Visual Journal of Emergency Medicine 21 (2020) 100834

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Visual Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/visj

Visual Case Discussion

Bladder rupture after a motor vehicle collision T

Eric F. Reichman
Clinical Associate Professor of Emergency Medicine, Department of Emergency Medicine, UT-Houston Houston, Texas, USA

ARTICLE INFO

Keywords:
Intraperitoneal bladder rupture
Blunt bladder trauma
Motor vehicle collision
Seat belt sign
FAST examination

1. Visual case discussion

A 44 year old male restrained driver after a motor vehicle collision

(MVC) complained of chest, abdominal, and extremity pain. He has not
urinated since before the incident. CT scans of the head, neck torso, and
extremities showed multiple minor injuries not needing repair or ad-
mission and free fluid in the abdomen. He was transferred from the
local ED to our trauma center.
Vital signs were normal. He smelled of alcohol. Tenderness was
noted on the right chest, diffusely over the abdomen, and over the right
hand. A seat belt sign was present. The rest of the exam was un-
remarkable. A FAST scan was positive. The combination of the seat belt
sign, free fluid, and no urine output suggested a bladder injury. A ca-
theter was placed in the urethral tip and a retrograde urethrogram was
normal. The catheter was advanced over a guidewire into the bladder to
obtain a retrograde cystogram Fig. 1-3. The patient was taken by the
trauma service to the OR for primary bladder repair.
An intraperitoneal bladder rupture is a rare condition seen in 1-2%
of blunt trauma.1–3 It is usually from a compressive force on a full
bladder. The thinning of distension makes it more vulnerable to injury. Fig. 1. An AP X-ray of the pelvis and abdomen with a thin guidewire placed
Most cases are due to MVC's, but also occur from iatrogenic injury. An through the urethra and into the bladder. A catheter was subsequently placed
injury can be isolated or associated with a pelvic fracture. over the guidewire.

E-mail address: eric.f.reichman@gmail.com.

https://doi.org/10.1016/j.visj.2020.100834
Received 4 June 2020; Received in revised form 19 June 2020; Accepted 24 June 2020
2405-4690/ © 2020 Elsevier Inc. All rights reserved.
E.F. Reichman
Fig. 2. An AP X-ray of the retrograde cystogram demonstrating the in-
traperitoneal bladder rupture. Contrast extravasates from the bladder dome
(arrowhead) and outlines the colon (arrows). The bladder (B) and the catheter
over the guidewire (wavy arrow) are visualized.
Fig. 3. An AP X-ray of the retrograde cystogram demonstrating the bladder (B)
after primary repair. The catheter over the guidewire (arrow) is visualized.
Visual Journal of Emergency Medicine 21 (2020) 100834
2. Question
1 Which of the following is true regarding blunt trauma bladder
rupture?
a CT cystography is equally efficacious as retrograde cystography.
b Extraperitoneal bladder injuries require surgical repair.
c Lack of gross hematuria rules out a bladder rupture.
d The retrograde cystogram is negative and complete if no extra-
vasation is seen upon bladder filling.
2 The indication for an open repair of a blunt bladder rupture is:
a Extraperitoneal bladder rupture with contrast extravasation
b Extraperitoneal bladder rupture with gross hematuria
c Extraperitoneal bladder rupture with an associated pelvic fracture
d Intraperitoneal bladder rupture with contrast extravasation
3. Answer
1 Correct Answer = d. Explanation: All intraperitoneal bladder rup-
tures require prompt repair to prevent urine ascites and possible
urine peritonitis. Intraperitoneal bladder ruptures do not heal
spontaneously as do extraperitoneal bladder ruptures do with ur-
inary catheter drainage and time.1,3
2 Correct Answer = c. Explanation: Lack of gross hematuria rules out a
bladder rupture. A retrograde cystogram is more sensitive than a CT
cystogram. Extraperitoneal bladder ruptures are treated with a ur-
inary drainage catheter and usually heal spontaneously in 7-10 days.
A retrograde cystogram is not complete until contrast is drained
from the bladder and a plain film obtained shows no extravasa-
tion.1,2
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.visj.2020.100834.
References
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10.4103/iju.IJU_118_19.
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