184
Fig. 30 Extraperitoneal bladder rupture. a Axial CTC image
demonstrates contrast leaking through a rupture in the left
anterolateral aspect of the bladder (arrow) and spreading in a
streaky manner through the retroperitoneum and into the left
angiography with embolization should be one of the
initial management steps considered (Blackmore et al.
2006).
7 Bladder
7.1 Bladder Trauma
7.1.1 Terminology and Clinical Issues
The most common injury of the bladder is a contusion,
which may present clinically with hematuria but can be
difficult or impossible to visualize on imaging studies.
The most common complete tear of the bladder wall
(through the entire thickness of the bladder wall)
results in an extraperitoneal bladder rupture (60–90%)
(Carroll and McAninch 1984, Vaccaro and Brody
2000) in which urine can leak through a defect in the
bladder into the extraperitoneal space (Fig. 30). Intra-
peritoneal bladder ruptures (15–25%) (Carroll and
McAninch 1984; Vaccaro and Brody 2000) are less
common; they occur when the defect is in the dome of
the bladder, allowing urine to leak into the intraperi-
toneal space (Fig. 31). Combined bladder ruptures
(5–12%) (Carroll and McAninch 1984; Vaccaro and
L. Mannelli et al.
anterior abdominal wall. b Coronal image demonstrates the
inferior location of the bladder rupture (arrow) and a displaced
left obturator ring fracture (arrowhead)
Brody 2000; Sandler et al. 1986) are even less common
and result in urine leakage into the intraperitoneal and
extraperitoneal spaces. An extremely rare injury is an
interstitial rupture, consisting of a tear of the inner wall
of the bladder that does not extend through the outer
wall. These can be extremely difficult to identify on
imaging studies.
Although less than 10% of patients with pelvic
fractures have bladder ruptures (Avey et al. 2006;
Corriere and Sandler 1999) more than 80% of patients
with bladder ruptures have pelvic fractures (Sandler
et al. 1986; Corriere and Sandler 1986) The presence
of osseous pelvic trauma should prompt the radiolo-
gist to consider the possibility of bladder injury and
the potential need for further imaging evaluation.
Almost all cases of extraperitoneal bladder ruptures
due to blunt trauma are associated with pelvic frac-
tures. In contrast, 25% of intraperitoneal bladder
ruptures occur in the absence of pelvic fractures and
almost always result in gross hematuria. These may
result when blunt trauma to the lower abdominal wall
generates a sudden rise in intravesical pressure in a
patient with a distended bladder, causing rupture of
the bladder dome, which is the weakest portion of the
bladder (Corriere and Sandler 1999).
The Pelvis
Fig. 31 a Intraperitoneal bladder rupture is demonstrated on
CTC, with intraperitoneal contrast in the paracolic gutters
(arrowheads) and between loops of small bowel and mesentery
Table 2 Indications for obtaining a CTC following blunt
abdominal trauma
Gross hematuria and free intraperitoneal fluid (which may
represent urine from an intraperitoneal bladder rupture)
OR
High levels of hematuria and pelvic ring injury
[30 RBC/HPF or gross hematuria
AND
Pelvic ring fracture or disruption (excluding isolated
acetabular fractures)
7.1.2 Imaging
Bladder abnormalities may be detected during spe-
cific evaluation of the urinary system by CT urogra-
phy (CTU) or CT cystography (CTC), or incidentally
while evaluating the abdomen and/or pelvis for other
reasons with CT, US, or MRI. Conventional radio-
graphic cystography has been replaced by CTC for
the evaluation of acute traumatic bladder injury. The
indications for obtaining a CTC following blunt
abdominal trauma are listed in Table 2. The technique
for performing a CTC is described in Table 3.
While the defect in the bladder wall may some-
times be well seen, it is often not directly visualized
on CTC, especially when the defect is small, or if the
bladder partially collapses as contrast leaks from it. In
185
(arrow). b A defect in the bladder dome is clearly demonstrated
(arrow) in this case, but the actual defect is not always visible
on CTC
Table 3 CT cystography (CTC) technique
Drain urine via Foley catheter to eliminate/reduce unopacified
bladder contents
Hang container of dilute water-soluble contrast (*2–3 grams
iodine per 100 ml of volume) 40 cm above the bladder to
generate adequate pressure
Fill the bladder with contrast until 350 ml or more have been
instilled, flow of contrast stops, or bladder distension is
painful to the patient
Obtain 2.5–5mm low-dose axial images through the pelvis.
Coronal and sagittal reformations may help with the
evaluation
If delayed images of the pelvis are being obtained for other
reasons, fill the bladder with contrast and collect CTC images
as part of that scan, obviating the need to further expose the
patient to radiation specifically for a bladder evaluation
Otherwise, CTC is obtained following the parenchymal
phase, after retrograde filling of the bladder
these cases, the presence of the relatively high density
CTC contrast in the extraperitoneal and/or intraperi-
toneal spaces provides presumptive evidence of
bladder rupture. Careful attention to prior images and
other phases of the study is necessary to prevent
extravasated vascular, enteric, or retrograde urethro-
gram contrast from being mistaken for bladder
extravasation.