CT Cystography in the Evaluation of Major Bladder Trauma1
Jonathan P. Vaccaro, MD and
Jeffrey M. Brody, MD
1 From the Department of Diagnostic Imaging, Brown University School of Medicine, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received May 3, 1999; revision requested June 1 and received July 20; accepted July 23. Address correspondence to J.P.V. (e-mail: jvaccaro@lifespan.org).
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Figure 1a. Extraperitoneal rupture in a 76-year-old woman who was involved in a motor vehicle accident. (a) Initial abdominopelvic CT scan obtained without retrograde bladder filling with contrast material demonstrates inadequate distention of the bladder from antegrade filling. Bladder rupture was not diagnosed from this image, although an intravesical clot (open arrow) and extraperitoneal fascial plane thickening (solid arrow) are seen. (b) CT scan obtained 5 hours later with retrograde bladder filling demonstrates extravasated contrast material (arrow), a finding that is diagnostic for extraperitoneal bladder rupture.
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Figure 1b. Extraperitoneal rupture in a 76-year-old woman who was involved in a motor vehicle accident. (a) Initial abdominopelvic CT scan obtained without retrograde bladder filling with contrast material demonstrates inadequate distention of the bladder from antegrade filling. Bladder rupture was not diagnosed from this image, although an intravesical clot (open arrow) and extraperitoneal fascial plane thickening (solid arrow) are seen. (b) CT scan obtained 5 hours later with retrograde bladder filling demonstrates extravasated contrast material (arrow), a finding that is diagnostic for extraperitoneal bladder rupture.
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Figure 2a. Intraperitoneal rupture in a 53-year-old man who was involved in a motor vehicle accident. (a) CT cystogram demonstrates the classic appearance of an intraperitoneal rupture, with extravasated contrast material between loops of small bowel (arrows) and the anterior pararenal fascia (arrowheads). (b) CT cystogram demonstrates heterogeneous attenuation at the bladder dome rupture site (arrow). (c) On a CT cystogram, an intravesical hematoma (arrow) and a small focus of air introduced during bladder filling are seen as filling defects.
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Figure 2b. Intraperitoneal rupture in a 53-year-old man who was involved in a motor vehicle accident. (a) CT cystogram demonstrates the classic appearance of an intraperitoneal rupture, with extravasated contrast material between loops of small bowel (arrows) and the anterior pararenal fascia (arrowheads). (b) CT cystogram demonstrates heterogeneous attenuation at the bladder dome rupture site (arrow). (c) On a CT cystogram, an intravesical hematoma (arrow) and a small focus of air introduced during bladder filling are seen as filling defects.
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Figure 2c. Intraperitoneal rupture in a 53-year-old man who was involved in a motor vehicle accident. (a) CT cystogram demonstrates the classic appearance of an intraperitoneal rupture, with extravasated contrast material between loops of small bowel (arrows) and the anterior pararenal fascia (arrowheads). (b) CT cystogram demonstrates heterogeneous attenuation at the bladder dome rupture site (arrow). (c) On a CT cystogram, an intravesical hematoma (arrow) and a small focus of air introduced during bladder filling are seen as filling defects.
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Figure 3a. Intraperitoneal rupture in a 41-year-old man who was involved in a motor vehicle accident. The patient underwent peritoneal lavage prior to CT cystography. (a) CT cystogram clearly depicts subtle intraperitoneal contrast material between small bowel loops (arrows) despite the presence of lavage fluid. (b) CT cystogram demonstrates intraperitoneal contrast material diluted by peritoneal lavage fluid in the rectovesical recess (curved arrow). Other intraperitoneal collections of lavage fluid with contrast material-fluid levels are also present (straight arrows).
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Figure 3b. Intraperitoneal rupture in a 41-year-old man who was involved in a motor vehicle accident. The patient underwent peritoneal lavage prior to CT cystography. (a) CT cystogram clearly depicts subtle intraperitoneal contrast material between small bowel loops (arrows) despite the presence of lavage fluid. (b) CT cystogram demonstrates intraperitoneal contrast material diluted by peritoneal lavage fluid in the rectovesical recess (curved arrow). Other intraperitoneal collections of lavage fluid with contrast material-fluid levels are also present (straight arrows).
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Figure 4a. Intraperitoneal rupture with subcutaneous contrast material extravasation in a 29-year-old man who sustained multiple pelvic fractures in a motor vehicle accident. (a) CT cystogram shows intraperitoneal contrast material outlining the liver (arrows). (b) CT cystogram demonstrates intraperitoneal contrast material outlining small bowel loops (arrowheads). Extravasation through a tear of the transverse and oblique muscles of the abdominal wall (arrow) without perivesicular extravasation is an unusual variant of intraperitoneal rupture.
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Figure 4b. Intraperitoneal rupture with subcutaneous contrast material extravasation in a 29-year-old man who sustained multiple pelvic fractures in a motor vehicle accident. (a) CT cystogram shows intraperitoneal contrast material outlining the liver (arrows). (b) CT cystogram demonstrates intraperitoneal contrast material outlining small bowel loops (arrowheads). Extravasation through a tear of the transverse and oblique muscles of the abdominal wall (arrow) without perivesicular extravasation is an unusual variant of intraperitoneal rupture.
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Figure 5. Interstitial injury in a 41-year-old man who was involved in a motor vehicle accident. CT cystogram demonstrates focal lenticular thickening of the bladder wall due to interstitial hematoma and likely muscular disruption (black arrow), even though no contrast material is seen delineating the injury. Multiple pelvic fractures are also noted (white arrows).
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Figure 6. Interstitial injury in a 23-year-old woman who sustained a single self-inflicted stab wound to the suprapubic region. The wound was initially thought to be only superficial at clinical examination. CT cystogram demonstrates a focus of intramural contrast material (black arrowhead) immediately posterior to the abdominal wound (white arrowhead) with fluid in the extraperitoneal prevesical space (Retzius space). Although the mechanism of injury would seem to indicate an extraperitoneal rupture, the imaging characteristics are that of an interstitial injury, which responded to conservative treatment with Foley catheter drainage.
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Figure 7. Simple extraperitoneal rupture in a 47-year-old woman who was involved in a motor vehicle accident. CT cystogram demonstrates extravasated contrast material confined to the perivesical space within the extraperitoneal pelvis (arrows). The extravasated contrast material demonstrates the typical "molar tooth" appearance.
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Figure 8. Complex extraperitoneal rupture in a 37-year-old woman who was involved in a motor vehicle accident. CT cystogram shows extravasated contrast material in the thigh due to disruption of the inferior fascia of the urogenital diaphragm (perineal membrane). Contrast material is also seen in the adductor muscles of both legs (solid arrows), in the perivesical space, and bordering the lateral portion of the vagina (open arrow). Fractures of the pubis symphysis and left inferior pubic ramus are also noted (arrowheads).
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Figure 9a. Complex extraperitoneal rupture in a 23-year-old man who was involved in a motor vehicle accident. (a) CT cystogram demonstrates extraperitoneal perivesicular extravasation with the typical molar tooth appearance (solid arrows) (cf Fig 7). There is extension into the rectus abdominis muscle as well as the superficial fatty layer (fascia of Camper) and deeper membranous layer (Scarpa fascia) of the subcutaneous fascia (open arrow). (b, c) CT cystograms (c obtained at a lower level than b) show diastasis of the pubis symphysis (arrowheads in b) with disruption of the urogenital diaphragm, which allows contrast material to extend directly into the deeper membranous subcutaneous fascial planes and along the scrotal sub-dartos fascia (arrows).
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Figure 9b. Complex extraperitoneal rupture in a 23-year-old man who was involved in a motor vehicle accident. (a) CT cystogram demonstrates extraperitoneal perivesicular extravasation with the typical molar tooth appearance (solid arrows) (cf Fig 7). There is extension into the rectus abdominis muscle as well as the superficial fatty layer (fascia of Camper) and deeper membranous layer (Scarpa fascia) of the subcutaneous fascia (open arrow). (b, c) CT cystograms (c obtained at a lower level than b) show diastasis of the pubis symphysis (arrowheads in b) with disruption of the urogenital diaphragm, which allows contrast material to extend directly into the deeper membranous subcutaneous fascial planes and along the scrotal sub-dartos fascia (arrows).
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Figure 9c. Complex extraperitoneal rupture in a 23-year-old man who was involved in a motor vehicle accident. (a) CT cystogram demonstrates extraperitoneal perivesicular extravasation with the typical molar tooth appearance (solid arrows) (cf Fig 7). There is extension into the rectus abdominis muscle as well as the superficial fatty layer (fascia of Camper) and deeper membranous layer (Scarpa fascia) of the subcutaneous fascia (open arrow). (b, c) CT cystograms (c obtained at a lower level than b) show diastasis of the pubis symphysis (arrowheads in b) with disruption of the urogenital diaphragm, which allows contrast material to extend directly into the deeper membranous subcutaneous fascial planes and along the scrotal sub-dartos fascia (arrows).
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Figure 10a. Complex extraperitoneal rupture in a 38-year-old man who was injured in a fall from scaffolding. (a) CT cystogram demonstrates multiple pelvic fractures (arrow), which caused disruption of the superior fascia of the urogenital diaphragm or of the urogenital diaphragm itself and allowed contrast material to extend into the scrotum. (b) On a CT cystogram, contrast material in the scrotum remains contained within the dartos fascia (open arrow) while contrast material has also extended into the left abductor muscles (solid arrow).
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Figure 10b. Complex extraperitoneal rupture in a 38-year-old man who was injured in a fall from scaffolding. (a) CT cystogram demonstrates multiple pelvic fractures (arrow), which caused disruption of the superior fascia of the urogenital diaphragm or of the urogenital diaphragm itself and allowed contrast material to extend into the scrotum. (b) On a CT cystogram, contrast material in the scrotum remains contained within the dartos fascia (open arrow) while contrast material has also extended into the left abductor muscles (solid arrow).
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Figure 11a. Complex extraperitoneal rupture in a 76-year-old man who was struck by an automobile while walking. (a) On a CT cystogram, contrast material is seen in the properitoneal space (extraperitoneal subserous tissue) of the right lower quadrant (arrowheads). This should not be confused with intraperitoneal contrast material. (b) CT cystogram shows perivesical contrast material in the extraperitoneal pelvis (arrows). On other images (not shown), this contrast material was contiguous with properitoneal contrast material (cf a).
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Figure 11b. Complex extraperitoneal rupture in a 76-year-old man who was struck by an automobile while walking. (a) On a CT cystogram, contrast material is seen in the properitoneal space (extraperitoneal subserous tissue) of the right lower quadrant (arrowheads). This should not be confused with intraperitoneal contrast material. (b) CT cystogram shows perivesical contrast material in the extraperitoneal pelvis (arrows). On other images (not shown), this contrast material was contiguous with properitoneal contrast material (cf a).
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Figure 12a. Combined intraperitoneal and extraperitoneal rupture in a 23-year-old man who was involved in a motor vehicle accident. (a) CT cystogram demonstrates free contrast material delineating loops of small bowel, a finding that is characteristic of an intraperitoneal rupture. (b) CT cystogram shows contrast material insinuating itself into the perivesical and perirectal spaces of the extraperitoneal pelvis (straight arrows). Pubic rami fractures are also noted (curved arrow).
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Figure 12b. Combined intraperitoneal and extraperitoneal rupture in a 23-year-old man who was involved in a motor vehicle accident. (a) CT cystogram demonstrates free contrast material delineating loops of small bowel, a finding that is characteristic of an intraperitoneal rupture. (b) CT cystogram shows contrast material insinuating itself into the perivesical and perirectal spaces of the extraperitoneal pelvis (straight arrows). Pubic rami fractures are also noted (curved arrow).
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Copyright © 2000 by the Radiological Society of North America.
