eMedicine Specialties > Radiology > Genitourinary

Bladder, Trauma: Imaging

Author: Daniel L Platter, MD, Consulting Staff, Department of Emergency Medicine, Kaiser Permanente Medical Center
Coauthor(s): Jonathan P Vaccaro, MD, Assistant Clinical Professor of Radiology, Department of Diagnostic Imaging, Rhode Island Hospital; Lawrence E Nelson, DO, Consulting Staff, Department of Surgery, Eastern Maine Medical Center, Marshfield Clinic
Contributor Information and Disclosures

Updated: Aug 12, 2008

Radiography

Findings

Retrograde cystography was considered the criterion standard for detecting bladder rupture (see Images 1-2). Reliability depends on several variables. To obtain dependable results, adequate bladder distention, requiring 350-400 mL of contrast material, is of paramount importance. To correctly perform the study, postevacuation images also should be obtained.

Degree of Confidence

With this method, diagnostic accuracy has been reported to be near 100%. However, the author was unable to find literature reporting sensitivity and specificity of retrograde cystography for intraperitoneal rupture.

False Positives/Negatives

False-negative findings occur, most commonly in association with penetrating injury. In this scenario, wound margins are believed to align well and prevent leakage. Some authors have recommended fluoroscopy, with the patient in the Trendelenburg position during the examination to increase sensitivity. Others have suggested instilling contrast material until discomfort occurs. Rarely, as mentioned before, a bladder hematoma also may block the wound orifice and prevent the leakage of contrast material.

Computed Tomography

Findings

CT scanning is rapidly becoming the most recommended study for trauma evaluation of the bladder. It is fast, it can be used to evaluate other urologic organs, and it requires no additional manipulation of the patient beyond that needed for routine evaluation. Furthermore, the literature suggests that plain abdominopelvic CT scanning may have a high negative predictive value for bladder rupture in a select subset of patients, even without cystography. This makes delaying cystography until after routine abdominopelvic CT scanning even more valuable. However, this approach applies if no hematuria is present and if no free fluid is observed anywhere in the abdomen or pelvis during routine abdominopelvic contrast-enhanced CT scanning.2,6

Additionally, all studies reviewed by the author demonstrated that bladder ruptures were not seen in patients in whom no free fluid was observed on standard contrast-enhanced CT scans, regardless of the degree of hematuria. Further study is needed to determine whether cystography, either CT scanning or standard cystography, can be safely omitted in this scenario.

Degree of Confidence

Many patients do not present with the above parameters, and when these parameters are not met, routine contrast-enhanced abdominopelvic CT scanning is highly inaccurate and insensitive in detecting bladder rupture. However, the results of CT cystography have been shown to be diagnostic. Overall, it is 95% sensitive and 100% specific in detecting bladder rupture. A group performing 1 small study took exception, suggesting that it is slightly less accurate when intraperitoneal rupture is present, with 80% sensitivity and 99% specificity. However, this is not a common concern.

Furthermore, CT cystography can be used to fully classify bladder injury beyond noting whether a rupture is intraperitoneal or extraperitoneal (see Images 3-6). Studies have demonstrated that CT cystography has requirements similar to those of retrograde cystography for diagnostic accuracy. Specifically, good bladder distention, provided with 350-400 mL of contrast material by means of retrograde infusion, is required.

False Positives/Negatives

See Degree of Confidence, above.

Magnetic Resonance Imaging

Findings

Magnetic resonance imaging (MRI) is not considered in the acute trauma setting in most centers.

Ultrasonography

Findings

Ultrasonography is mentioned here only in passing. It may be helpful in diagnosing bladder contusion, but it has been demonstrated to be unreliable in diagnosing bladder rupture.4

Nuclear Imaging

Findings

Nuclear medicine is not generally used for the acute trauma evaluation of the bladder.

Angiography

Findings

Angiography has no role in the evaluation of bladder trauma.

More on Bladder, Trauma

Overview: Bladder, Trauma
Imaging: Bladder, Trauma
Follow-up: Bladder, Trauma
Multimedia: Bladder, Trauma
References
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References

  1. Brewer ME, Wilmoth RJ, Enderson BL, et al. Prospective comparison of microscopic and gross hematuria as predictors of bladder injury in blunt trauma. Urology. Jun 2007;69(6):1086-9. [Medline].

  2. Quagliano PV, Delair SM, Malhotra AK. Diagnosis of blunt bladder injury: A prospective comparative study of computed tomography cystography and conventional retrograde cystography. J Trauma. Aug 2006;61(2):410-21; discussion 421-2. [Medline].

  3. Sivit CJ, Taylor GA, Newman KD. Safety-belt injuries in children with lap-belt ecchymosis: CT findings in 61 patients. AJR Am J Roentgenol. Jul 1991;157(1):111-4. [Medline].

  4. Tayal VS, Nielsen A, Jones AE, et al. Accuracy of trauma ultrasound in major pelvic injury. J Trauma. Dec 2006;61(6):1453-7. [Medline].

  5. Nachshen S, Abusaid D, Nauta M, Govind A, Yoong W. The "catheter bag" sign revisited: a simple way detecting bladder trauma during operative laparoscopic procedures. Arch Gynecol Obstet. Jan 2008;277(1):65-6. [Medline].

  6. Corriere JN Jr, Sandler CM. Diagnosis and management of bladder injuries. Urol Clin North Am. Feb 2006;33(1):67-71, vi. [Medline].

  7. Morgan DE, Nallamala LK, Kenney PJ. CT cystography: radiographic and clinical predictors of bladder rupture. AJR Am J Roentgenol. Jan 2000;174(1):89-95. [Medline]. [Full Text].

  8. Kim FJ, Chammas MF Jr, Gewehr EV, Campagna A, Moore EE. Laparoscopic management of intraperitoneal bladder rupture secondary to blunt abdominal trauma using intracorporeal single layer suturing technique. J Trauma. Jul 2008;65(1):234-6. [Medline].

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Further Reading

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Keywords

bladder trauma, bladder injury, bladder pain, bladder rupture, bladder contusion, urinary tract injury, bladder symptoms, bladder injury in pelvic trauma, bladder insult, urologic injury in pelvic fractures

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Contributor Information and Disclosures

Author

Daniel L Platter, MD, Consulting Staff, Department of Emergency Medicine, Kaiser Permanente Medical Center
Daniel L Platter, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Jonathan P Vaccaro, MD, Assistant Clinical Professor of Radiology, Department of Diagnostic Imaging, Rhode Island Hospital
Jonathan P Vaccaro, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Lawrence E Nelson, DO, Consulting Staff, Department of Surgery, Eastern Maine Medical Center, Marshfield Clinic
Lawrence E Nelson, DO is a member of the following medical societies: American Association for the Surgery of Trauma
Disclosure: Nothing to disclose.

Medical Editor

Neela Lamki, MD, Professor, Department of Radiology, Sultan Qaboos University, Oman; Adjunct Professor, Department of Radiology, Baylor College of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Joshua A Becker, MD, Professor, Department of Radiology, New York University School of Medicine
Joshua A Becker, MD is a member of the following medical societies: Society of Uroradiology
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Clinical Assistant Professor of Radiology, University of Washington Medical School
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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