CT cystography in the evaluation of major bladder trauma

Hidden dangers of pelvic fracture: A meta-analysis on urinary tract injury incidence and risk factors

BACKGROUND

Pelvic fractures are often associated with significant morbidity, including injuries to the urinary tract. Understanding the incidence and risk factors for urinary tract injury in these patients is crucial for prompt diagnosis and management. This meta-analysis aims to synthesize existing evidence to determine the overall incidence and identify specific risk factors associated with urinary tract injuries in patients with pelvic fractures.

AIM

To determine the incidence and risk factors for urinary tract injuries in patients with pelvic fractures.

METHODS

A systematic search of PubMed, EMBASE, Scopus, and the Cochrane Library was conducted without date restrictions. Studies examining the incidence and risk factors of urinary tract injuries in patients with pelvic fractures were included. Data extracted included demographics, injury mechanism, pelvic fracture type, urinary tract injury incidence, mortality, and discharge disposition. Review Manager 5.4 was used for data analysis.

RESULTS

Ten studies comprising 22700 patients were included. The pooled incidence of urinary tract injury associated with pelvic fracture was 6.88% (95%CI: 6.20%-7.55%). Vehicle, motorcycle, and pedestrian accidents were identified as risk factors for urinary tract injury, with relative risks (RR) of 1.08 (95%CI: 1.06-1.11), 1.89 (95%CI: 1.78-2.00), and 1.53 (95%CI: 1.20-1.95), respectively. Pubic fracture and pelvic ring disruption were significantly associated with urinary tract injury [odds ratio (OR) 1.94, 95%CI: 1.09-3.44 and OR 5.53, 95%CI: 4.67-6.54, respectively)]. Patients without urinary tract injury were more likely to be discharged home (RR 0.79, 95%CI: 0.67-0.92). Mortality was higher in patients with urinary tract injury (OR 1.92, 95%CI: 1.77-2.09).

CONCLUSION

Urinary tract injury occurs in nearly 7% of patients with pelvic fractures. Motorcycle accidents, pubic fractures, and pelvic ring disruptions are significant risk factors. Urinary tract injury following pelvic fracture is associated with increased mortality.

Imaging findings of traumatic injuries in survivors of the 6 February 2023 earthquake in Turkey

In the southeastern part of Turkey, two earthquakes measuring 7.7 and 7.8 on the Richter scale occurred within 9 h on 6 February 2023, causing 120,000 injuries and over 50,000 deaths. Evacuees were transferred to various secondary and tertiary hospitals as the health system and hospitals in the affected region were affected by the earthquake. Injuries were mostly caused by blunt trauma and/or prolonged bruising under rubble. The severity and pattern of traumatic injuries in earthquake victims differed from other trauma patients who were not affected by an earthquake. In addition to traumatic injuries that affected multiple body regions and systems, patients who were trapped under debris for long periods of time were also frequently found to have crush syndrome. Pulmonary thromboembolism and hypoxic-ischaemic brain injury were observed in some patients. In this review, we present the imaging findings of traumatic injuries in earthquake victims, emphasising the earthquake-related distinct injury types.

Manifestation of Spontaneous Rupture of the Urinary Bladder in Pregnancy: A Systematic Review of the Literature

Spontaneous rupture of the urinary bladder (SRUB) during pregnancy is a potentially fatal event that necessitates immediate surgery. The aim of this systematic review is to determine the symptoms, causes, associated factors, and prognosis of SRUB in pregnancy. We searched the literature from inception until December 2022 using the Cochrane Central Register, PubMed, EMBASE, ProQuest, Scopus, and Google Scholar. Articles not in English and those unrelated to the topic were excluded. The JBI Critical Appraisal Checklist for case reports was employed for the risk of bias assessment. The search strategy yielded 312 citations; 29 full-text articles were evaluated for eligibility after screening. Five case reports were included in this review. The age range of the cases was 27-39 years. Four cases were in their second trimester of pregnancy, and one was in her third. Two cases had undergone previous cesarean sections, and one had an appendectomy and salpingectomy due to an ectopic pregnancy. One case reported a history of alcohol and drug abuse. The most common symptoms were abdominal pain, abdominal distension, oliguria, voiding difficulty, hematuria, fever, and vomiting. The diagnosis of SRUB was primarily made via emergency laparotomy due to the patients' critical conditions. Beyond its diagnostic role, laparotomy was also the treatment method in all cases. Tear repair, antibiotic therapy, and urinary catheterization were all integral parts of the treatment. Four cases resulted in an uneventful pregnancy and a healthy, full-term baby. In one case, a hysterectomy was performed due to a combined uterus and bladder rupture. SRUB often presents with non-specific symptoms, leading to a delayed diagnosis. A high index of suspicion is essential when a pregnant woman exhibits urinary symptoms and severe abdominal pain, especially in those with a history of previous surgery. Early detection and treatment of SRUB are critical for an uneventful recovery.

Endovascular Management of Extra-Peritoneal Hematoma Secondary to Bladder Catheterization

Bladder rupture related to Foley catheter insertion is a rare condition mainly reported in patients with chronic bladder disease. In the present case, this rare condition was associated with massive hematoma due to active arterial bleeding, which was treated by embolization. We present the case of a 38-year-old woman admitted to the gastroenterology department with decompensated alcoholic liver cirrhosis, anemia, malnutrition, and diabetes. Six days after admission, she presented with hypotension and tachycardia associated with gross hematuria. An abdominal computed tomography scan revealed a Foley catheterization-related bladder perforation and a massive extra-peritoneal hematoma caused by active arterial bleeding from a distal branch of the right vesical artery. A successful embolization was performed with microparticles and coiled with complete hemorrhage control on post-procedure imaging. The bladder perforation was treated conservatively with a urinary drainage catheter, irrigation, and antibiotics. Despite these measures, the patient died 15 days later due to liver failure and sepsis. Our case highlights that commonly performed simple procedures can lead to severe complications, especially in frail patients.

The use of agitated saline as contrast agent in a contrast-enhanced cystosonography for detection of urinary bladder rupture in animal cadavers

OBJECTIVE

To determine the value of microbubble contrast cystosonography in the diagnosis of bladder rupture in animals.

DESIGN

Prospective, method comparison study from November 2019 to October 2020.

SETTING

University teaching hospital.

ANIMALS

Thirty-four ethically sourced cadavers of dogs, rats, and rabbits.

INTERVENTIONS

In a prospective and blinded study, the cadavers were divided into 2 randomized groups: with bladder rupture (CR), and without bladder rupture (SR). Urinary catheterization was performed in all cadavers. Through the urethral catheter, bladders in CR group were ruptured using a rigid stainless steel guide wire. Microbubble contrast was infused into the bladder through the urethral catheter, while a single, blinded observer sonographically assessed the bladder. The time to diagnosis and the number of attempts needed for diagnosis were recorded.

MEASUREMENTS AND MAIN RESULTS

The study included cadavers of 16 female Wistar rats, 6 female dogs, 11 male dogs, and 1 male rabbit. Time to diagnosis in dogs (2.25 ± 0.91 min) was statistically higher when compared to rats (1.15 ± 0.75 min; P = 0.03). Of the 34 cases, incorrect diagnosis of bladder rupture was made in only 2 dogs (6%), indicating a diagnostic sensitivity of 88.88%, specificity of 100%, and an accuracy of 94%. The positive predictive value was 1 and the negative predictive value was 0.9.

CONCLUSIONS

Our study showed that the described method is accurate, sensitive, and specific for the detection of bladder rupture in animal cadavers of different species, size, and sex.

Non-osseous considerations in diagnostic imaging for pelvic and acetabular trauma

High-quality imaging is crucial for orthopedic traumatologists in the evaluation and management of pelvic and acetabular fractures. Computed tomography (CT) plays an essential role in the diagnosis and treatment of patients with these complex injuries. A thoughtful evaluation of associated soft tissues can reveal additional details about the patient and their injury that may impact treatment. This review aims to highlight soft tissue findings that should be identified when evaluating the initial diagnostic imaging after pelvic and acetabular trauma.

Pseudo-Renal Failure in the Context of Traumatic Bladder Rupture

The bladder is both an intraperitoneal and extraperitoneal structure. Its anatomical position increases its risk of rupture. The resultant urine leak or extravasation can be intraperitoneal, extraperitoneal, or even both-with the former leading to more sinister outcomes. Intraperitoneal bladder rupture can lead to urinary ascites which along with anuria and abdominal pain, can present with an apparent abrupt decline in renal function as the creatinine-rich products diffuse across the peritoneal membrane. Glomerular filtration rate, a measure of kidney function is related to the levels of serum creatinine. Clinicians can therefore misdiagnose their patient with acute kidney injury when the serum creatinine is elevated as a consequence of urine being present in the peritoneal space.  This is a case report of a 62-year-old male with pseudo-renal failure following intraperitoneal bladder rupture after a fall face-forwards three hours previously. The fall was due to icy conditions outside and no preceding symptoms were reported. He presented to the Accident and Emergency department with abdominal pain and no other positive symptoms. The patient had a good World Health Organisation (WHO) performance status with a background of hypertension, diabetes, and hypercholesterolemia. The bedside examination of the patient revealed a distended, abdomen with peritonitis. There were no signs of urogenital trauma. Blood testing revealed a low estimated glomerular filtration rate (eGFR) and raised creatinine (eGFR of 7 millilitres/minute and creatinine of 658 micromoles/litre). Computerised tomography examination of the abdomen and pelvis (CTAP) revealed free fluid within the peritoneal cavity and an irregular bladder wall. A CT cystogram and consultation with urology led to the diagnosis of intraperitoneal bladder rupture. The patient's renal function from an initial set of blood tests was reduced. This was not a true impairment in renal function but rather a complication secondary to extravasation of urine in the intraperitoneal space, ie., pseudo renal failure. This supposed impairment in renal function had numerous implications. It affected the choice of antibiotics; amoxicillin and gentamicin were given at a reduced dose due to the patient's renal function and the patient was prepared for operation theatre. The patient's blood creatinine was falsely elevated at 658 micromoles/litre due to the diffusion of creatinine from the free urine in the peritoneal space into the blood. This painted a false image of renal failure and protracted the clinical decision-making process. Relatively simple measures like an ascitic tap could have helped to differentiate this from a true acute kidney injury and could have resulted in quicker and more effective treatment of this patient.  The patient went on to have bladder repair under urology. His follow-up cystogram four weeks post-operation did not show any leak.

Intraperitoneal Rupture of the Urinary Bladder Mimics an Intra-Abdominal Hemorrhage: A Case Report

Hemorrhagic shock due to polytrauma is a life-threatening condition, requiring immediate diagnosis of the bleeding site and determination of an appropriate hemostatic procedure. Intra-abdominal injuries and pelvic fractures are major causes of massive hemorrhage, although the appropriate hemostatic procedures are different for each injury. We present a case of intraperitoneal rupture of the urinary bladder associated with pelvic fracture, in which urine extravasation into peritoneal spaces mimics intra-abdominal hemorrhage. A 33-year-old man with a known case of schizophrenia attempted suicide by jumping down from the 4th floor of his apartment (approximately 10 meters in height). He was in a state of shock on arrival. Focused assessment with sonography for trauma (FAST) showed fluid collection around his spleen only but not the perivesical space. Pelvic X-ray showed multiple pelvic fractures. We suspected the patient was in a state of hemorrhagic shock due to intra-abdominal hemorrhage and pelvic fracture. The patient's hemodynamic status did not respond to massive fluid infusion and blood transfusion, including eight units of packed RBCs transfusion. Resuscitative endovascular balloon occlusion of the aorta was performed; however, the patient's hemodynamic status did not recover. We performed an emergency laparotomy to control the suspected intra-abdominal hemorrhage. In peritoneal space, we found a large amount of non-bloody fluid. The liver, spleen, and bowels were not injured, whereas the urinary bladder was ruptured, indicating the correct diagnosis was intraperitoneal rupture of the urinary bladder associated with pelvic fracture. The ruptured urinary bladder wall was sutured, and temporary abdominal closure was performed. A contrast-enhanced CT performed after the laparotomy showed massive hemorrhage around the pelvic fracture. After arrival at the angiography room, the patient became bradycardia, and the pulsation at the carotid artery was not palpable. We performed cardiopulmonary resuscitation; however, the patient died eventually. Intraperitoneal rupture of the urinary bladder would mimic an intra-abdominal hemorrhage. Therefore, a comprehensive diagnostic-treatment approach such as a hybrid ER system would be beneficial for early and accurate diagnosis.

A 12-year experience in the management of traumatic bladder rupture at an Australian level 1 trauma centre

Objective:

To review the contemporary bladder trauma epidemiology, diagnosis and management over a 12-year period at a level 1 trauma centre in Australia.

Patients and Methods:

From July 2001 through June 2013, 97 multi-trauma patients at a level 1 trauma centre in Australia were identified to have sustained bladder rupture. Data on demographics, clinical presentation, diagnosis, management and complications were extracted from the TraumaNET database, medical records and health-coding database.

Results:

Of the 97 patients, 98% of bladder ruptures resulted from blunt trauma mostly from road accidents. There was a male preponderance of 64%. Intra-peritoneal bladder rupture (51%) was the most common type of injury followed by extra-peritoneal bladder ruptures (42%) and combined intra- and extra-peritoneal bladder ruptures (7%). Concomitant pelvic fractures occurred in 78% of patients and concurrent intra-abdominal injuries in 68%. Initial imaging missed 28% of bladder ruptures, with computed tomography with intravenous contrast missing 65% of bladder ruptures. The majority of intra-peritoneal bladder ruptures and 56% of extra-peritoneal bladder ruptures were repaired surgically, with 83% of repairs performed in conjunction with another surgical procedure. The in-hospital mortality rate was 9%, and all deaths were due to concomitant injuries.

Conclusion:

Traumatic bladder rupture is associated with a 9% mortality rate due to the frequently associated significant concurrent injuries. Computed tomography cystogram or plain cystogram is the imaging modality of choice in diagnosing bladder rupture. Intra-peritoneal bladder ruptures should be repaired surgically, while extra-peritoneal bladder ruptures can be treated conservatively in selected patients. The timing of surgical repair should be coordinated with other specialties.

Level of evidence:

4

Imaging Review of Pelvic Ring Fractures and Its Complications in High-Energy Trauma

Pelvic ring fractures are common in high-energy blunt trauma, especially in traffic accidents. These types of injuries have a high rate of morbidity and mortality, due to the common instability of the fractures, and the associated intrapelvic vascular and visceral complications. Computed tomography (CT) is the gold standard technique in the evaluation of pelvic trauma because it can quickly and accurately identify pelvic ring fractures, intrapelvic active bleeding, and lesions of other body systems. To properly guide the multidisciplinary management of the polytrauma patient, a classification criterion is mandatory. In this review, we decided to focus on the Young and Burgess classification, because it combines the mechanism and the stability of the fractures, helping to accurately identify injuries and related complications.

Spontaneous Rupture of Urinary Bladder: Two Case Reports and Review of Literature

Objectives: Spontaneous rupture of the urinary bladder (SRUB) is extremely rare and might be misdiagnosed, leading to a high mortality rate. The current study aimed to identify the cause, clinical features, and diagnosis strategy of SRUB. Methodology: We presented a case report for two women (79 and 63 years old) misdiagnosed with acute abdomen and acute kidney injury, respectively, who were finally confirmed to have SRUB by a series of investigations and exploratory surgery. Meanwhile, literature from multiple databases was reviewed. PubMed, the Chinese National Knowledge Infrastructure (CNKI), the Chinese Biological Medical Literature Database (CBM), WANFANG DATA, and the Chongqing VIP database for Chinese Technical Periodicals (VIP) were searched with the keywords "spontaneous bladder rupture" or "spontaneous rupture of bladder" or "spontaneous rupture of urinary bladder." All statistical analyses were conducted using SPSS 20.0 software. Results: A total of 137 Chinese and 182 English literature papers were included in this article review. A total of 713 SRUB patients were analyzed, including the two patients reported by us. The most common cause of SRUB was alcohol intoxication, lower urinary tract obstruction, bladder tumor or inflammation, pregnancy-related causes, bladder dysfunction, pelvic radiotherapy, and history of bladder surgery or bladder diverticulum. Most cases were diagnosed by exploratory laparotomy and CT cystography. Patients with extraperitoneal rupture could present with abdominal pain, abdominal distention, dysuria, oliguria or anuria, and fever. While the main symptoms of intraperitoneal rupture patients could be various and non-specific. The common misdiagnoses include acute abdomen, inflammatory digestive disease, bladder tumor or inflammation, and renal failure. Most of the patients (84.57%) were treated by open surgical repair, and most of them were intraperitoneal rupture patients. Overall, 1.12% of patients were treated by laparoscopic surgery, and all of them were intraperitoneal rupture patients. Besides, 17 intraperitoneal rupture patients and 6 extraperitoneal rupture patients were treated by indwelling catheterization and antibiotic therapy. Nine patients died of delayed diagnosis and treatment. Conclusions: SRUB often presents with various and non-specific symptoms, which results in misdiagnosis or delayed treatment. Medical staff noticing abdominal pain suggestive of peritonitis with urinary symptoms should be suspicious of bladder rupture, especially in patients with a history of bladder disease. CT cystography can be the best preoperative non-invasive examination tool for both diagnosis and evaluation. Conservative management in the form of urine drainage and antibiotic therapy can be used in patients without severe infection, bleeding, or major injury. Otherwise, surgical treatment is recommended. Early diagnosis and management of SRUB are crucial for an uneventful recovery.

A case of traumatic rupture of the urinary bladder due to a fall from a chair-style ski lift

We report our experience with an 8-year-old boy who incurred a traumatic rupture of the urinary bladder due to a fall from a chair-type ski lift. This boy felt like he needed to urinate before getting on the lift, but he did not do so. He was trembling from the sensation of needing to urinate and fell from the lift while it was at least 6 m in the air. He complained of abdominal pain, and on-site emergency physicians performed focused assessment with sonography for trauma, which showed fluid in the abdomen. He subsequently developed abdominal guarding. Enhanced abdominal computed tomography revealed a rupture of the urinary bladder. At laparotomy, two ruptures were seen along the dome of the bladder; the bladder wall was repaired in three layers. The patient was discharged with a cast on his foot for a fracture of the left heel bone on postoperative day 16.

Imaging spectrum of traumatic urinary bladder and urethral injuries

Urinary bladder and urethral injuries usually occur as part of multiple injuries in polytrauma patients. These injuries are easily overlooked because the initial evaluation is focused on other life-threatening injuries such as traumatic brain injury, hemopneumothorax or hemoperitoneum. Although the urinary bladder and urethral injuries are not life-threatening, they pose the risk of long-term morbidity which can be burdensome. These complications include urinary incontinence, voiding dysfunction, urethrocutaneous fistula, urethral stricture and erectile dysfunction. Computed tomography (CT) findings of urinary bladder and urethral injuries are usually subtle. Retrograde fluoroscopic/CT cystography and urethrography remain the mainstay imaging techniques for complete evaluation, diagnosis, staging, and follow-up of these traumatic injuries. In this review, we discuss the pathophysiology and imaging spectrum of urinary bladder and urethral injuries with an emphasis on the classification schemes. Familiarity with the pelvic anatomy and the injury pattern leads to the prompt diagnosis, accurate classification and appropriate management, which have been associated with better prognosis.

A kaleidoscopic view of male urethral pathologies on 64-slice multidetector computed tomographic urethrography: A novel technique

Pathologies of the male urethra are mostly obstructive in nature and require imaging to delineate the lesion type, site, extent and associated abnormality of the urinary bladder. Contrast urethrography (CU) is the gold standard investigation for urethral assessment but has many limitations. Cross-sectional imaging is infrequently used for the evaluation of the urethra but has been gaining importance recently. Multidetector computed tomographic urethrography (MDCTU) has the capability of evaluating the entire length of a male urethra in a single setting and overcomes many technical and patient limitations of CU. Being a novel technique, most radiologists are not familiar with MDCTU and the imaging spectrum of various urethral and bladder pathologies. This pictorial review attempts to present the imaging appearance of the normal male urethra and spectrum of pathological findings, with highlights on its advantages over the CU technique.

A Pictorial Review of Postpartum Complications

The postpartum period, also known as the puerperium, begins immediately after delivery of the neonate and placenta and ends 6-8 weeks after delivery. The appearance of physiologic uterine changes during puerperium can overlap with that of postpartum complications, which makes imaging interpretation and diagnosis difficult. Obstetric and nonobstetric postpartum complications are a considerable source of morbidity and mortality in women of reproductive age, and the radiologist plays an important role in the assessment of these entities, which often require a multimodality imaging approach. US and contrast material-enhanced CT are the techniques of choice in the emergency department, and they can show characteristic radiologic findings that enable differentiation between normal and abnormal features to help radiologists and emergency department practitioners to reach a correct diagnosis and provide timely treatment. The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery-related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy). The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Multidetector CT in Vascular Injuries Resulting from Pelvic Fractures: A Primer for Diagnostic Radiologists

Pelvic vascular injuries are typically caused by high-energy trauma. The majority of these injuries are caused by motor vehicle collisions, and the rest are caused by falls and industrial or crush injuries. Pelvic vascular injuries are frequently associated with pelvic ring disruption and have a high mortality rate due to shock as a result of pelvic bleeding. Morbidity and mortality resulting from pelvic vascular injury are due to pelvic hemorrhage and resultant exsanguination, which is potentially treatable and reversible if it is diagnosed early with multidetector CT and treated promptly. The pelvic bleeding source can be arterial, venous, or osseous, and differentiating an arterial (high-pressure) bleed from a venous-osseous (low-pressure) bleed is of paramount importance in stratification for treatment. Low-pressure venous and osseous bleeds are initially treated with a pelvic binder or external fixation, while high-pressure arterial bleeds require angioembolization or surgical pelvic packing. Definitive treatment of the pelvic ring disruption includes open or closed reduction and internal fixation. Multidetector CT is important in the trauma setting to assess and characterize pelvic vascular injuries with multiphasic acquisition in the arterial and venous phases, which allows differentiation of the common vascular injury patterns. This article reviews the anatomy of the pelvic vessels and the pelvic vascular territory; discusses the multidetector CT protocols used in diagnosis and characterization of pelvic vascular injury; and describes the spectrum of pelvic vascular injuries, the differentiation of common injury patterns, mimics, and imaging pitfalls. Online supplemental material is available for this article. ^©RSNA, 2019 See discussion on this article by Dreizin.

Cross-sectional anatomy of the male pelvis

The visceral organs of the male pelvis have complex anatomic relationships with the surrounding extraperitoneal spaces, supplying arteries and adjacent pelvic musculature. Since various neoplastic, vascular, and traumatic pathologies can often involve multiple organs and spread into adjacent pelvic spaces, a keen understanding of this intricate anatomy can help radiologists to accurately characterize findings and improve recognition of the routes in which these conditions can spread. The purpose of this review is to examine the relationships between the anatomic compartments of the pelvic extraperitoneal space, summarize the pelvic arterial anatomy, and identify the pelvic muscles that support normal genitourinary function.

Lower Urinary Tract Injuries: A Guide for the Emergency Radiologist

Traumatic lower urinary tract injuries are uncommon and mainly occur in patients with severe trauma and multiple abdominopelvic injuries. In the presence of other substantial injuries, bladder and urethral injuries may be overlooked and cause significant morbidity and mortality. Therefore, it is important that radiologists are familiar with mechanisms and injuries that are high risk for bladder and urethral trauma. We review the imaging findings associated with these injuries and the appropriate modalities and techniques to further evaluate the patient and accurately diagnose these injuries. Computed tomography cystography and conventional retrograde urethrography are effective tools in identifying injuries to the lower urinary tract and play a crucial role in patient care and prognosis.

Computed tomography (CT) in the evaluation of bladder and ureteral trauma: indications, technique, and diagnosis

INTRODUCTION

Trauma to the genitourinary system includes blunt and penetrating injuries to bladder and ureters. These are rare injuries and are overlooked as other abdominal and pelvic injuries often take priority. Delayed diagnosis can lead to significant morbidity and mortality. Computed tomography has taken a central role in the imaging of the ureters and bladder.

METHODS

This article reviews the anatomic relationships, mechanisms of injury, and clinical presentation to help physicians determine when bladder and ureteral injuries should be suspected and further imaging should be pursued. Radiologic evaluation of bladder and ureteral injury with CT cystography and CT urography, respectively, will be reviewed.

CONCLUSION

CT cystography and CT urography are effective tools in identifying potentially serious injuries to the genitourinary system. Timely recognition of these injuries can be crucial for the overall management and prognosis.

MDCT Imaging of Acute Bladder Pathology

In this review, we will discuss and illustrate the pathophysiology, presentation, and multidetector computed tomography findings associated with emergent bladder conditions, limiting our discussion to traumatic, infectious, and obstructive etiologies. After reviewing computed tomography cystographic technique, the commonly utilized classification systems for bladder trauma will be presented with illustrative examples of associated typical and more infrequent secondary injuries and complications. Next, the pathogenesis and imaging appearance of both mechanical and neurogenic acute urinary retention will be addressed, including less common though potentially pathognomonic obstructive etiologies including urethral calculi and ectopic ureteroceles. Finally, we will review and illustrate the imaging features of both inflammatory and infectious cystitis, including hemorrhagic and emphysematous variants, as well as the potentially encountered secondary complications.

Successful Conservative Treatment of Traumatic Intraperitoneal Bladder Rupture in a Child: A Case Report

The urinary bladder is protected by the pelvic bones and hence is a site less susceptible to external force injury than other organs. As children’s bones are not fully developed, the risk of bladder injury by external force is greater in children than adults. Pelvic fractures often cause the bladder to rupture, as do strong external forces when the bladder is filled. Bladder rupture is categorized as extraperitoneal or intraperitoneal, and treatments differ between the two. Extraperitoneal injury usually heals after drainage alone, whereas intraperitoneal injury usually requires surgical intervention such as a combination of surgical repairs and drainage. Herein, we report a pediatric case of intraperitoneal bladder rupture successfully treated without surgical repair (i.e., with drainage via an intraperitoneal tube and a urethral catheter only). Our report suggests that nonoperative treatment is an option for pediatric patients with intraperitoneal bladder rupture if certain conditions are met.

Management of blunt intraperitoneal bladder rupture: Case report and literature review

INTRODUCTION

Urinary bladder ruptures are an uncommon injury, occurring in less than 1% of all blunt abdominal trauma. Extraperitoneal bladder ruptures are generally associated with pelvic fractures and usually managed nonoperatively. Conversely, intraperitoneal injuries are often caused by large compressive and shear forces produced during seatbelt injuries and almost invariably require surgical intervention.

PRESENTATION OF CASE

A 29-year-old woman presented as a trauma alert after a motor vehicle collision with abdominal/flank pain and gross hematuria. Free intraperitoneal fluid was found on ultrasound and CT imaging. Exploratory laparotomy located an intraperitoneal rupture across the bladder dome. The patient recovered without complications, was discharged on postoperative day three, and continued bladder catheter care at home for an additional week until outpatient follow up and catheter removal.

DISCUSSION

As evidence for surgical management of bladder trauma continues to grow, clinical practice guidelines have been developed for trauma surgeons. Recent recommendations from the Eastern Association for the Surgery of Trauma appraise the evidence for cystography in the perioperative setting. Postoperative care is focused on preventing catheter-associated urinary tract infections in patients recovering from urotrauma in the critical care setting.

CONCLUSION

We present a case of intraperitoneal bladder rupture in the setting of a blunt traumatic seatbelt injury. Our patient recovered uneventfully after surgical repair, a three-day hospitalization, and ten days with an indwelling bladder catheter.

Autosomal dominant polycystic kidney disease and minimal trauma: medical review and case report

Background

Blunt abdominal trauma in the setting of polycystic kidney disease is still scantly described in the literature and management guidelines of such patients are not well-established.

Case presentation

The authors herein present a case of hypovolemic shock secondary to segmental renal artery bleed in a 75-year-old man with polycystic kidney disease after minimal blunt abdominal trauma, who underwent successful selective arterial embolization, and provide a thorough review of similar cases in the literature, while shedding the light on important considerations when dealing with such patients.

Conclusions

It is important to suspect renal injury in patients with pre-existing renal lesions irrespective of the mechanism of injury; and, vice-versa to suspect an underlying abnormality in patients with a clinical deterioration that’s out of proportion to the mechanism of injury.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0192-3) contains supplementary material, which is available to authorized users.

Trauma radiology in the UK: an overview

NHS Choices defines ‘major trauma’ as multiple, serious injuries that could result in disability or death. Worldwide, trauma is the leading cause of death and disability in people under 40 years of age. The National Audit Office estimates that there are at least 20 000 major trauma cases in England every year, resulting in 5400 deaths and leaving many others with serious permanent disability. Because the incidence of trauma is particularly high in younger patients, an average of 36 life years is lost for every trauma death ( Chaira and Cimbanassi, 2003 ).

The landscape in major trauma imaging has evolved over the last 30 years, and this review chronicles these changes and the reasons for them, and looks at how the current guidelines have been formulated.

Imaging after treatment in uterine malignancies: Spectrum of normal findings and most common complications

Uterine malignancies account for the majority of gynaecologic cancers. Different treatment options are available depending on histology, disease grade and stage. Hysterectomy is the most frequent surgical procedure. Chemotherapy and radiation therapy (CRT) represents the preferred therapeutic choice for locally advanced uterine and cervical malignancies. Imaging of the female pelvis following these treatments is particularly challenging due to alteration of the normal anatomy. Radiologists should be familiar with both the expected post-treatment imaging findings and the imaging features of possible complications to make the correct interpretation and avoid possible pitfalls. The purpose of this review is to show the expected computed tomography (CT) and Magnetic Resonance Imaging (MRI) appearances of the female pelvis following surgery and CRT for uterine and cervical cancer, to illustrate the imaging findings of early and delayed most common complications after surgery and CRT, describing the suitable imaging modalities and protocols for evaluation of patients treated for gynaecologic malignancies.

Imaging Genitourinary Trauma

Contrast-enhanced multidetector computed tomography (MDCT) has become a critical tool in the evaluation of the trauma patient. MDCT can quickly and accurately assess trauma patients for renal, ureteral, and bladder injuries. Moreover, CT guides clinical management triaging patients to those requiring discharge, observation, angioembolization, and surgery. Recognition of urinary tract trauma on initial scan acquisition should prompt delayed excretory phase imaging to identify urine leaks. Urethral and testicular trauma are imaged with retrograde urethrography and sonography, respectively.

Errors in imaging of traumatic injuries

The advent of multi-detector computed tomography (MDCT) has drastically improved the outcomes of patients with multiple traumatic injuries. However, there are still diagnostic challenges to be considered. A missed or the delay of a diagnosis in trauma patients can sometimes be related to perception or other non-visual cues, while other errors are due to poor technique or poor image quality. In order to avoid any serious complications, it is important for the practicing radiologist to be cognizant of some of the most common types of errors. The objective of this article is to review the various types of errors in the evaluation of patients with multiple trauma injuries or polytrauma with MDCT.

Genitourinary Considerations in Reoperative and Complex Colorectal Surgery

Genitourinary structures are at risk of injury during colorectal surgery. The incidence of injury is low; however, the risk is higher in cases involving severe inflammatory or infectious processes, locally advanced or recurrent cancer, previous radiation, and reoperation. Consideration of the anatomical relationship between the genitourinary system, and the colon and rectum is crucial to avoid injuries. Intraoperative diagnostic techniques such as intravenous pyelogram (IVP), fluoroscopic cystogram, or retrograde urethrogram can aid in identifying suspected injuries. Early recognition and repair of injuries decrease the morbidity of an injury. Repair of injuries depends on the location and extent of the injury. Simple injuries may be repaired primarily, while complex injuries may require more advanced repairs such as a flap reconstruction.

Diagnostic imaging of blunt abdominal trauma in pediatric patients

Trauma is a leading cause of morbidity and mortality in childhood, and blunt trauma accounts for 80-90 % of abdominal injuries. The mechanism of trauma is quite similar to that of the adults, but there are important physiologic differences between children and adults in this field, such as the smaller blood vessels and the high vasoconstrictive response, leading to the spreading of a non-operative management. The early imaging of children undergoing a low-energy trauma can be performed by CEUS, a valuable diagnostic tool to demonstrate solid organ injuries with almost the same sensitivity of CT scans; nevertheless, as for as urinary tract injuries, MDCT remains still the technique of choice, because of its high sensitivity and accuracy, helping to discriminate between an intra-peritoneal form a retroperitoneal urinary leakage, requiring two different managements. The liver is the most common organ injured in blunt abdominal trauma followed by the spleen. Renal, pancreatic, and bowel injuries are quite rare. In this review we present various imaging findings of blunt abdominal trauma in children.

Spontaneous puerperal extraperitoneal bladder wall rupture in young woman with diagnostic dilemma

A young female presented with an acute abdominal pain and oliguria for 1 week following normal vaginal delivery. No history of hematuria was present. Patient was having lochia rubra. Sealed uterine rupture was suspected clinically. Initial ultrasound of the patient showed distended urinary bladder containing Foley catheter ballon with clamping of Foley catheter and particulate ascites. Abdominal paracentesis revealed hemorrhagic fluid. Contrast-enhanced computed tomography of abdomen revealed ascites, distended urinary bladder and no extraluminal contrast extravasation in delayed scan. As patient condition deteriorated, repeat ultrasound guided abdominal paracentesis was done which revealed transudative peritoneal collection with distended bladder. Cystoscopy revealed urinary bladder ruptures with exudate sealing the rupture site. Exploratory laparotomy was done and a diagnosis of extraperitoneal bladder rupture was confirmed. The rent was repaired in layers. She was put on continuous bladder drainage for 3 weeks followed by bladder training. It presented in a unique way as there was hemorrhagic peritoneal tap, no macroscopic hematuria and urinary bladder was distended in spite of urinary bladder wall rupture which delayed the diagnosis and treatment. Complete emptying of urinary bladder before second stage of labor and during postpartum period with perineal repair is mandatory to prevent urinary bladder rupture.

Is CT cystography an accurate study in the evaluation of spontaneous perforation of augmented bladder in children and adolescents?

BACKGROUND

Spontaneous bladder perforation (SBP) is a potentially fatal complication of augmented bladder. Imaging is often used for diagnosis. In this study we present our experience with CT cystography (CTC) in the diagnosis of SBP.

OBJECTIVE

To determine CTC accuracy in the evaluation of SBP in children with an augmented bladder.

STUDY DESIGN

The institutional review board approved this HIPAA-compliant study; informed consent was waived. All patients under 20 years old, who underwent CTC for SBP evaluation from 2003 to 2013, were identified. Two radiologists independently reviewed CTC studies for contrast extravasation, ascites, and pneumoperitoneum. Ascites was graded: small - confined to the rectovesical pouch (RVP); moderate - beyond the RVP; large - beyond the pelvis.

RESULTS

Eighty-nine patients (47 males, age 4.2-19.8 years) had 132 CTCs. SBP was diagnosed in 14% (19/132). Both radiologists found contrast extravasation in 74% (14/19) of patients with SBP; two patients had only pneumoperitoneum, and three had only ascites (large = 2, moderate = 1) (Fig.). SBP was found in 1% of CTCs with no ascites or small ascites (1 of 98 and 92; radiologists 1 and 2, respectively). Findings of extraluminal extravasation, unexplained pneumoperitoneum, or large ascites, yielded a detection rate of 95% for SBP by each radiologist. In eight patients, small bowel obstruction was diagnosed.

DISCUSSION

Contrast extravasation was detected in only 74% of patients with SBP. The use of indirect signs of perforation (unexplained pneumoperitoneum and large ascites) in addition to contrast extravasation, increased the detection rate of SBP to 95%. US screening for SBP and selection of patients with moderate or large ascites for CTC, may eliminate the need for most CT scans. In the absence of SBP, other abdominal abnormalities should be evaluated. Bowel obstruction was the most common non-urological emergency detected in this series. The main limitations of the study are: the small number of SBP cases; the diagnosis of SBP not based on surgical findings in three patients; and inability to completely exclude occult SBP in patients not explored surgically.

CONCLUSION

Extraluminal contrast was seen on CTC in most cases of SBP, but some patients with sealed bladder perforation had only pneumoperitoneum or moderate/large ascites. Therefore, SBP should be suspected in any patient with moderate/large volumes of pelvic fluid or unexplained pneumoperitoneum, even when there is no evidence of contrast extravasation. Patients with no ascites, or small volumes, are unlikely to have SBP; therefore, US can be used to screen low risk patients.

BWH emergency radiology-surgical correlation: intraperitoneal urinary bladder rupture

We describe the radiological and intraoperative correlation of two cases of intraperitoneal bladder rupture: a 23-year-old man involved in a high-speed motor vehicle collision and a 49-year-old man with hematuria and abdominal pain after a night of heavy alcohol ingestion. Both patients underwent urgent exploratory laparotomies and repair of their bladder injuries. The purpose of this article is to emphasize the importance of understanding the different etiologies of bladder rupture and recognizing the imaging findings on computed tomography (CT) and CT cystography to help guide the surgeons in the patient's management.

Imaging of Urinary System Trauma

Computed tomography (CT) imaging of the kidney, ureter, and bladder permit accurate and prompt diagnosis or exclusion of traumatic injuries, without the need to move the patient to the fluoroscopy suite. Real-time review of imaging permits selective delayed imaging, reducing time on the scanner and radiation dose for patients who do not require delays. Modifying imaging parameters to obtain thicker slices and noisier images permits detection of contrast extravasation from the kidneys, ureters, and bladder, while reducing radiation dose on the delayed or cystographic imaging. The American Association for the Surgery of Trauma grading system is discussed, along with challenges and limitations.