Teaching Case

33 year old male involved in a motor car accident and brought to hospital unconscious. Physical examination demonstrated blood per urethra.

Patient involved in a motor car accident and brought to hospital unconscious. Physical examination demonstrated blood per urethra. Focussed abdominal ultrasound for trauma demonstrated moderate pelvic free fluid. Following insertion of a suprapubic catheter into the bladder, a retrograde urethrogram was performed to further assess integrity of the urethra and bladder.

Bladder rupture is due to blunt, penetrating or iatrogenic injury, and can be classified as intraperitoneal or extraperitoneal. Intraperitoneal bladder rupture accounts for 20% of all bladder ruptures. It occurs at the dome of the bladder especially with a distended bladder. There is sudden rise in intravesical pressure usually as a result of blunt abdominal trauma. Individuals in motor car accidents, especially those wearing a lap type seat belt, are especially prone to this type of injury. 25% of individuals with this type of bladder injury do not have associated pelvic fractures. Cystogram or delayed contrast enhanced CT will demonstrate intraperitoneal contrast extravasation, especially into the paracolic gutters, and outlining of small bowel loops. This usually requires emergent surgical repair. Extraperitoneal bladder rupture accounts for 80% of all bladder ruptures. It usually occurs close to the bladder base or the anterolateral wall. It is usually due to laceration from an adjacent bony spicule from a fracture of the anterior pelvic arch. Cystogram or delayed contrast enhanced CT will demonstrate perivesical contrast extravasation which may extend into the retroperitoneum, perineum, scrotum, thigh or anterior abdominal wall. Most extraperitoneal bladder ruptures will close spontaneously, and hence, will be managed conservatively.