Tag Archives: bladder

CT Cystography For Bladder Trauma

Bladder injury after blunt trauma is relatively uncommon, but needs to be identified promptly. Nearly every patient (97%+) with a bladder injury will have hematuria that is visible to the naked eye. This should prompt the trauma professional to obtain a CT of the abdomen/pelvis and a CT cystogram.

The CT of the abdomen and pelvis will identify any renal or ureteral (extremely rare!) source for the hematuria. The CT cystogram will demonstrate a bladder injury, but only if done properly!

During most trauma CT scanning of the abdomen and pelvis, the bladder is allowed to passively fill, either by having no urinary catheter and having the patient hold it, or by clamping the catheter if it is present. Unfortunately, this does not provide enough pressure to demonstrate small intraperitoneal bladder injuries and most extraperitoneal injuries.

The proper technique involves infusing contrast into the bladder through a urinary catheter. At least 350cc of dilute contrast solution must be instilled for proper distension and accurate diagnosis. This can be done prior to the abdominal scan. Once the initial scan has been obtained, the bladder must be emptied and a focused scan of just the bladder should be performed (post-void images). Several papers have shown that this technique is as accurate as conventional retrograde cystography, with 100% sensitivity and specificity for intraperitoneal ruptures. The sensitivity for extraperitoneal injury was slightly less at 93%.

Bottom line: Gross hematuria equals CT of the abdomen/pelvis and a proper CT cystogram, as described above. Don’t try to cheat and passively fill the bladder. You will miss about half of these injuries!

Related posts:

Reference: CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. Am J Roentgenol 187(5):1296-302, 2006.

Intraperitoneal bladder injury

Intraperitoneal bladder rupture

Extraperitoneal bladder

Extraperitoneal bladder injury

Compliance With Bladder Injury Guidelines

Management of bladder injury seems straightforward. For many years, the gold standard was the cystogram. But for best results, this study had to be done a certain way. This included bladder instillation, imaging in two planes (AP and lateral), and a post-void view.

As CT scan use became more prevalent, we discovered that diagnosis of bladder injury became even more accurate. However, we also soon discovered that even though the pictures looked very good, some bladder injuries were being missed. It turns out that allowing passive filling of the bladder by clamping the urinary catheter (or not inserting one) missed upwards of 50% of injuries.

So the standard became the “CT cysto” technique. It is performed similar to a non-CT cystogram, by infusing contrast into the bladder under pressure. With this modification, the accuracy of the study approaches 100%. But do we all do it this way? No!

A study from the University of Utah reviewed registry data from all Utah Level I trauma centers over a 15 year period. A total of 124 patients with bladder injuries were identified. Interesting results include:

  • Extraperitoneal rupture was more common (60%) than intraperitoneal (31%) or both (9%)
  • Conventional CT was used in 56%, and cysto or CT cysto in 24%. The remainder were found in OR.
  • Initial imaging missed or incorrectly diagnosed this injury in 13% of patients! Nine of these used the wrong study (conventional CT), but 4 of these missed occurred using the recommended one.
  • Overall compliance with using the recommended study was only 44%

Bottom line: Compliance in this 15 year study was low. Unfortunately, they lumped conventional cystogram with CT cysto. These days, fewer conventional studies are performed and the error rate may be higher. However, current day compliance is still low in my experience. A bladder evaluation guideline should be developed and disseminated to emergency physicians, surgeons and radiologists (see the CT cysto link below). This is the only way we’ll be able to decrease the number of missed injuries for this problem.

Related posts:

Reference: Process improvement in trauma: traumatic bladder injuries and compliance with recommended imaging. J Trauma 74(1):264-269, 2013.

CT Cystography For Bladder Trauma

Bladder injury after blunt trauma is relatively uncommon, but needs to be identified promptly. Nearly every patient (97%+) with a bladder injury will have hematuria that is visible to the naked eye. This should prompt the trauma professional to obtain a CT of the abdomen/pelvis and a CT cystogram.

The CT of the abdomen and pelvis will identify any renal or ureteral (extremely rare!) source for the hematuria. The CT cystogram will demonstrate a bladder injury, but only if done properly!

During most trauma CT scanning of the abdomen and pelvis, the bladder is allowed to passively fill, either by having no urinary catheter and having the patient hold it, or by clamping the catheter if it is present. Unfortunately, this does not provide enough pressure to demonstrate small intraperitoneal bladder injuries and most extraperitoneal injuries.

The proper technique involves infusing contrast into the bladder through a urinary catheter. At least 350cc of dilute contrast solution must be instilled for proper distension and accurate diagnosis. This can be done prior to the abdominal scan. Once the initial scan has been obtained, the bladder must be emptied and a focused scan of just the bladder should be performed (post-void images). Several papers have shown that this technique is as accurate as conventional retrograde cystography, with 100% sensitivity and specificity for intraperitoneal ruptures. The sensitivity for extraperitoneal injury was slightly less at 93%.

Bottom line: Gross hematuria equals CT of the abdomen/pelvis and a proper CT cystogram, as described above. Don’t try to cheat and passively fill the bladder. You will miss about half of these injuries!

Related posts:

Reference: CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. Am J Roentgenol 187(5):1296-302, 2006.

Intraperitoneal bladder injury

Intraperitoneal bladder rupture

Extraperitoneal bladder

Extraperitoneal bladder injury

Followup Cystogram After Bladder Injury

I’ve previously written about management of extraperitoneal bladder injuries. One of the tenets is that every injury needs to have a routine followup cystogram to ensure healing and allow removal of any bladder catheter. I routinely like to question dogma, so I asked myself, is this really necessary? A retrospective registry review from the Ryder trauma center in Miami helped to answer this question.

Over 20,000 records were screened for bladder injury and 87 were found in living patients. Fifty were intraperitoneal injuries, and half of them were caused by pelvic fractures (interesting). All were operated on, and 47 were classified as simple (dome disruption or through and through penetrating) and 3 were “complex” (involving trigone). All trackable patients (42 of the 50) had followup cystograms 9-16 days later. All of the simple injuries had a normal followup exam, but a leak was detected on one of the complex injuries.

There were 42 patients with extraperitoneal bladder injuries. All were due to blunt trauma, and 92% were associated with pelvic fractures. Most were found with CT cystogram. Two patients had operative repair, probably due to the need to fix the pubic bones with hardware. 37 of the 42 were available for followup, and 22% of repeat cystograms were positive (average study done on day 9). In the studies that showed a leak, repeat cystograms were done, and they took an average of 47 days to fully heal.

Bottom line: Patients with extraperitoneal or complex intraperitoneal bladder injuries (trigone) really do need a followup cystogram before removing the bladder catheter. Those who underwent a simple repair of their intraperitoneal injury do not.

Related posts:

Reference: Cystogram follow-up in the management of traumatic bladder disruption. J Trauma 60(1):23-28, 2006.

Extraperitoneal Bladder Rupture

This injury is likely to occur in patients who have a full bladder and sustain anterior pelvic trauma that typically leads to fractures. They generally present with gross hematuria upon placement of the bladder catheter. This should prompt an abdominal CT scan with cystogram technique.

CT cystogram involves pressurizing the bladder with contrast prior to the study. This differs from the usual method of clamping the catheter and allowing the bladder to passively fill. The literature here is clear: failure to use cysto technique will miss 50% of these injuries.

The majority of extraperitoneal bladder injuries can be treated nonoperatively, and probably do not need Urology involvement. The bladder catheter is left in place 10-14 days (we do 10 days), and a repeat cystogram is obtained. If there is no leak, the catheter can be removed. If there is still some leakage, Urology consultation should then be obtained. 

There are a few cases where operative management is required:

  • There is some intraperitoneal component of bladder injury
  • Fixation of the pubic rami is required (bathing the orthopedic hardware with urine is frowned upon)
  • Failure of conservative management

Arrows in the photo show extraperitoneal extravasation of cystogram contrast.

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