Multidetector Computed Tomography Cystography

Bladder Trauma:

Multidetector Computed Tomography Cystography

Self-Assessment Module:

Outline:

-Abstract

-Introduction

-Educational Objectives

-Multiple Choice Questions

-Solutions to Multiple Choice Questions

-Recommended Reading List

Abstract:

The educational objectives of this self-assessment module are for the participants to

exercise, self-assess, and improve their understanding of the most important features of

bladder trauma.

Introduction:

This self-assessment module on bladder trauma has an educational component and a

self-assessment component. The self-assessment componentconsists of 10 multiple-choice questions with solutions. The educational component consists of 3 required and 3 recommended articles that the participant should read.

Educational Objectives:

By completing this educational activity, the participant will:

A. Exercise, self-assess and improve his or her understanding of the most important

features of MDCT cystography of bladder trauma.

B. Exercise, self-assess, and improve his or her understanding of the role of MDCT cystography inthe diagnosis of bladder trauma.

Multiple Choice Questions:

Question 1

The Bladder is separated from the pubic symphysis by a space known as space of:

A- Scarpa

B- Retzius

C- Camper

D- Douglas

E- Morison

Question 2

If Bladder rupture occurs above the peritoneal bladder reflections, the leakage is:

A- Intraperitoneal

B- Extraperitoneal

C- Combined

D- Interstitial

E- Intramural

Question 3

Trauma to the genitourinary system occurs in approximately ____ of all patients with

trauma.

A- 5-10%

B- 25-40%

C- 50-60%

D- 65-75%

E- 80-90%

Question 4

Which of the following is true?

A- Patients with pelvic fracture have a bladder rupture in more than 50% of cases

B- Patients with bladder rupture have a pelvic fracture in more than 50% of cases

C- Patients with pelvic fracture have a bladder rupture in more than 90% of cases

D- Patients with bladder rupture have a pelvic fracture in less than 10% of cases

E- None of the above

Question 5

The most common mechanism of bladder trauma is:

A- Gunshot wounds

B- Iatrogenic injury

C- Assaults

D- Motor vehicle accidents

E- Stabbing wounds

Question 6

The most common type of bladder rupture is:

A- Intraperitoneal

B- Interstitial

C- Extraperitoneal

D- Combined

E- intraluminal

Question 7

In the setting of trauma, Multi-Detector Computed Tomography cystography is indicated

if there is

A- Bowel Injury

B- Hip fracture

C- Hematuria

D- Lumbar Spondylolysis

E- Urethral Injury

Question 8

Multi-Detector Computed Tomography cystography may show contrast material

between mesenteric folds with:

A- Extraperitoneal bladder rupture

B- Intraperitoneal bladder rupture

C- Combined bladder rupture

D- Both A & C

E- Both B & C

Question 9

Molar tooth appearance on Multi-Detector Computed Tomography cystography in the

setting of bladder trauma can be seen with:

A- Intraperitoneal bladder rupture

B- Extraperitoneal bladder rupture

C- Combined bladder rupture

D- Both A & C

E- Both B & C

Question 10

Surgical emergency and vesical exploration repair is required for all of the following

except:

A- Penetrating injury

B- Intraperitoneal injury

C- Combined rupture

D- Extraperitoneal rupture

E- Bladder neck injury

Solutions to Multiple Choice Questions

Solution to Question 1

Answer: B.

The Bladder is separated from the pubic symphysis by a potential prevesical space

known as the space of Retzius. Morison’s pouch is the eponym for the hepato-renal

space. Pouch of Douglas is the extension of the peritoneal cavity between the rectum

and the posterior wall of the uterus. Camper fascia is the superficial layer of the anterior

abdominal wall. Scarpa’s fascia is the deep layer of the anterior abdominal wall.

Solution to Question 2

Answer: A

The type of urinary leakage, either intraperitoneal or extraperitoneal, depends upon the

location of the injury in relation to the peritoneal reflections. If the rupture occurs above

the peritoneal reflections, the leakage is intraperitoneal. If the injury occurs below the

peritoneal reflections, the leakage is extraperitoneal. Urinary leakage may be combined,

intraperitoneal and extraperitoneal, if the rupture occurs directly at the level of peritoneal

reflections.

Solution to Question 3

Answer: A

Trauma to the genitourinary system occurs in approximately 5-10% of all patients with

trauma. Most of these injuries are secondary to blunt trauma, and approximately 10% of

genitourinary injuries result in bladder trauma.

Solution to Question 4

Answer: B

Bladder rupture occurs in 2-11% of patients with pelvic fractures. However, 60-90% of

patients with bladder rupture have a pelvic fracture.

Solution to Question 5

Answer: D

Bladder trauma may arise from a variety of mechanisms divided into blunt trauma 60-

85%, penetrating trauma 15-40% and iatrogenic injury. Blunt pelvic trauma secondary to

motor vehicle accidents accounts for between 70 and 90% of cases.

Solution to Question 6

Answer: C

Extraperitoneal bladder rupture is the most common type occurring in 70–80% whereas

intraperitoneal and combined bladder ruptures occurs in 15–20% and 5-10% of patients,

respectively.

Solution to Question 7

Answer: C

Multi-Detector Computed Tomography cystography (MDCT) cystography is required

immediately in the presence of hematuria and pelvic fracture. MDCT Cystography is

performed after assessment and appropriate management of urethral injury, due to the

high incidence of concomitant urethral injury.

Solution to Question 8

Answer: E

In intraperitoneal rupture, MDCT cystography demonstrates intraperitoneal contrast

material around bowel loops, between mesenteric folds, and in the paracolic gutters.

In extraperitoneal rupture, the pathway of extravasated contrast material is variable:

Extravasation is confined to the perivesical space in simple extraperitoneal ruptures,

whereas in complex extraperitoneal ruptures, contrast material extends beyond the

perivesical space and may dissect into a variety of fascial planes and spaces.

Solution to Question 9

Answer: E

Free contrast-enhanced urine pooling in the anterior perivesical spaces on Axial MDCT

has been described as having a ‘molar tooth’ appearance on axial MDCT, seen in

combined and extraperitoneal bladder rupture but not with intraperitoneal rupture.

Solution to Question 10

Answer: D

Surgical emergency exploration repair is required for penetrating, isolated

intraperitoneal and combined ruptures. Catheter drainage is used for isolated

extraperitoneal rupture, whereas bladder contusion is treated conservatively with

subsequent healing without intervention. A suprapubic catheter is placed if there is coexistingurethral injury. If the bladder neck is involved, surgical exploration and repair

are required.