Answer

Cystogram with extra-peritoneal bladder rupture. The cystogram demonstrates extravasation of contrast into the extra-peritoneal space around the bladder. Note the multiple pelvic fractures.

Lower genitourinary trauma

Bladder injuries are most common following blunt trauma and 85% are associated with pelvic fractures. Urethral injury (particularly of the proximal segment) is also usually associated with pelvic fracture and is mainly a male problem. Pelvic pain, inability to void, high riding prostate on PR examination, and haematuria are all clues to urethral or bladder trauma.

Bladder injuries are best classified as either intra-peritoneal (15-35%) or extra-peritoneal (65-85%). Intra-peritoneal rupture is usually caused by a burst injury of the bladder dome in a distended bladder and infrequently by pelvic fractures. Extra-peritoneal injuries are associated with penetration injury from pelvic fractures especially pubic bone fractures (95%).

Imaging investigations should include plain films to diagnose the presence of pelvic fractures and a retrograde urethrogram if urethral injury is suspected. The latter should be performed prior to Foley catheter insertion (if urethral injury is suspected). A retrograde cystogram is a reliable method of assessing the presence of bladder injury.

Fig. 3.31 Bladder trauma. Pelvic fractures should raise the suspicion of bladder trauma. Either delayed CT images or a CT cystogram can be performed.

Fig. 3.32 Intra-peritoneal bladder rupture. Delayed CT imaging demonstrates dense contrast (excreted in the urine) in the peritoneal space. The normal mechanism is a blunt injury to the full bladder which ruptures into the peritoneal space.

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