Case Presentation

Christopher Mejias
12/1/2016
 History
• 78 y/o female comes to the ED after a fall
Pelvic Radiograph
Pelvic Radiograph
 Findings
• There is a fracture of the right superior and
inferior pubic rami
 Next Step
• Ortho consult
• Anything else?
Hip, Pelvis CT
Hip, Pelvis CT
 Possible Causes of fluid collection
• Hematoma
• Bladder rupture
• Ascites
• Abscess
• Seroma
 Diagnostic approach
• Clinical History
– Acute time course with trauma makes hematoma
or bladder rupture more likely.
– No malignancy or hepatic disease (would make
ascites more likely.)
– No inflammatory disease such as pancreatitis,
diverticulitis (would raise suspicion for abscess)
– No recent surgery (would raise suspicion for
abscess or seroma)
 Diagnostic approach
• Location
– This collection is in the pelvis which raises concern
for bladder rupture
– There is no fluid in the peritoneum.
– Tubo-ovarian abscess would be seen in the pelvis
but would have a different appearance and clinical
history.
 Diagnostic approach
• Radiographic features:
– Fluid density: >30 HU for hemoperitoneum, <20 HU
for ascites or fluid (though low attenuation
hemoperitoneum is possible). In this patient ~10 HU
– Shape of the fluid collection: diffuse suggesting
bladder rupture or possibly hematoma rather than
walled off.
– Surrounding inflammation not present (would be
compatible with abscess)
Hip, Pelvis CT
CT cystogram
 Findings
• Contrast injected into the bladder leaks into
the pelvic space confirming the diagnosis of
bladder rupture.
• It does not enter the peritoneum making this
an extra-peritoneal rupture.
 Discussion
• Bladder rupture is caused by trauma – either blunt or
penetrating.
• Clinically patients may present with hematuria,
difficulty urinating and pain, however these are non-
specific, and none may be present.
• Retrograde cystogram (using a radiograph) or
retrograde CT cystogram is the preferred method of
diagnosis.
• Can be either intraperitoneal or extraperitoneal or
both
Cryptography showing bladder rupture
 Management
• Often accompanies other injuries – especially pelvic
fracture. Search for other injuries and address urgent
ones.
• Urethral injury can occur, especially in men.
– This is diagnosed via retrograde urethrography which is
similar to retrograde cystography (contrast is injected into
the urethra instead of the bladder)
– Foley cannot be placed in this case – instead a suprapubic
catheter is placed.
– Since there is usually other trauma with urethral injury,
treatment is usually delayed surgery several weeks later
though other approaches are possible
 Bladder Rupture Management
• Intraperitoneal rupture is more serious and
requires surgical intervention. Can lead to
peritonitis.
• Extraperitoneal rupture can be initially
managed with continuous bladder drainage via
catheter. Surgery may be required.
• This patient had a Foley placed for 2 weeks.
Subsequent cystogram showed no leak
indicated that it healed.
 Citations
• https://www.dynamed.com/topics/dmp~AN~
T902791/Bladder-trauma-emergency-
management
• https://radiopaedia.org/articles/urinary-
bladder-rupture