Download Bladder Trauma - Lieberman`s eRadiology

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
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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
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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
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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.
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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
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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
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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)
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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)
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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
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Andrew Dervan HMS III
Gillian Lieberman, MD
Relevant Anatomy: Intraperitoneal
Bladder Rupture
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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.
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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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