ILLUSTRATIVE CASE
Intraperitoneal Bladder Rupture as an Isolated Manifestation
of Nonaccidental Trauma in a Child
Timothy Lautz, MD, Dan Leonhardt, MD, Erin Rowell, MD, and Marleta Reynolds, MD
Abstract: Nonaccidental trauma is a significant cause of morbidity and
mortality in children. We describe a case of a child who presented with
intraperitoneal bladder rupture after sustaining blunt abdominal trauma.
As per confession, the injury was apparently the result of the child being
forcibly pulled into her caretaker’s knee while the child had a full
bladder. Diagnostic findings included an acute abdomen, gross
hematuria, azotemia, and free intraperitoneal fluid visualized on
computed tomography. Emergency exploratory laparotomy revealed
rupture at the dome of the bladder. Bladder rupture as a result of
nonaccidental trauma has been reported in 3 previous cases.
Key Words: bladder rupture, nonaccidental trauma, child abuse
(Pediatr Emer Care 2009;25: 260Y262)
N onaccidental trauma (NAT) is a significant cause of
morbidity and mortality in children.1 Specific patterns of
skeletal, cutaneous, and neurologic injuries are well described.2,3
Abdominal injury is a less common but important manifestation.
In one series of NAT admissions, 9% had intra-abdominal
injuries, and this subset had higher injury severity scores.4
In another series of 646 cases of pediatric blunt abdominal
trauma, excluding motor vehicle accidents, child abuse was
suspected in 40.5% of cases and 84% of deaths.5 In this cohort,
the liver (46.1%) was the most frequently injured organ,
followed by the spleen (26%), hollow viscous (17.9%), and
pancreas (8.6%). Isolated bladder rupture is a very rare mani-
festation of NAT, and only 3 cases have been previously re-
ported in the literature.
CASE
A 4-year-old girl was transferred to our institution for
management of an acute abdomen with intraperitoneal free fluid
on computed tomography. Her clinical history was significant
for sudden onset of abdominal pain the morning of presentation,
followed by progressive abdominal distention and nonbilious,
nonbloody emesis. She was previously healthy, although her
mother described a pattern of large, infrequent voids with
occasional daytime urinary incontinence.
On arrival to our emergency department, the patient
appeared pale and acutely ill. Vitals included temperature of
36.4-C, heart rate of 128 beats per minute, respiratory rate of
60 breaths per minute, blood pressure 121/99 mm Hg, and
oxygen saturation 97%. On examination, the child was alert and
crying. Her abdomen was firm, distended, and very tender, with
no evidence of ecchymosis or abrasion. A nasogastric tube and
From the Children’s Memorial Hospital, Feinberg School of Medicine,
Northwestern University, Chicago, IL.
Reprints: Marleta Reynolds, MD, Division of Pediatric Surgery, 2300
Children’s Plaza, Box #63, Chicago, IL 60614 (e-mail: mreynolds@
childrensmemorial.org).
There are no disclaimers or sources of funding or support to report.
Copyright * 2009 by Lippincott Williams & Wilkins
ISSN: 0749-5161
260
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urinary catheter were placed. Urine output was grossly bloody.
The patient was given a fluid bolus, morphine for pain, and
empiric antibiotic coverage with ampicillin, gentamicin, and
flagyl.
Laboratory data from the referring hospital were signif-
icant for azotemia, with blood urea nitrogen of 42 mg/dL and
creatinine level of 1.9 mg/dL. She also had a leukocytosis, with a
white blood cell count of 35  109/L. Computed tomographic
scan of the abdomen and pelvis revealed free fluid with no solid
organ injury (Fig. 1).
The constellation of clinical, laboratory, and radiologic
findings was highly suspicious for bladder rupture, and the
patient was taken for immediate exploratory laparotomy.
Exploration confirmed rupture of the dome of the bladder,
which was repaired. No other visceral organs were injured.
Postoperatively, the patient did very well. Her azotemia
and leukocytosis resolved promptly. After discontinuation of her
urinary catheter, she voided spontaneously without pain,
hematuria, or incontinence. She was initially managed with
total parental nutrition but tolerated early diet advancement and
discontinuation of intravenous nutrition.
The hospital child abuse team was consulted early in the
child’s hospital admission because of suspicion for child abuse.
A skeletal survey was performed and revealed no evidence of
occult fracture. The initial information provided by the child’s
stepmother did not include any history of trauma. The
stepmother subsequently stated that on the morning of
admission, the child had fallen to the floor from a standing
position. Later, the stepmother confessed to forcibly pulling the
child into her knee while she attempted to spank the child. The
stepmother described the child as being immediately symptom-
atic with pain, which continued for several hours before medical
attention was sought.
DISCUSSION
Bladder rupture is an uncommon injury in the pediatric
trauma population. The incidence was 7 (0.05%) of 1500 in a
series of pediatric patients with blunt abdominal trauma imaged
with a computed tomography protocol designed to detect
bladder rupture.6 Extraperitoneal rupture is typically associated
with pelvic fractures and can usually be managed conservatively
with bladder drainage. Intraperitoneal bladder rupture has been
described in children with a full urinary bladder who sustain
seatbelt injuries or other mechanisms of blunt abdominal
trauma.7,8 Intraperitoneal rupture generally requires open
operative repair to avoid complications of peritonitis, although
good results have been reported in a small number of children
treated conservatively with urethral or suprapubic catheters
combined with peritoneal drainage.7,9
Three cases of bladder rupture associated with NAT have
been previously described in the literature (Table 1). Sirotnak10
reported the case of a 4-year-old boy who presented with lower
abdominal pain, emesis, leukocytosis, and hematuria. Ultra-
sound revealed bilateral hydronephrosis, and cystogram con-
firmed intraperitoneal bladder rupture. Protective services
Pediatric Emergency Care & Volume 25, Number 4, April 2009
Pediatric Emergency Care & Volume 25, Number 4, April 2009 Isolated Manifestation of NAT in a Child

FIGURE 1. Computed tomographic images of the abdomen demonstrating (A) air-fluid level in the bladder with pelvic free fluid
concerning for bladder rupture. B, Extensive free fluid surrounding the liver and spleen with no evidence of solid organ injury.

TABLE 1. Case Reports of Bladder Rupture From Nonaccidental Trauma

Diagnostic Mechanism Associated

Author Age Symptoms Clinical Findings Laboratory Findings Imaging of Injury Injuries
Sirotnak10 4y Abdominal pain Abdominal Leukocytosis, azotemia,
Abdominal Punched in None
and emesis distention and hematuria ultrasound and the abdomen
cystogram by stepfather
Halsted and 6 y Abdominal pain, Altered mental Leukocytosis, azotemia, Abdominal Unknown Cutaneous
Shapiro11 constipation, status, abdominal acidosis, hyponatremia, radiograph, ecchymoses
emesis, anuria, distention, and hyperkalemia, and cystogram, and
and lethargy multiple hematuria retrograde
ecchymoses pyelography
Sawyer 10 mo Emesis and Abdominal Azotemia, Abdominal Struck by Femur, rib,
et al12 anuria distention hyperkalemia, radiograph father and parietal
and acidosis and bone
abdominal fractures
ultrasound

investigation revealed that the boy had a history of encopresis
since his father’s suicide, and the injury occurred after his
stepfather punched him in the stomach for soiling his pants.
Halsted and Shapiro11 reported the case of a 6-year-old boy
admitted with acute renal failure of unknown etiology, emesis,
lethargy, and multiple unexplained ecchymoses. He was noted to
have urinelike fluid draining from his peritoneal dialysis
catheters, and subsequent cystogram confirmed bladder rupture.
Sawyer et al12 described the case of a 10-month-old girl admitted
with abdominal distention, emesis, and acute renal failure.
Radiographs demonstrated intraperitoneal fluid, pneumoperito-
neum, and a metaphyseal fracture of the left femur. Hollow
viscus injury was suspected; however, at the time of exploratory
laparotomy, the viscus was normal, but an intraperitoneal bladder
laceration was noted and repaired. The father subsequently
admitted to striking the child.
According to the history provided by the stepmother, our
patient often withheld urination, leading to large, infrequent
voids and occasional daytime incontinence. In her confession,
the stepmother described becoming angry and forcibly pulling
the child into her knee while she attempted to spank the child. It
is most likely the combination of a full bladder and the blunt
abdominal force from the mother’s knee that caused the bladder
to rupture.
Intraperitoneal bladder rupture is a rare consequence of
blunt abdominal trauma. The diagnosis should be considered in
patients with free fluid in the abdomen without solid organ
injury. Peritoneal resorption of urine can produce electrolyte
imbalances and azotemia that may further suggest the diagnosis.
As in children with other blunt abdominal injuries, physicians
must consider NAT as a potential etiology for bladder rupture. A
thorough protective services evaluation and follow-up mental
health therapy for the victim are imperative.
REFERENCES
1. Child Welfare Information Gateway. Child Abuse & Neglect: National
and State Statistics. Available at: http://www.childwelfare.gov/can/
prevalence/stats.cfm. Accessed February 29, 2008.
2. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad
Orthop Surg. 2000;8:10Y20.
3. Duhaime AC, Christian CW, Rorke LB, et al. Nonaccidental head injury
in infantsVthe Bshaken-baby syndrome[. N Engl J Med.
1998;338:1822Y1829.
4. Roaten JB, Partrick DA, Bensard DD, et al. Visceral injuries in
nonaccidental trauma: spectrum of injury and outcomes. Am J Surg.
2005;190:827Y829.
5. Trokel M, Discala C, Terrin NC, et al. Patient and injury
characteristics in abusive abdominal injuries. Pediatr Emerg Care.
2006;22:700Y704.
6. Sivit CJ, Cutting JP, Eichelberger MR. CT diagnosis and localization of
rupture of the bladder in children with blunt abdominal trauma:
significance of contrast material extravasation in the pelvis. Am J
Roentgenol. 1995;164:1243Y1246.

* 2009 Lippincott Williams & Wilkins 261

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Lautz et al
7. McAleer IM, Kaplan GW. Pediatric genitourinary trauma. Urol Clin
North Am. 1995;22:177Y188.
8. Stoddart A. Intraperitoneal bladder rupture and the wearing of rear
seat-beltsVa case report. Arch Emerg Med. 1993;10:229Y231.
9. Osman Y, El-Tabey N, Mohsen T, et al. Nonoperative treatment of
isolated posttraumatic intraperitoneal bladder rupture in children-is it
justified? J Urol. 2005;173:955Y957.
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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care & Volume 25, Number 4, April 2009
10. Sirotnak AP. Intraperitoneal bladder rupture: an uncommon
manifestation of child abuse. Clin Pediatr (Phila). 1994;33:
695Y696.
11. Halsted CC, Shapiro SR. Child abuse: acute renal failure from ruptured
bladder. Am J Dis Child. 1979;133:861Y862.
12. Sawyer RW, Hartenberg MA, Benator RM. Intraperitoneal bladder
rupture in a battered child. Int J Pediatr Nephrol. 1987;8:227Y230.
* 2009 Lippincott Williams & Wilkins