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Bladder Trauma


KEY FACTS

Terminology

  • Injury due to blunt, penetrating, or iatrogenic trauma

Imaging

  • Extravasation of contrast-opacified urine at cystography (CT or conventional): Almost 100% accuracy

  • Contusion (type 1)

    • Ecchymosis of localized segment of bladder wall

  • Intraperitoneal rupture (type 2)

    • Opacified urine in peritoneal spaces (pouch of Douglas), outlining bowel loops & intraperitoneal viscera

    • Requires surgical repair

  • Interstitial injury (type 3)

    • Intramural tear with intact serosa

  • Extraperitoneal rupture (type 4)

    • Perforation by bony spicules of pelvic fractures

    • Molar tooth sign : Extravasated perivesical urine assumes rounded configuration cranially & pointed contours inferolaterally

    • Usually managed nonoperatively

    • Complex (type 4B): Extravasation extends beyond perivesical space; thigh, scrotum, etc.

  • Combined injury (type 5): Intra- & extraperitoneal rupture

Top Differential Diagnoses

  • Male urethral injury

    • Extravasated urine can extend into perivesical spaces

  • Pelvic or abdominal bleeding

    • Active hemorrhage may simulate bladder rupture

  • Blood clot in bladder

Pathology

  • Location of extravasation depends on anatomy

    • Anterosuperior rupture: Extravasation to intraperitoneal, Retzius space, or both

    • Injury below peritoneal reflection → extraperitoneal (paravesical, presacral spaces)

Axial CECT reveals diastasis
of the pubic symphysis and fluid
within the ventral soft tissues; it is difficult to determine if this is due to urine, hematoma, or a combination of both.

AP view from a follow-up cystogram in the same patient shows extravasation of contrast from the urinary bladder into the extraperitoneal tissues
surrounding the bladder and along the left superior thigh and scrotum. A small volume of contrast is within the urinary bladder
.

Axial CECT during the initial trauma evaluation reveals perivesical fluid
for which differential considerations include urine and blood. Mild hemorrhage resides in the ventral subcutaneous tissues
and presacral space
.

Axial CT cystogram in the same patient reveals that the perivesical fluid was from extravasated contrast-opacified urine
due to extraperitoneal bladder rupture. Note the molar tooth configuration of the extraperitoneal contrast in the perivesical spaces.

TERMINOLOGY

Definitions

  • Bladder injury due to blunt, penetrating, or iatrogenic trauma

IMAGING

General Features

  • Best diagnostic clue

    • Extravasation of contrast-opacified urine at cystography (CT or conventional)

  • Other general features

    • Classification of bladder injury after blunt trauma

      • –

        Type 1: Bladder contusion

      • –

        Type 2: Intraperitoneal rupture

      • –

        Type 3: Interstitial injury

      • –

        Type 4A: Simple extraperitoneal rupture

      • –

        Type 4B: Complex extraperitoneal rupture

      • –

        Type 5: Combined injury

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