Fact-sheet: Bladder perforation - rupture
Updated on 07/01/2020 at 10:07 AM
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Definition
Bladder rupture is rare: 5 to 7%, owing to the good protection afforded by the Bony pelvis.
Bladder injuries are either intraperitoneal (IP), extraperitoneal (EP), or combined.
Extraperitoneal and urethral ruptures are the most common, and are associated with a pelvic fracture in 95% of cases.
Intraperitoneal ruptures are rarer, accounting for 35% of cases, and are associated with a pelvic fracture in 50%. They are favored by a full bladder at the time of trauma. They result from a fracture of the bladder dome, the most fragile portion of the bladder, in contact with the pelvic parietal peritoneum.
Thus, when urinary ascites is observed, the defect can only be located at the bladder dome and requires surgical management (unlike EP rupture)
Trauma involving the bladder floor and/or urethra will result in a Urinoma or uro-Hematoma of extraperitoneal location.
Clinical features
Hematuria++
Tender, distended abdomen
Inability to void, or even bladder distension
Perineal or suprapubic Hematoma
Laboratory findings
Uremia with elevated creatinine may be noted in cases of intraperitoneal rupture (reabsorption)
Radiography
Retrograde cystography
This is the oldest technique, performed under surgical asepsis, by cautious retrograde catheterization given the risk of associated urethral injury in cases of pelvic trauma.
Contrast extravasation is sought (see CT semiology below).
CT
Images are obtained at the early phase after IV contrast injection, allowing visualization of bladder wall enhancement and pelvic hematoma.
*Delayed images with bladder opacification allow visualization of bladder wall rupture and contrast leakage into the extraperitoneal space or around small bowel loops if the rupture is intraperitoneal.
*CT is especially useful for assessing associated bone injuries.
Intraperitoneal rupture is characterized by contrast extravasation from the bladder dome, with small bowel loops outlined by contrast material and extensive contrast spread within the paracolic gutters up to the subdiaphragmatic region. There should be no contrast extravasation at the bladder base or along its lateral margins.
Extraperitoneal rupture is characterized by contrast material along the lateral margin of the bladder, extending down toward the bladder neck region. No contrast material is seen around the small bowel loops.
Management
Treatment of extraperitoneal bladder and urethral ruptures is most often conservative.
Treatment of intraperitoneal ruptures is surgical (suture of the defect).
Classification
AAST Classification - Bladder Injury
Grade 1: Contusion, Hematoma, partial-thickness bladder wall injury
Grade 2: Extraperitoneal laceration < 2 cm
Grade 3: Extraperitoneal laceration > 2 cm or intraperitoneal laceration < 2 cm
Grade 4: Intraperitoneal laceration > 2 cm
Grade 5: Intraperitoneal or extraperitoneal laceration extending into the bladder neck or ureteral orifice