Genitourinary Radiology > Bladder > Rupture


Rupture

Bladder rupture occurs most often in the setting of trauma, and is classified as intraperitoneal, extraperitoneal, or both. It is often associated with fracture of the anterior pelvic ring, such as separation of the pubi symphisis with fractures of the pubic rami. Concomitant injury to the urethra in males must be considered. Spontaneous rupture occurs in the setting of a lesion that weakens the bladder wall, such as tumor, cystitis, perivesical inflammation, bladder outlet obstruction, neurogenic bladder, or radiation injury.

With extraperitoneal rupture, standard cystography shows extravasation of contrast material into the perivesical space frequently of the anterolateral bladder wall.

Intraperitoneal rupture shows contrast delineation of intraperitoneal organs such as bowel loops or liver edge. These are most often due to horizontal tear along dome of the bladder. 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 superior to the bladder.

Contrast enhanced CT of pelvis in a trauma patient. This delayed scan was performed to allow the bladder to fill with excreted contrast. Alternatively, a CT Cystogram can be performed with gravity assisted installation of sterile contrast into the patient's bladder following Foley ballon insertion by the urologist in the ER. The scan shows contrast filling the bladder (B) with extravasation of contrast into the extraperitoneal spaces (anteriorly = space of retzius (r), laterally and posteriorly (arrows)). Contrast is contained in the extraperitoneal spaces.

Delayed contrast enhanced CT of pelvis following trauma shows contrast extravasated into space between the bladder and rectum.

Contrast outlines bowel loops in the peritoneum. This is diagnostic of intraperitoneal bladder rupture.

Conventional cystogram performed in urology following bladder biopsy during cystoscopy. Instillation of contrast into the Foley balloon shows contrast extravasating into abdomen (arrows) from the biopsy site.

Conventional Retrograde Urethrogram (RUG) following trauma. Note diastasis (i.e., widening) of symphysis pubis (line between two halves of symphysis) related to traumatic injury. Injuries involving the low pelvic ring have a high associated injury rate to the urethra. In this RUG, the urologist is instilling contrast into the urethra at the tip of the penis through a Tummey (SP?) syringe (S). Contrast shows a normal anterior urethra but the contrast does not fill the posterior urethra and stops abruptly at the level of urethral injury at the urogenital diaphragm (arrow). This is the most common level of urethral injury due to the relatively fixed position of the urethra resulting in sheer or distraction urethral injury with pelvic trauma.



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