Learning Radiology xray montage

Bladder Rupture
Intraperitoneal and Extraperitoneal



General Considerations

  • Can be secondary to traumatic or iatrogenic injury
  • Five types of rupture
    • Type I: Bladder contusion
      • Most common form
      • Results from incomplete tear of bladder mucosa
      • Cystography is normal
    • Type II: Intraperitoneal rupture
      • Results from trauma to lower abdomen when bladder is distended
      • Because bladder dome is weakest portion, it ruptures most easily
      • Contrast is then seen in the paracolic gutters and between loops of small bowel
    • Type III: Interstitial injury-rare
      • Caused by a tear of the serosal surface
      • Mural defect without extravasation will be seen
    • Type IV: Extraperitoneal
      • Almost always associated with pelvic fractures
      • Usually close to base of bladder anterolaterally
      • Subdivided into
        • Simple, with extraluminal contrast limited to perivesical space
        • Complex, with extraluminal contrast extending to thigh, scrotum or perineum
    • Type V: Combined extra- and intraperitoneal rupture
  • Extraperitoneal bladder rupture is the most common type
    • Occurs in 80% of bladder rupture cases.
    • Extraperitoneal bladder rupture generally secondary to adjacent pelvic fracture or an avulsion tear at fixation points of puboprostatic ligaments
  • Intraperitoneal bladder rupture
    • Usually iatrogenic or secondary to penetrating injury
    • Blunt trauma more likely to result in intraperitoneal rupture in children than in adults
      • Because the pediatric bladder is more intraperitoneal in location.
      • The adult bladder dome remains mostly extraperitoneal
        • Blunt trauma in an adult can result in intraperitoneal rupture only if the bladder is fully distended
    • Imaging findings
      • Extraluminal contrast extends into paracolic gutters
        • Contrast outlines loops of bowel
  • While extraperitoneal bladder rupture can be treated conservatively, intraperitoneal bladder rupture requires surgical repair
  • Highest morbidity and rupture mortality is associated with intraperitoneal rupture because of potential for development of chemical peritonitis

Imaging findings

  • Diagnostic evaluation of bladder rupture includes voiding cystourethrography (VCUG) or CT scan
    • VCUG
      • Voiding cystourethrography historically been preferred contrast enhanced study for diagnosis of bladder rupture
      • Bladder needs to be fully distended and evaluation of a post-voiding film essential
    • Plain film:
      • "Pear-shaped" bladder
      • Paralytic ileus
      • Upward displacement of ileal loops
      • Flame-shaped contrast extravasation into perivesical fat
        • Best seen on postvoid films
        • May extend into thigh / anterior abdominal wall
      • US
        • "Bladder within a bladder" = bladder surrounded by fluid collection

bladder rupture

Bladder Rupture, Extraperitoneal. One image from an IVU shows a flame-shaped density adjacent to
right lateral wall of bladder representing extra-peritoneal contrast from a bladder rupture

Amersham Health Encyclopedia