UOTW #1

This is a 41-year-old white male who presents after a major motor vehicle collision. He complains of abdominal pain and feels like he needs to urinate but is unable to do so. What is the diagnosis?

Answer

 

Diagnosis: intraperitoneal bladder rupture (IPBR)

Comprising 25% of urinary bladder ruptures, IPBR is a surgically managed violation of the bladder dome. It is usually associated with a pelvic fracture in high energy blunt trauma.

This ultrasound demonstrates a small amount of free fluid in Morison’s Pouch, as well as a partially distended bladder with heterogenous material within. IPBR was strongly suspected based on these findings, and an IV contrasted CT of the abdomen and pelvis confirmed the diagnosis.

Take home points:

  • FAST is sensitive for moderate amounts of free fluid in the peritoneal cavity (at least 200 mL) 1
  • FAST is not specific for a particular source or type of fluid: it could be blood, ascities, gastric/bowel contents or urine
  • IPBR is considered a surgical emergency with a significant mortality
  • IPBR should be suspected when an “irregularly contracted bladder is seen with free fluid accumulating anterior to the bladder wall, and the patient has difficulty voiding or evidence of gross hematuria on examination”2
  • This case demonstrates that IPBR should also be high on DDx when urinary symptoms are associated with a partially distended bladder with heterogenous fluid collection within.

1. Tiling T, Bouillon B, Schmid A. Ultrasound in blunt abdomino-thoracic Trauma. in: Border J, Allgoewer M, Hansen S (eds.), Blunt Multiple Trauma: Comprehensive Pathophysiology and Care. Marcel Dekker: New York,1990;415-433.

2. Wu TS, Pearson TC, Meiners S, Daugharthy J. Bedside ultrasound diagnosis of a traumatic bladder rupture. J Emerg Med. 2011;41(5):520-3.

  1. I’ve had your site saved for a while and am finally getting around to catching up on the cases. Is that hematoma that we see in the extraperitoneal tissue we see anterior to the bladder? Thanks for this awesome resource, and props on such a beautiful layout!

  2. Vince, thanks for visiting. What you are seeing anterior to the bladder is the rectus abdominis muscle. As the beam fans through you can see the striations typical of muscle appearance on ultrasound.

    Impressive blog of yours The Medial Approach.

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