High rising flames: a sign of complex extraperitoneal bladder rupture

Abstract

Extraperitoneal bladder rupture is the most common type of bladder injury following pelvic trauma and is seen in 80–90% of cases. Generally, the contrast extravasation seen on computed tomography (CT) cystography is confined to the perivesical space, giving a characteristic flame-shaped appearance. Occasionally contrast extravasation can extend to the scrotum, thigh or anterior abdominal wall, depending on the extent of injury. Here we report an unusual CT cystogram finding of complex extraperitoneal bladder rupture with associated pelvic fracture urethral distraction defect, showing large-volume contrast extravasation extending beyond the perivesical space to the left perinephric region resembling high rising flames.

Background

Extraperitoneal bladder rupture resulting from pelvic trauma is diagnosed by the pattern of contrast extravasation on CT cystogram. The extravasation of contrast in these injuries is usually restricted to the perivesical space, and its extension varies with the severity of the injury. We report a case of complex extraperitoneal bladder rupture with contrast extravasation up to the perinephric space, resembling high rising flames on CT cystogram.

Case history

A 20-year-old man presented to the emergency department with severe pelvic fracture and haematuria following a road traffic accident. The patient had hypotension and tachycardia with a drop in haemoglobin level on arrival. He was resuscitated with intravenous fluids, blood and blood products in view of haemorrhagic shock. A pelvic binder was applied, and the fractured pelvis was stabilised. After adequate resuscitation, the patient underwent contrast-enhanced computed tomography (CECT) abdomen and pelvis with computed tomography (CT) cystography with instillation of 300ml of diluted contrast. CECT abdomen showed pelvic fracture and a large left retroperitoneal haematoma. CT cystogram showed extravasation of contrast beyond the perivesical region extending to the left perinephric space resembling high rising flames (Figure 1a and b). The patient underwent exploratory laparotomy in view of persistent hypotension despite adequate resuscitation. A large 4 × 3cm extraperitoneal bladder rent on the anterior wall of bladder and urethral disruption above the urogenital diaphragm were noted. No associated injury to bowel or solid organs was observed. After primary urethral realignment over per urethral catheter, the bladder was repaired over a suprapubic catheter.

Figure 1 .

(a) Coronal computed tomography cystogram images showing classical flame-shaped appearance suggestive of extraperitoneal bladder rupture. (b) Contrast extravasation extending from perivesical space to the left perinephric space.

Discussion

Bladder injuries, both intraperitoneal and extraperitoneal, are accurately detected by CT cystogram performed by retrograde filling of contrast.¹ Extraperitoneal bladder rupture is classified into simple and complex according to the extent of contrast extravasation on CT cystogram.² In complex bladder rupture, extravasation extends beyond the perivesical space, and can extend to the scrotum or thigh due to disruption of the urogenital diaphragm. Sometimes contrast may extend to the anterior abdominal wall.³ Larger bladder rent as in this case could be the reason for contrast extravasation extending as high as the perinephric space.

Conclusion

Simple extraperitoneal bladder injuries may be managed conservatively by nonoperative measures. However, CT cystography findings of contrast extravasation beyond usual fascial planes and spaces should be a red flag for complex extraperitoneal bladder injury.