Percutaneous peritoneal drainage for the management of. Gross hematuria is the classic sign of bladder rupture and is present in 90 % of the cases. Intraperitoneal urinary bladder rupture diagnosed with. Case report nonoperative treatment for intraperitoneal bladder rupture jiunhung genga, hsiaochun changb, shiudong chungb, peihwei chenb, bin chiub, chungyou tsaib, chinghwa yangb, shunfa hungb adepartment of urology, kaohsiung medical university hospital, kaohsiung, taiwan b department of surgery, far eastern memorial hospital, banciao, new taipei city, taiwan. Here, we report a case of a patient who experienced a spontaneous intraperitoneal bladder. Delayed presentation of traumatic intraperitoneal bladder. Often, computed tomography ct is the first test performed in patients with blunt abdominal trauma. Bladder perforations may be extraperitoneal or intraperitoneal and can be a consequence of inadvertent full. Laparoscopic management of intraperitoneal bladder rupture. Urine may also leak into the pouch of douglas, located midline and posterior to the bladder and anterior to rectosigmoid colon, or into the lateral pelvic recesses. Extraperitoneal rupture of the bladder is uncommon. Coronal reformatted image of the pelvis from a ct cystogram showing hyperdense fluid in the bladder and in the intraperitoneal space. Laparoscopic repair of intraperitoneal bladder perforation. Exploratory laparotomy located an intraperitoneal rupture.
Distinction between intraperitoneal and extraperitoneal processes. Intraperitoneal bladder rupture has to be repaired surgically, whereas extraperitoneal rupture can. Ct cystography was applied to a classification scheme for bladder injury based on the degree of wall injury and anatomic location and demonstrated characteristic imaging features for each type of injury. For intraperitoneal rupture, the sensitivity and specificity were 100% and 99%, respectively. A urinary bladder that is full is more prone to rupture than an empty one. Cedarssinai imaging case of the month february 2018. Laparoscopic repair of intraperitoneal bladder rupture. Urinary bladder rupture radiology reference article. Extraperitoneal bladder rupture is more common, with an 8090% frequency rate, whereas intraperitoneal bladder rupture occurs in 1520% of patients. Bi may be evaluated by conventionalcystography or ctcystography, with the latter having the additional benefit of evaluating pelvic fracture and other intraabdominal injuries. The diagnosis was suggested by abdominal ct scan and confirmed with a cystogram. One image from an ivu shows a flameshaped density adjacent to right lateral wall. Voiding cystourethrography historically been preferred contrast enhanced study for diagnosis of bladder rupture. Intraperitoneal rupture shows contrast delineation of intraperitoneal organs such as bowel loops or liver edge.
Aug 12, 2015 gross hematuria is the classic sign of bladder rupture and is present in 90 % of the cases. This report describes a rare case of an 86yearold man with an indwelling urethral catheter who developed severe abdominal pain and was diagnosed with intraperitoneal urinary bladder perforation. Trauma, education and training, technical aspects, cystography uretrography, contrast agentother, ultrasound, fluoroscopy, ct, urinary tract. Mar 28, 2018 pelvic fracture was present in 80%, hollow viscus injury in 34. Management of blunt force bladder injuries the eastern. Six retrospective studies were used to determine the incidence of urine leakage rates on initial followup imaging in low simple extraperitoneal or intraperitoneal ruptures that are surgically repaired, medium complex intraperitoneal ruptures that are surgically repaired, and high simple extraperitoneal bladder rupture managed by catheter.
Learningradiology bladder rupture, intraperitoneal and. Intraperitoneal bladder rupturechildnonsurgical treatmentblunt traumapelvic. Spontaneous bladder rupture diagnosis based on urinary. The ct cystography results were compared with the findings at surgery, clinical followup, or both. Mar 26, 2019 while most trauma patients with bladder perforation have multiple injuries and ct imaging is a regular part of the trauma evaluation, this does not preclude obtaining a separate cystogram if bladder findings on the ct scan are equivocal. Schwartz clinical history 50yearold male with history of motor vehicle collision. Finding for the evaluation of intraperitoneal bladder rupture following blunt trauma objective. The common condition associated with pelvic fractures is intraperitoneal rupture of urinary bladder. Diagnostic laparoscopy identified intraperitoneal bladder rupture, which required open surgical repair. Delayed presentation of traumatic intraperitoneal rupture of. Delayed presentation of traumatic intraperitoneal rupture. This is a true surgical emergency managed conventionally by open laparotomy with single or double layer repair.
Bladder rupture is an uncommon injury, occurring in 10% of patients with pelvic fractures. The laparoscopic approach is the best short recovery and less traumatic treatment allowing visualization of. Sagittal and coronal multiplanar reformations may be helpful in identifying most sites of bladder rupture. Ct cystography with multiplanar reformation for suspected bladder. Distinction between intraperitoneal and extraperitoneal. Intraperitoneal bladder rupture constitutes about 1040% of all bladder ruptures 12. The small intraperitoneal bladder rupture was treated conservatively via continued urinary drainage under urinary antibiotic prophylaxis until closure. Intraperitoneal ruptures can lead to sepsis and carry a higher mortality than extraperitoneal injuries.
We present a case of intraperitoneal bladder rupture in the setting of a blunt. No other posttraumatic lesions in the abdominal cavity. In the present case, we could not rule out perforation of the digestive tract. This is commonly seen but sometimes not classed as true rupture, since it involves an incomplete tear of the mucosa. Learningradiology bladder, rupture,intraperitoneal. Peritoneal lavage would reveal urinary ascitic fluid. In the setting of trauma to the bladder it is important to differentiate extraperitoneal from intraperitoneal rupture. Cross section of contrastenhanced computed tomography and cystography shows bladder rupture with massive ascites in the peritoneal space.
Urotrauma guideline american urological association. In general, patients with intraperitoneal bladder ruptures should undergo operative repair. Intraperitoneal bladder rupture can be handled by exploration and primary bladder closure or laparoscopic repair gunnarsson and heuman, 1997, while the extraperitoneal bladder injury is. Extraperitoneal bladder rupture can be managed conservatively 8. Evidence for this mechanism is found in the fact that these injuries overwhelmingly involve the dome, suggesting. In the past diagnosis of bladder rupture was often missed or delayed. These are most often due to horizontal tear along dome of the bladder. Ecr 2019 c2071 urinary bladder rupture, our experience epos. Laparoscopic repair of intraperitoneal bladder perforation was first described in 1994 and since then, a few cases of such approach have been reported to treat traumatic, spontaneous and iatrogenic bladder rupture, avoiding laparotomy. Bladder injuries can be categorized into several types. A large volume of contrast is demonstrated in the abdominal cavity consistent with an intraperitoneal urinary bladder rupture. Occurs in approximately 15% range 1020% of major bladder injuries, and typically is the result of a direct blow to the already distended bladder. The rupture is commonly intraperitoneal, usually at the dome, as this is the weakest point within the bladder wall.
A transverse unenhanced ct image shows a highattenuating hematoma. Abdominal vessels trauma, intraperitoneal bladder rupture. To our knowledge, this is the first series of lrib reported secondary to blunt abdominal trauma. Intraperitoneal bladder rupture occurs in approximately 10%20% of major bladder injuries, 12. I versus no imaging study be used to diagnose bladder injuries o. Pelvic fracture was present in essentially all patients with extraperitoneal bladder rupture, and hollow viscus injuries were present more often in patients with intraperitoneal bladder rupture. Spontaneous bladder rupture is an extremely rare clinical event that is associated with urinary ascites and apparent acute renal failure. Ct cystography with multiplanar reformation for suspected.
All these injuries should be treated with prompt surgical exploration. In blunt trauma, probability of bladder rupture depends upon the degree of bladder distention. In patients sustaining blunt abdominopelvic trauma with intraperitoneal bladder rupture p, should operative repair i versus nonoperative management c be used to decrease complications from the bladder injury o. It may be identified on plain films, contrast studies, and sectional imaging studies fig. Isolated intraperitoneal bladder rupture from a vaginal delivery is extremely rare. It typically follows significant trauma to the pelvis, for example following a rta, assualt or a fall from a height. Although the most frequent location for intraperitoneal perforation was the dome or the posterior wall of the bladder 6. Even in the absence of a clear history of trauma, the presence of a large volume of free fluid and acute renal impairment should raise suspicion of intraperitoneal bladder rupture. Intraperitoneal bladder rupture is usually managed surgically because of the high probability of associated injuries and possibility of herniation of bowelloops through the tear, which causes adhesions 5,8. Ultrasound findings such as irregular posterior bladder wall, moderate amount of intraperitoneal free fluid, rent in bladder wall, and flow of fluid through the rent into the peritoneum while infusing saline through foleys catheter as shown in our case suggest ipr. A defect is visible at the bladder dome, indicating the site of the bladder rupture with extravasation of intravesicular contrast from the bladder arrow into the peritoneal spaces along the.
Computed tomography ct cystogram demonstrating a complex extraperitoneal bladder rupture with contrast material extending through the. Emergency urological care with celioscopic suture of the intraperitoneal bladder rupture. However as mentioned before the intraperitoneal rupture is more common, bladder repair is indicated in the form of primary closure, partial cystectomy or radical cystectomy. However, bladder irrigation could not subsequently be performed. In this position, the appendix may be intraperitoneal or extraperitoneal fig. Urinary bladder disease includes urinary bladder inflammation such as cystitis, bladder rupture and bladder obstruction tamponade. Management of blunt intraperitoneal bladder rupture. Cystitis is common, sometimes referred to as urinary tract infection uti caused by bacteria, bladder rupture occurs when the bladder is overfilled and not emptied while bladder tamponade is a result of blood clot formation near the bladder outlet. Mortality with bladder rupture from external trauma can approach 20%.
The differential diagnosis of bladder rupture includes urethral injury in males, during which extravasated urine. Symptomatic extraperitoneal bladder perforation following. Conservative treatment of an intraperitoneal bladder. The intraperitoneal investigation confirmed the presence of a large, transverse bladder rupture at the dome, measuring approximately 8 cm in length. Nonoperative treatment for intraperitoneal bladder rupture. Axial contrastenhanced ct image of the pelvis demonstrates simple free fluid posterior to the bladder arrow. Spontaneous bladder rupture is rare and life threatening event, with a high mortality rate reaching up to 50%. On the 18 positive examinations, 11 were extraperitoneal bladder rupture, five were intraperitoneal bladder rupture, and two were combined intraperitoneal and extraperitoneal bladder rupture. Conclusion a conservative treatment of a small intraperitoneal bladder perforation is possible under certain conditions. This can occur with minimal trauma when the bladder is full. Pelvic fracture was present in 80%, hollow viscus injury in 34.
Given the rapid development of abdominal ascites and pleural effusion over the course of days, malignant related etiologies were felt unlikely. Diagnostic evaluation of bladder rupture includes voiding cystourethrography vcug or ct scan. Pdf introduction urinary bladder ruptures are an uncommon injury, occurring in less than. Axial ct image of the pelvis from a ct cystogram demonstrates hyperdense intraperitoneal. Two cases of intraperitoneal bladder rupture following. This event is difficult to diagnose clinically, even with advanced techniques such as computed tomography. Blunt injury of the urinary bladder is well known and usually associates pelvic fractures. A homevisiting nurse suspected catheter obstruction and performed a catheter exchange. The possible pathogenesis of bladder rupture in bladder cancer is precipitation of perforation on the weakened body wall by the tumour.
I versus no imaging study be used to diagnose bladder inju. Recent studies have described laparoscopic repair of intraperitoneal urinary bladder rupture. Oct 25, 2011 intraperitoneal rupture of the bladder is an uncommon condition that is usually caused by pelvic fractures. Leakage of urine into perivesicular space tear drop shape on imaging. Ct cystography is accurate for diagnosing bladder rupture. While extraperitoneal bladder rupture can be treated conservatively, intraperitoneal bladder rupture requires surgical repair.
A child with urine ascites as a delayed manifestation of posttraumatic intraperitoneal bladder rupture is presented. This injury is typically the result of a direct blow to the already distended bladder. Intraperitoneal urinary bladder perforation observed in a. Ct cystography in the evaluation of major bladder trauma. The final diagnosis in this case was a urinothorax occurring in conjunction with intraperitoneal bladder rupture of an acquired bladder dome diverticulum. It is more common with a full bladder and blunt abdominal trauma. A ct cystogram has been performed after approximately 400ml of urograffin contrast has been administered via a urinary catheter. Herein, we described an unusual case of isolated delayed intraperitoneal bladder rupture that occurred on the third post injury day in a young male in the absence of free. Bladder rupture can be categorized into five types depending on the location and extent of the rupture. Intraperitoneal associated with compressive force in presence of.
Highest morbidity and rupture mortality is associated with intraperitoneal rupture because of potential for development of chemical peritonitis imaging findings diagnostic evaluation of bladder rupture includes voiding cystourethrography vcug or ct scan. Extraperitoneal bladder rupture is the most common type. Complications of bladder injuries include urinary ascites free urine in the peritoneal cavity due to intraperitoneal rupture, infection including sepsis, persistent hematuria, incontinence, bladder instability, and fistula. Mar 20, 2020 in this position, the appendix may be intraperitoneal or extraperitoneal fig. Table 1 case series of nonoperative treatment for intraperitoneal bladder rupture. An abdominal ct with a contrast media filled bladder can substitute all above mentioned imaging studies except for retrograde urethrography.
A, axial ct cystography image shows contrast extravasation into peritoneal space. Conservative treatment of an intraperitoneal bladder perforation. Bladder needs to be fully distended and evaluation of a. Urinary bladder rupture is generally caused by a direct blow or penetrating trauma to the urinary bladder the probability of bladder rupture is variable. Other causes are spontaneous rupture intraperitoneal rupture of urinary bladder. Isolated bladder injury is a rare condition and on the other hand, delayed bladder perforation is an extremely rare entity.
Free intraperitoneal fluid was found on ultrasound and ct imaging. While uncommon, late presentation of intraperitoneal bladder rupture following trauma may occur from masking of a primary laceration or development. Computed tomography ct scan of the abdomen and urinary cystogram can yield. Contusion represents an intramural injury, with hematoma within the bladder wall. Pdf management of blunt intraperitoneal bladder rupture. Mar 18, 2011 the small intraperitoneal bladder rupture was treated conservatively via continued urinary drainage under urinary antibiotic prophylaxis until closure. Urinary bladder rupture is generally caused by a direct blow or penetrating trauma to the urinary bladder.
The sudden increase in intravesicular pressure causes intraperitoneal rupture of the bladder dome. Twenty of the 74 patients had intraperitoneal bladder rupture. Successful conservative treatment of traumatic intraperitoneal. Patients usually present with vague symptoms, such as diffuse suprapubic pain and tenderness, mild shock, oliguria, and mildly raised renal function, mimicking other abdominal. They tend to be large and most commonly occur at the dome of the bladder. Intraperitoneal bladder rupture frequently occurs at the anatomically vulnerable bladder dome, the weakest and most mobile part of the bladder. Suad ali saleh alaghbari, md, general surgery resident level 3, omsb, sultanate of oman abstract. Bladder perforations may be extraperitoneal or intraperitoneal and can be a consequence of inadvertent full thickness bladder wall resection during surgery. Crosssectional images through the pelvis provide information on the status of both the pelvic organs and bony structures.
Many complications of appendicitis are related to anatomic variations in the position of the appendix, refig. Ct without opacification of the bladder may depict a sentinel clot sign abutting the bladder dome which indicates injury, with a. Bladder injuries are extraperitoneal in approximately 60%, intraperitoneal in approximately 30%, and the remaining injuries are both intraperitoneal and extraperitoneal ruptures. For claims with a date of service on or after october 1, 2015, use an equivalent icd10cm code or codes. Multiplanar reformation images were obtained by using a software package. It can occur as a direct or indirect consequence of other associated conditions such as urothelial carcinoma uc, the less common squamous cell carcinoma scc, pelvic radiotherapy, chronic cystitis, bladder outflow obstruction, alcohol intoxication and others. Many complications of appendicitis are related to anatomic variations in. Urinothorax occurring in conjunction with intraperitoneal. On the 18 positive examinations, 11 were extraperitoneal bladder rupture, five were intraperitoneal bladder rupture, and two were combined intraperitoneal and. Laparoscopic repair of traumatic intraperitoneal bladder rupture.
Imaging of gastrointestinal and abdominal emergencies in. An important fact is that 85 % of bladder ruptures are the result of pelvic fractures, but that only 10 % of pelvic fractures are associated with bladder injuries. Squamous cell carcinoma of the bladder presented with. However, 83% of patients with bladder rupture have a pelvic fracture.
From january of 2002 through june of 2006, a total of 9 patients were identified in our trauma registry with bladder ruptures secondary to abdominal blunt. Highest morbidity and rupture mortality is associated with intraperitoneal rupture because of potential for development of chemical peritonitis. Intraperitoneal ruptures occur because rapidly rising intraperitoneal pressure causes the bladder to burst 5. Laparoscopic repair of intraperitoneal bladder rupture secondary to blunt abdominal trauma dr.
Bladder rupture in the puerperium is commonly associated with concomitant uterine rupture in the obstetric setting. To evaluate the frequency and relevance of the sentinel clot sign on ct for patients with traumatic intraperitoneal bladder rupture in a retrospective study. Intraperitoneal rupture occurs in approximately 25% of patients1. The bladder receives urine from the kidney via the ureters right and left, which enter the bladder inferiorly and posteriorly.
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