluid in all four quadrants. MDCT of the abdomen and pelvis revealed a large volume of free intraperitoneal fluid, mostly of simple fluid attenuation, along with pelvic hematoma, and asymmetric thickening of the left side of the bladder dome. The patient subsequently underwent a CT cystogram following the administration of 350 mL of dilute water soluble-contrast through the indwelling Foley catheter.
Emerg Radiol Fig. 1 a Coronal contrastenhanced CT scan shows intraperitoneal bladder rupture with a focal defect in the bladder dome (black arrow) and adjacent bladder wall hematoma with active intravenous contrast extravasation (white arrow) indicating active bleeding. Note large volume of intraperitoneal free fluid (asterisk) around the liver and small bowel loops. b Intraoperative photo with the head beyond the top of the photo, demonstrating a large fullthickness laceration in the bladder dome (bracket), with adjacent hematoma (white arrow) corresponding to that seen on CT
This revealed a large defect at the bladder dome with leakage of cystographic contrast into the peritoneum (Fig. 2a). The patient underwent urgent exploratory laparotomy. Intraoperative findings included approximately 300 ml of blood clot in the intraperitoneal cavity, a large thick-walled bladder, and a 5-cm laceration of the dome of the bladder (Fig. 2b). The bladder was repaired with a double layer suture and subsequently distended with 750 mL of methylene blue stained saline to assess for any leak at the suture line. A drain was placed in the pelvis. The post operative course was notable for increased bleeding from the drain and hematuria after resuming aspirin which resolved when the aspirin was held. His creatinine returned to baseline at 0.6 mg/dL. The patient was Fig. 2 a Sagittal CT cystogram shows intraperitoneal bladder rupture with a defect in the bladder dome (arrow) and large amount of contrast material outlining small bowel loops and mesenteric folds (black asterisk). Pelvic hematoma (H) is also seen posterior to the bladder. b Intraoperative photo with the head beyond the top of the photo, showing a large full-thickness laceration in the bladder dome (bracket) with the Foley catheter visible through the defect (white asterisk)
discharged 4 days later with his Foley catheter in situ for follow up. Three weeks later, the Foley catheter was removed following conventional cystography with no evidence of leak.
Discussion Urinary bladder injuries may result from either blunt or penetrating trauma. The most frequent causes are motor vehicle accidents, which account for approximately 90 % of the cases—often from seat belt compression of the full bladder or ejection- or from falls, crush injuries, and blows to the lower abdomen [1]. The risk of bladder rupture increases with
Emerg Radiol
the degree of bladder distention. Sixty to 90 % of patients with bladder injuries due to blunt trauma have associated pelvic fractures while only 6 % of patients with pelvic fractures have bladder rupture [1]. Iatrogenic causes also contribute to bladder injuries, with the bladder as the most commonly injured organ during pelvic surgery [1]. In the absence of trauma or instrumentation, urinary bladder rupture can occur spontaneously secondary to underlying diseases of the bladder wall or bladder outflow with some of the underlying causes including acute or chronic inflammation, pelvic or bladder malignancy, radiation, and neurogenic bladder [2]. Idiopathic bladder rupture has been increasingly reported in non-diseased bladders secondary to alcohol intoxication [3], which increases the risk of bladder rupture due to the large volume of ingested alcohol and its diuretic effect leading to bladder overdistention in a patient with decreased sensation to bladder filling. Intoxicated patients are also more susceptible to minor trauma which may be forgotten or unnoticed. Bladder injuries were initially classified into five types using conventional cystography by Sandler et al. [4]. Type 1 is a simple bladder contusion which is an incomplete or partial tear of the bladder mucosa. Patients present with hematuria with normal findings at cystography. Although bladder contusion is considered the most common bladder injury in trauma patients, it is not considered a major injury, and the true incidence is unknown [4, 5]. Type 2 is an intraperitoneal (IP) bladder rupture accounting for 10–20 % of major bladder injuries and usually caused by a direct blow to a distended bladder creating a sudden increase in intravesicular pressure causing intraperitoneal rupture of the bladder dome which is the weakest and most mobile part of the bladder. On cystography, extravasated contrast material surrounds bowel loops and pools between mesenteric folds and in the paracolic gutters [4–6]. Type 3 is an interstitial bladder injury which is an intramural or partial-thickness laceration with intact serosa. This is a rare injury. On cystography, contrast may be seen in the bladder wall. Type 4 is an extraperitoneal bladder (EP) rupture which is the most common type representing 80–90 % of major bladder injuries. Extraperitoneal bladder rupture is typically associated with pelvic fractures, and the mechanism of injury is direct due to laceration from bone fragments or indirect related to contra-coup injury from traction or breakdown of the adjacent ligaments. On cystography, the rupture can be simple with contrast extravasation confined to the pelvic and perivesical space (a molar tooth appearance of extra vasated con trast an d h ematoma within the extraperitoneal space of Retzius) or can be complex with contrast extending beyond the perivesical space into the retroperitoneal space, perineum, and anterior abdominal wall [4, 5]. Type 5 bladder injuries are combined IP and EP bladder rupture with a prevalence of 5–12 % [4, 5].
Bladder injuries can also be classified by the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) into five grades based on severity of injury [7]; grade 1 is contusion, intramural hematoma, and partial-thickness laceration; grade 2, EP wall lacerations or=2 cm and IP laceration or = 2 cm; and grade 5, IP or EP lacerations that extend into the bladder neck or trigone. The most common sign associated with bladder rupture is gross hematuria. Other clinical findings include history of trauma to the lower abdomen, suprapubic pain, inability to pass urine, oliguria or anuria, and distention of the abdomen from increasing ascites (in the case of intraperitoneal bladder rupture). Peritonitis and sepsis can be present with delayed diagnosis of intraperitoneal bladder ruptures [1]. Peritoneal resorption of urea and creatinine can present as acute renal failure on laboratory studies, as in our second patient [8]. Absolute indications for dedicated bladder imaging are gross hematuria with pelvic fractures. Relative indications for cystography after blunt trauma include gross hematuria without pelvic fracture, microhematuria with pelvic fracture, and isolated microhematuria, with imaging recommended in patients with clinical symptoms as described above or with altered mental status including intoxication [9]. Most patients with bladder rupture are high-energy blunt trauma patients who routinely undergo contrastenhanced abdominal and pelvic CT scans first to investigate other injuries. The absence of pelvic fluid is a strong negative predictor for bladder rupture, and follow-up cystography is not recommended [10]. Imaging findings however which can be seen in bladder rupture include pelvic fluid, abnormal location of Foley catheter, defect in the bladder wall, or pelvic/bladder wall hematoma [10, 11]. Passive distention of the bladder during routine abdominal and pelvic CT scan cannot exclude bladder rupture, and dedicated bladder imaging should be performed when indicated [12]. CT cystography and conventional cystography are equivalent for detecting bladder injury with high sensitivity and specificity of 95 and 100 %, respectively [13]. In the emergent setting, CT cystography with retrograde distention using 350–400 mL of dilute contrast is the modality of choice. Adequate distention is achieved by instilling contrast by gravity with the bag held 4 ft above the patient, and stopping due to patient discomfort (a sign of bladder distention), or when the flow stops or the bag has been fully instilled. Coronal and sagittal multiplanar reformations can help identify bladder rupture sites, especially in intraperitoneal bladder ruptures where the bladder dome is parallel to the axial scan plane [14]. Post drainage imaging is not typically necessary [10]. Of note, patients with suspected urethral
Emerg Radiol
injuries (i.e., blood at the meatus) should undergo retrograde urethrography prior to insertion of the Foley catheter or pericatheter retrograde urethrography after CT cystogram if the Foley has already been placed [10]. Treatment ranges from conservative management to surgical intervention. Bladder contusions and interstitial injuries may only require observation or catheter drainage alone. Most extraperitoneal bladder ruptures are treated with catheter drainage alone with follow-up cystogram 10 days later; 85 % of bladders will be healed by then with most healed by 3 weeks [1]. Complicated extraperitoneal ruptures with presence of bone fragments in the bladder or concurrent vaginal or rectal injury require early surgical treatment to prevent fistula formation. Involvement of the bladder neck can lead to incontinence, also requiring surgical intervention. If the patient is undergoing laparotomy for orthopedic or other intraabdominal injuries, bladder repair is advised [1, 15]. Intraperitoneal bladder ruptures from blunt trauma usually result in a large defect at the bladder dome necessitating surgical repair. Penetrating injuries must also be repaired. Delay in treatment of intraperitoneal bladder ruptures can result in urinary extravasation leading to sepsis and peritonitis [1, 15]. In conclusion, we have shown radiological and surgical correlation of two patients with intraperitoneal bladder rupture from different causes. Although uncommon, it is important to consider bladder rupture in patients with acute alcohol intoxication with hematuria or vague abdominal symptoms. Early diagnosis and definitive management are critical to reduce morbidity and mortality.
References 1. 2. 3.
4. 5. 6. 7.
8.
9. 10.
11. 12. 13.
14. Conflict of interest The authors declare that they have no conflict of interest.
15.
Gomez RG, Ceballos L, Coburn M et al (2004) Consensus statement on bladder injuries. BJU 94:27–32 Huffman JL, Schraut W, Bagley D et al (1983) Atraumatic perforation of bladder. Urology 22(1):30–35 Parker H, Hoonpongsimanont W, Vaca F et al (2007) Spontaneous bladder rupture in association with alcoholic binge: a case report and review of the literature. J Emerg Med 37(4):386–389 Sandler CM, Hall JT, Rodriguez M et al (1986) Bladder injury in blunt pelvic trauma. Radiology 158:633–638 Vacarro JP, Brody JM (2000) CT cystography in the evaluation of major bladder trauma. Radiographics 20:1373–1381 Corriere JN, Sandler CM (1999) Bladder rupture from external trauma: diagnosis and management. World J Urol 17:84–89 Moore EE, Cogbill TH, Jurkovich GJ et al (1992) Organ Injury scaling. III: Chest wall, abdominal vascular, ureter, bladder, and urethra. J Trauma 33(3):337–339 Daignault MC, Saul T, Lewiss R (2012) Bedside ultrasound diagnosis of atraumatic bladder rupture in an alcohol-intoxicated patient: a case report. Crit Ultrasound J 4(1):9 Morey AF, Iverson AJ, Swan A et al (2001) Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma 51:683–686 Morgan DE, Nallamala LK, Kenney PJ (2000) CT cystography: radiographic and clinical predictors of bladder rupture. AJR Am J Roentgenol 174:89–95 Gross JS, Rotenberg S, Horrow M (2014) Bladder injury: types, mechanisms, and diagnostic imaging. Radiographics 34(3):802–803 Pao DM, Ellis JH, Cohan R et al (2000) Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol 7:317–324 Quagliano PV, Delari SM, Malhotra AK (2006) Diagnosis of blunt bladder injury: a prospective comparative study of computed tomography cystography and conventional retrograde cystography. J Trauma 61(2):410–421 Ishak C, Kanth N (2011) Bladder trauma: multidetector computed tomography cystography. Emerg Radiol 18:321–327 Morey AF, Brandes S, Dugi DD 3rd et al (2014) Urotrauma: AUA guideline. J Urol Aug 192(2):327–335
