Andrew Dervan HMS III Gillian Lieberman, MD

September 2006

Bladder Trauma

www.surgery.ubc.ca/presentarch/santucci_urologicinjuries_03.pdf

Andrew Dervan, HMS III Gillian Lieberman, MD

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Andrew Dervan HMS III Gillian Lieberman, MD

Outline • Who’s at risk? • Who should we image? • What tests are available to assess the lower urinary tract – Retrograde Urethrogram (RUG) – Cystogram – CT Cystogram

• Relevant Findings on Cystogram and CT Cystogram – Intraperitoneal Rupture – Extraperitoneal Rupture

• Our Patient: CG • Medical Management of Bladder Rupture • Take Home Points 2

Andrew Dervan HMS III Gillian Lieberman, MD

Who’s at risk?

http://msjensen.education.umn.edu/webanatomy/urinary/bladder-female.gif

This is a picture of a normal pelvis (female) facing left. The bladder is light blue. The pubic symphysis (bone) is orange. Notice how the normal bladder sits behind the bony pelvis when empty protecting it against blunt and penetrating trauma.

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Andrew Dervan HMS III Gillian Lieberman, MD

Who’s at risk? Children

http://www.bartleby.com/107/255.html

This is a picture of a child’s pelvis (female) facing right. Notice how the bladder is naturally suspended above the pubic symphysis. This can expose the bladder to trauma.

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Andrew Dervan HMS III Gillian Lieberman, MD

Who’s at risk? Older Men

http://www.bartleby.com/107/255.html

This is a picture of a male pelvis facing left. In elderly males, an enlarged prostate can displace the bladder superiorly above the pubic symphysis.

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Andrew Dervan HMS III Gillian Lieberman, MD

Who’s at risk? Drunk Drivers

www.surgery.ubc.ca/presentarch/santucci_urologicinjuries_03.pdf

The bladder, when full, rises about the pubic symphysis and when traumatized is prone to bursting superiorly. Those same people with full bladders (heavy drinkers) are the ones most likely to have motor vehicle crashes.

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Andrew Dervan HMS III Gillian Lieberman, MD

Is bladder trauma bad? • Overall 20% mortality rate in trauma patients whose presentation includes a ruptured bladder – While the bladder trauma may not be the cause of death, such trauma is correlated with serious multisystem injuries J Urol 1984; 132:254-257

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Andrew Dervan HMS III Gillian Lieberman, MD

Who should we image? • No firm guidelines • Most studies retrospective • Patients in studies are usually mixtures of blunt and penetrating trauma patients • Degree of hematuria (blood in the urine), a potential indicator for imaging, not quantified in many studies Morey 2006

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Andrew Dervan HMS III Gillian Lieberman, MD

Who should we image? • Meta analysis of bladder trauma patients shows 90% present with gross hematuria, 88% present with pelvic fracture • Look for BOTH pelvic fracture on x-ray AND gross hematuria (>25 RBC/HPF)

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J Trauma 2001;51:683-6

Andrew Dervan HMS III Gillian Lieberman, MD

Who should we image? • Clinical Indicators of Bladder Rupture – Suprapubic pain or tenderness – Inability to void, clots in urine – Signs of major perineal trauma: swelling or hematoma, blood at urethral meatus – Unresponsiveness, intoxication, inability of physician to complete proper physical exam – Free intraperitoneal fluid on CT scan or ultrasound • However, can be confounded by (orthopedic) hematoma

– Prior urological surgery

• These indicators would raise or lower your suspicion for an atypical patient who presents without classic combo of pelvic fracture and gross hematuria J Trauma 2001;51:683-6 10

Andrew Dervan HMS III Gillian Lieberman, MD

However, we should avoid unnecessary bladder imaging • Overwhelming majority of trauma patients do not need specific bladder imaging: – Only 10% of patients with pelvic fractures have bladder rupture J Trauma 2001;51:683-6

• Gross hematuria without documented pelvic fracture – Typical source of blood is kidney, upper urogenital – Small prospective study: 0/25 had bladder rupture in setting of gross hematuria without pelvic fracture 11

Am Surg 1993;59:335-337

Andrew Dervan HMS III Gillian Lieberman, MD

What tests can we order to assess lower urinary tract? • Retrograde Urethrogram (Plain Film) – Assesses patency of anterior urethra (in males)

• Cystogram (Plain Film) – Gold Standard

• CT Cystogram

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Andrew Dervan HMS III Gillian Lieberman, MD

Retrograde Urethrogram (RUG) • Fluoroscopy study, anterior urethra • Rules out urethral tear • Failure to identify torn urethra before Foley insertion can exacerbate tear and lead to: – permanent incontinence – sexual dysfunction – stricture

• Procedure: pediatric Foley catheter inserted into tip of urethra and inflated • Gentle injection of 5-30cc of 30% contrast solution from the tip of the urethra retrograde • The external sphincter usually spasms allowing for good visualization of a distended anterior urethra. 13

Andrew Dervan HMS III Gillian Lieberman, MD

Retrograde Urethrogram or RUG (Normal)

http://www.lahey.org/Images/Radiology/ClickableImages/RetrogradeUrethrogram_Male.jpg

Companion Patient #1: No filling defects, no extravasating contrast

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Andrew Dervan HMS III Gillian Lieberman, MD

Cystogram (Normal) • Fluoroscopy or static image – Foley catheter in bladder – Use diluted contrast (3050% contrast in saline) – Use 300-400cc total, slowly fill bladder by gravity (source of fluid is held above level of pelvis) http://www.lahey.org/Images/Radiology/ClickableImages/Cystogram_UrinaryBladder.jpg

Companion Patient #2: No extravasation of contrast beyond bladder wall 15

Andrew Dervan HMS III Gillian Lieberman, MD

Cystogram cont. (Normal) • 3 films taken: – Pre filling – Full (>300cc) – Post drainage

• Views: AP view necessary; lateral and/or oblique if possible • Post drainage view to catch extravasation hidden by distended bladder

Bladder

http://rad.usuhs.mil/rad/iong/pelvis/p024.jpg

Companion Patient #3: No extravasation of contrast beyond bladder wall

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Andrew Dervan HMS III Gillian Lieberman, MD

Example: Post Drainage Film Important • Above: Full bladder fails to demonstrate abnormality on Cystogram (AP view) • Below: post drainage film reveals simple extraperitoneal rupture (AP view)

B

B Companion Patient #4: Cystogram

17 Radiology 1986;158:633-638

Andrew Dervan HMS III Gillian Lieberman, MD

CT Cystogram (Normal) • CT scan of pelvis

Bladder

AJR. 2000;174:89-95

Companion Patient #5: CT scan: distended bladder with no contrast extravasation, see air-fluid level inside bladder, which is normal after Foley insertion

– Retrograde filling of bladder via Foley for complete bladder distention – Gravity flow used – 2-4% diluted contrast solution used – Clamp catheter after filling to maintain bladder distention – 5-15mm sections taken from dome of diaphragm to perineum (which will include upper thighs) 18

Andrew Dervan HMS III Gillian Lieberman, MD

CT Cystogram vs. Standard Cystogram • Advantages of CT cystogram over plain film cystogram: – No need for post drainage images – No need to remove Foley to identify bladder base lacerations – With adequate (>300cc) distention, CT cystogram is equivalent to plain film cystography, both have ~95% sensitivity and specificity RadioGraphics 2000;20:1373-1381 http://www.trauma.org/cases/classic001.html

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Andrew Dervan HMS III Gillian Lieberman, MD

CT with I.V. Contrast vs. Retrograde Contrast I.V. contrast • CT with I.V. contrast not equivalent to CT cystogram (which uses retrograde contrast) – I.V. contrast does not distend bladder enough – Takes additional time for I.V. contrast to collect in bladder AJR Am J Rotentgenol 1999;173:1269-1272 Companion Patient #6: Example shows no extravasation with I.V. contrast (upper picture), but frank extravasation with retrograde contrast (lower picture). Bladder marked with “B”

Retrograde contrast (cystogram)

20 Radiol Clin North Am 1999

Andrew Dervan HMS III Gillian Lieberman, MD

I.V. contrast inadequate, another example

B B

Radiology 1986;158:633-638

Companion Patient #7: Excretory urogram with I.V. contrast (no extravasation)

Companion Patient #7: Cystogram with retrograde contrast (frank intraperitoneal rupture)

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Andrew Dervan HMS III Gillian Lieberman, MD

A note about contrast • Use Gastrograffin, not Barium – When imaging patients with suspected bladder trauma, water soluble contrast (Gastrograffin) is used in place of the more common barium sulfate because the former is less likely to cause peritonitis if contrast leaks outside the bladder

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Andrew Dervan HMS III Gillian Lieberman, MD

What test to order? • CT Cystogram: If patient is already going for CT scan, CT cystogram is preferred. • Cystogram: If patient is not getting a CT for another reason, Cystography is recommended. J Trauma 2001;51:683-6

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Andrew Dervan HMS III Gillian Lieberman, MD

Relevant Anatomy

http://msjensen.education.umn.edu/webanatomy/urinary/bladder-female.gif

• • •

The abdominal peritoneum reflects over the dome of the bladder Below the bladder, the urogenital diaphragm prohibits contents from escaping the pelvis The inferior fascia of the urogenital diaphragm fuses inferolaterally with the fascia lata of the thigh

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Andrew Dervan HMS III Gillian Lieberman, MD

What might you expect to see on Cystography with… • Bladder Contusion – incomplete tear of bladder mucosa – no findings on cystography – diagnosis of exclusion

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Andrew Dervan HMS III Gillian Lieberman, MD

What might you expect to see on Cystography with… • Intraperitoneal rupture: 10-20% of ruptures – Occurs as a horizontal tear at the dome of the bladder where bladder is covered by peritoneum – This is a weak point in the bladder wall as the bladder’s muscle fibers are spread thin here – Often the result of a blow to a distended bladder • Patients with lap seatbelts during MVA potentially predisposed

– Radiological: demonstration of contrast material entering the peritoneal cavity from the bladder 26

Andrew Dervan HMS III Gillian Lieberman, MD

Relevant Anatomy: Intraperitoneal Bladder Rupture

27 http://msjensen.education.umn.edu/webanatomy/urinary/bladder-female.gif

Andrew Dervan HMS III Gillian Lieberman, MD

Intraperitoneal Rupture • CT Cystography – Contrast has smooth, regular contours – Contrast accumulates near dome of the bladder and extends laterally filling peritoneal cavity – Contrast surrounds bowel, forming gas-filled defects – May outline liver margin as seen here

RadioGraphics 2000;20:1373-1381

Companion Patient #8: CT cystography of a 29 year old man who sustained multiple pelvic fractures in a MVA 28

Andrew Dervan HMS III Gillian Lieberman, MD

Intraperitoneal Rupture • CT Cystography – Contrast can surround loops of bowel, intraperitoneal viscera and fill paracolic gutters.

RadioGraphics 2000;20:1373-1381

Companion Patient #9: 53 year old man in MVA, contrast between loops of small bowel (white arrows) and pararenal fascia (black arrows)

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Andrew Dervan HMS III Gillian Lieberman, MD

Extraperitoneal Rupture • Extraperitoneal rupture: 7080% of ruptures – Can be associated with a spicule of bone from fractured anterior pelvic arch lacerating the pelvic base of the bladder – Simple type: contrast leakage is limited to the pelvic extraperitoneal space – Complex type: contrast leakage into scrotum, penis, retroperitoneum, thigh, or anterior abdominal wall

B

Radiology 1986;158:633-638

Comparison Patient #10: Complex extraperitoneal rupture on Cystogram: contrast extravasation laterally into pelvis and thigh (AP view) 30

Andrew Dervan HMS III Gillian Lieberman, MD

Relevant Anatomy: Extraperitoneal Rupture

31 http://msjensen.education.umn.edu/webanatomy/urinary/bladder-female.gif

Andrew Dervan HMS III Gillian Lieberman, MD

Extraperitoneal Rupture • CT Cystogram – Often contrast seen in perivesicular and anterovesicular space (Space of Retzius) – Dissects fascial planes – Dense, flame-shaped

B

http://www.mypacs.net/repos/mpv3_repo/viz/full/846/42346.jpg

Comparison Patient #11: CT cystogram with characteristic flame-shaped extravasation 32

Andrew Dervan HMS III Gillian Lieberman, MD

Another Example of Extraperitoneal Rupture Contrast in penis

http://www.trauma.org/cases/classic001.html

Comparison Patient #12: CT cystogram where the inferior fascia of the urogenital diaphragm is violated, allowing contrast to leak into the penis

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Andrew Dervan HMS III Gillian Lieberman, MD

Our patient: CG • • • • •

32 year old male, motorcycle collision with minivan CG is thrown 25 feet from his vehicle CG complains of suprapubic tenderness Foley placed drains rose colored urine Scout image shows: – Sacroiliac joint space widened on left – 15 mm pubic diastasis (widening) • No clear pelvic fracture

– Left radius fracture

• CT Cystography ordered (along with other CT scans) 34

Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography Air-fluid level in bladder secondary to Foley placement

Contrast superficial to the L rectus muscle

B Contrast in bladder

Perivesicular contrast

35 Courtesy AC Kim, MD, BIDMC

Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography Extraperitoneal extravasation of contrast

Courtesy AC Kim, MD, BIDMC

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography Extraperitoneal extravasation of contrast

Courtesy AC Kim, MD, BIDMC

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography Extraperitoneal extravasation of contrast

Courtesy AC Kim, MD, BIDMC

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography Extraperitoneal extravasation of contrast

Courtesy AC Kim, MD, BIDMC

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography Extravasation of contrast in subcutaneous tissue and the fascia lata of thigh

Courtesy AC Kim, MD, BIDMC

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography Chest tube Chest tube

Extra peritoneal contrast Artifact

Courtesy AC Kim, MD, BIDMC

Coronal image

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography

Extra peritoneal contrast

Courtesy AC Kim, MD, BIDMC

Coronal image

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography

Extra peritoneal contrast

Coronal image

Courtesy AC Kim, MD, BIDMC

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: CT Cystography

Contrast anterior to rectus muscle Extra peritoneal contrast Axial image

Courtesy AC Kim, MD, BIDMC

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Andrew Dervan HMS III Gillian Lieberman, MD

Comparative example of pubic diastasis

RadioGraphics 2000;20:1373-1381 Courtesy AC Kim, MD, BIDMC

Our Patient CG: 15mm pubic diastasis

Comparison patient #13: 23 year old man in a MVA showing pubic diastasis (black arrows) and contrast leakage along scrotal sub-dartos fascia (white 45 arrows)

Andrew Dervan HMS III Gillian Lieberman, MD

Medical Management of Rupture • Intraperitoneal: surgical repair – Immediate laparotomy (J Trauma 2001;51:683-6) – Otherwise you risk infection and chemical peritonitis from urine extravasation

• Extraperitoneal: conservative management – Catheter drainage for 7-10 days (compress bladder to allow healing) – Antibiotics (1 week) – If urine stays clear of blood and bladder neck not injured, no further treatment – Follow up at 1 week with repeat Cystography 46

Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG • Our patient CG was diagnosed with complex extraperitoneal bladder rupture and managed conservatively with bladder compression and antibiotics • A follow up cystogram was taken 1 week later

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG: Cystogram 1 week later No signs of extravasation from bladder

Still see obvious pubic diastasis

Foley catheter Courtesy AC Kim, MD, BIDMC

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Andrew Dervan HMS III Gillian Lieberman, MD

Our Patient CG • Our Patient CG was discharged home after his clear cystogram to complete his recovery

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Andrew Dervan HMS III Gillian Lieberman, MD

Take Home Points • Blunt abdominal trauma – – – –

Look for hematuria, abdominal pain On scout x-ray, look for pelvic fracture 90% of bladder ruptures have both features! HOWEVER, expect only 10% of your trauma patients with pelvic fractures will have a bladder rupture

• CT Cystogram – If bladder fully distended (>300cc), equivalent to standard cystogram (AJR 1999;173:1269-1272)

• Standard Cystogram – Pre, full (>300cc) and post void images needed 50

Andrew Dervan HMS III Gillian Lieberman, MD

Take Home Points • • • •

RUG first if frank blood at meatus Intraperitoneal rupture  surgery Extraperitoneal rupture  conservative Don’t drink and drive!

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Andrew Dervan HMS III Gillian Lieberman, MD

References • • • • • • • • • •

Santucci, R. Lecture: Diagnosis and Management of Urologic Injuries: The Fundamentals. Accessed 17 Sept. 2006. http://www.surgery.ubc.ca/presentarch/santucci_urologicinjuries_03.pdf. Carroll et al. Major bladder trauma: mechanisms of injury and a unified method of diagnosis and repair. J Urol. 1984;132:254-257. Fuhrman et al. The single indication for cystography in blunt trauma. Am Surg. 1993;59:335-337. Peng et al. CT cystography versus conventional cystography in evaluation of bladder injury. AJR Am J Roentgenol. 1999;173:1269-1272. Morey et al. Bladder Rupture after Blunt Trauma: Guidelines for Diagnostic Imaging. J Trauma. 2001;51:683-686. Morey, A. Lecture: Bladder Trauma 2006: Imaging and Intervention. Accessed 17 Sept. 2006 www.facs.org/education/gs2005/sp01morey.pdf. Sandler et al. Bladder Injury in Blunt Pelvic Trauma. Radiology. 1986;158:633-638. Vaccaro et al. CT Cystography in the Evaluation of Major Bladder Trauma. RadioGraphics 2000;20:1373-1381. Brohi, K. Lateral compression pelvic injury & extraperitoneal rupture of the bladder. Accessed 17 sept. 2006. http://www.trauma.org/cases/classic001.html. Morgan et al. CT Cystography: Radiographic and Clinical Predictors of Bladder Rupture. AJR. 2000;174:89-95. 52

Andrew Dervan HMS III Gillian Lieberman, MD

Thanks! • • • •

AC Kim, MD, BIDMC Gillian Lieberman, MD, BIDMC Pamela Lepkowski, BIDMC Larry Barbaras, Webmaster, BIDMC

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