Visual Diagnosis in Emergency Medicine - Journal of Emergency ...

The Journal of Emergency Medicine, Vol. 27, No. 4, pp. 411– 413, 2004 Copyright © 2004 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/04 $–see front matter

doi:10.1016/j.jemermed.2004.04.019

Visual Diagnosis in Emergency Medicine

EXTRAPERITONEAL BLADDER RUPTURE AND POSTERIOR URETHRAL INJURY Mustafa Secil,

MD,*

Mahmut Oksuzler,

MD,*

and Ozgur Karcioglu,

MD†

*Department of Radiology and †Department of Emergency Medicine, Dokuz Eylul University Medical School and Hospital, Izmir, Turkey Reprint Address: Mustafa Secil, MD, Department of Radiology, Dokuz Eylul University Faculty of Medicine, Inciraltı, 35340, Izmir, Turkey

An 83-year-old man involved in a car crash presented with pelvic pain. On admission he was conscious and cooperating; vital signs were stable. Inspection revealed an asymmetry and deformity in the right pelvic area. There was tenderness to palpation in the suprapubic region, and the right hip movement was painful and limited. A hemorrhagic discharge in the urethral meatus was noticed. The initial pelvic radiographs showed multiple pelvic bone fractures including right acetabular fracture and protrusion of the right femoral head. The patient was evaluated by computed tomography (CT) scan, which demonstrated multiple displaced fractures of the pelvic girdle and protrusio acetabuli on the right side (Figure 1). There was a large amount of extraperitoneal fluid in the pelvic area. Retrograde urethrography was then performed, which demonstrated contrast extravasation from the posterior urethra and bladder (Figure 2). Urethral leakage was prominent at the base of the bladder and was also extending to the groin region. The bladder had lost its original shape. Transurethrally applied contrast agent escaped from the bladder to the pelvic space in the form of irregular, stranding densities. This radiographic appearance of extravasation is consistent with extraperitoneal rupture of the bladder. Major bladder injury occurs in approximately 10% of patients sustaining blunt trauma with pelvic fracture (1). Bladder injuries resulting from pelvic fracture may take one of two forms— contusion or rupture. Contusion of

the bladder is defined as incomplete, non-perforating tears of the mucosa. It is self-limited and requires no specific therapy. Isolated extraperitoneal rupture is more common (50 – 85%) than intraperitoneal rupture (15– 45%) or combined intra- and extraperitoneal rupture (0 –12 %) (2). Urethral injuries occur in about one-third of bladder ruptures with pelvic fracture. In 85% of cases it is together with extraperitoneal bladder rupture (3). Extraperitoneal rupture is thought to result from disruption of ligamentous attachments between the bladder and pelvis or from direct laceration of the bladder wall by bony spicules. Intraperitoneal bladder rupture occurs at the dome of the bladder, especially with a distended bladder. A rapid rise in intravesical pressure results in a full-thickness tear at its weakest point—along the peritonealized posterior wall. Approximately 25% of patients with intraperitoneal bladder rupture do not have associated pelvic fractures (4). Radiological evaluation of the lower urinary tract injury is performed using retrograde urethrography, conventional cystography or computed tomographic cystography (5). Patients suspected of having posterior urethral injuries, particularly those with blood at the urethral meatus or gross hematuria, should undergo retrograde urethrography before insertion of a Foley catheter. In extraperitoneal rupture, the path of extravasated contrast media varies. If it is simple, contrast media extravasation is limited to the pelvic extraperitoneal space. In the

Visual Diagnosis in Emergency Medicine is coordinated by Stephen R. Hayden, MD, of the University of California San Diego Medical Center, San Diego, California

RECEIVED: 18 July 2003; ACCEPTED: 1 April 2004 411

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Figure 1. (a) Pelvic CT scan showing the protrusion of the right femoral head (FH); the extraperitoneal pelvic fluid that is dissecting the fat tissue (arrows). Bladder is denoted as B. (b) The CT slice at the level of the urethral base demonstrating the displaced fragment of the right ischion fracture (long arrow) that injured the urethra (short arrow).

complex form, extravasation may extend into the anterior abdominal wall, the scrotum, the perineum, and posteriorly to the presacral space. In intraperitoneal rupture, on the other hand, contrast media outline the small-bowel loops and opacify the rectouterine or rectovesical pouch. Extravasated contrast media may extend to the lateral paravesical recesses and paracolic gutters. The radiological discrimination of extraperitoneal and intraperitoneal bladder rupture is important because the treatment ap-

proaches are different. Most of the extraperitoneal ruptures can be treated with catheter drainage alone, but all intraperitoneal ruptures require surgery (4). REFERENCES 1. Sandler CM, Hall JT, Rodriguez MB, Corriere JN Jr. Bladder injury in blunt pelvic trauma. Radiology 1986;158:633– 8. 2. Bodner DR, Selzman AA, Spirnak JP. Evaluation and treatment of bladder rupture. Semin Urol 1995;13:62–5.

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413 3. Mundy AR. Pelvic fracture injuries of the posterior urethra. World J Urol 1999;17:90 –5. 4. Corriere JN Jr, Sandler CM. Bladder rupture from external trauma: diagnosis and management. World J Urol 1999;17:84 –9. 5. Horstman WG, McClennan BL, Heiken JP. Comparison of computed tomography and conventional cystography for detection of traumatic bladder rupture. Urol Radiol 1991;12:188 –93.

Figure 2. Retrograde urethrography showing the protrusion of the femoral head (FH) on the right side. Urethral injury appears as irregular densities in the urethral lumen and leakage of the contrast agent through the urethra is seen (small white arrows). Extravasation extends to the right groin (long white arrow). The original shape of the bladder is lost, extravasated contrast from the bladder causes irregular, streaking densities typical for extraperitoneal rupture of the bladder (black arrows).