CLINICAL CASES:

1.- A 24-year-old male suffered an assault with abdominal trauma. Hypogastric pain, 24-hour anuria and worsening renal function.

CT-cystography. Diluted contrast is administered through a Foley catheter that completely opacifies the urine inside the bladder. This case presents extensive extravasation of contrast into the peritoneal cavity, occupying the rectovesical recess, the paravesical spaces, the space between the intestinal loops, the parietocolic gutters and the subhepatic space. Findings in relation to intraperitoneal bladder rupture.

Fig 5: Figure 5. Case 1. CT-cystography. Diluted contrast is administered through a Foley catheter that completely opacifies the urine inside the bladder. This case presents extensive extravasation of contrast into the peritoneal cavity, occupying the rectovesical recess, the paravesical spaces, the space between the intestinal loops, the parietocolic gutters and the subhepatic space. Findings in relation to intraperitoneal bladder rupture.

Fig 6: Figure 6. Case 1. CT-cystography. Diluted contrast is administered through a Foley catheter that completely opacifies the urine inside the bladder. This case presents extensive extravasation of contrast into the peritoneal cavity, occupying the rectovesical recess, the paravesical spaces, the space between the intestinal loops, the parietocolic gutters and the subhepatic space. Findings in relation to intraperitoneal bladder rupture.

Fig 7: Figure 7. Case 1. CT-cystography. Diluted contrast is administered through a Foley catheter that completely opacifies the urine inside the bladder. This case presents extensive extravasation of contrast into the peritoneal cavity, occupying the rectovesical recess, the paravesical spaces, the space between the intestinal loops, the parietocolic gutters and the subhepatic space. Findings in relation to intraperitoneal bladder rupture.

2.- A 40-year-old woman underwent a caesarean section the previous day. She presented with hypogastric pain without spontaneous urination. CT scan was performed to rule out bladder perforation.

CT-cystography. Extravasation of contrast into the peritoneal cavity, drawing the subhepatic space, both paritetocolic gutters, the small bowel loops and the anterior vesical, vesicouterine and rectouterine recesses in relation to intraperitoneal bladder rupture. Enlarged uterus and post-surgical changes with pneumoperitoneum bubbles and subcutaneous emphysema in relation to previous caesarean section. 

Note: the site of contrast leakage is not exactly visualised.

Fig 8: Figure 8. Case 2. CT-cystography. Extravasation of contrast into the peritoneal cavity, drawing the subhepatic space, both paritetocolic gutters, the small bowel loops and the anterior vesical, vesicouterine and rectouterine recesses in relation to intraperitoneal bladder rupture. Enlarged uterus and post-surgical changes with pneumoperitoneum bubbles and subcutaneous emphysema in relation to previous caesarean section.  Note: the site of contrast leakage is not exactly visualised.

Fig 9: Figure 9. Case 2. CT-cystography. Extravasation of contrast into the peritoneal cavity, drawing the subhepatic space, both paritetocolic gutters, the small bowel loops and the anterior vesical, vesicouterine and rectouterine recesses in relation to intraperitoneal bladder rupture. Enlarged uterus and post-surgical changes with pneumoperitoneum bubbles and subcutaneous emphysema in relation to previous caesarean section.  Note: the site of contrast leakage is not exactly visualised.

Fig 10: Figure 10. Case 2. CT-cystography. Extravasation of contrast into the peritoneal cavity, drawing the subhepatic space, both paritetocolic gutters, the small bowel loops and the anterior vesical, vesicouterine and rectouterine recesses in relation to intraperitoneal bladder rupture. Enlarged uterus and post-surgical changes with pneumoperitoneum bubbles and subcutaneous emphysema in relation to previous caesarean section.  Note: the site of contrast leakage is not exactly visualised.

3.- A 47-year-old man underwent percutaneous left nephrolithotomy the day before with placement of a double J catheter due to ureteral lithiasis. He presented with poor general condition and hypogastric pain with signs of peritoneal irritation. Wound with no signs of infection. Analytical deterioration of renal function.

CT-cystography. Leakage of iodinated bladder contrast into the retropubic or Retzius space extending posteriorly into both perivesical spaces giving rise to the typical “molar sign”. Findings in relation to extraperitoneal bladder rupture. Defect in the anterosuperior wall of the bladder. Left double J catheter.

Fig 11: Figure 11. Case 3. CT-cystography. Leakage of iodinated bladder contrast into the retropubic or Retzius space extending posteriorly into both perivesical spaces giving rise to the typical “molar sign”. Findings in relation to extraperitoneal bladder rupture. Defect in the anterosuperior wall of the bladder. Left double J catheter.

Fig 12: Figure 12. Case 3. CT-cystography. Leakage of iodinated bladder contrast into the retropubic or Retzius space extending posteriorly into both perivesical spaces giving rise to the typical “molar sign”. Findings in relation to extraperitoneal bladder rupture. Defect in the anterosuperior wall of the bladder. Left double J catheter.

Fig 13: Figure 13. Case 3. CT-cystography. Leakage of iodinated bladder contrast into the retropubic or Retzius space extending posteriorly into both perivesical spaces giving rise to the typical “molar sign”. Findings in relation to extraperitoneal bladder rupture. Defect in the anterosuperior wall of the bladder. Left double J catheter.

4.- A 74-year-old man underwent transurethral resection (TUR) for bladder neoplasia. He reported inability to urinate and hypogastric pain with greater involvement of the right side.

CT-cystography. Opacified and poorly distended bladder due to contrast extravasation into the right perivesical and Retzius spaces. Contrast extends cranially into the right anterior pararenal space and retroperitoneum. Multiple gas bubbles in the right perivesical and iliac fossa regions in relation to a history of difficult catheterisation. Extravesical location of the distal end of the catheter due to a defect in the right lateral bladder wall corresponding to the old location of the recently operated bladder neoplasia. Findings which, taken together, suggest extraperitoneal bladder rupture.

Fig 14: Figure 14. Case 4. CT-cystography. Opacified and poorly distended bladder due to contrast extravasation into the right perivesical and Retzius spaces. Contrast extends cranially into the right anterior pararenal space and retroperitoneum. Multiple gas bubbles in the right perivesical and iliac fossa regions in relation to a history of difficult catheterisation. Extravesical location of the distal end of the catheter due to a defect in the right lateral bladder wall corresponding to the old location of the recently operated bladder neoplasia. Findings which, taken together, suggest extraperitoneal bladder rupture.

Fig 15: Figure 15. Case 4. CT-cystography. Opacified and poorly distended bladder due to contrast extravasation into the right perivesical and Retzius spaces. Contrast extends cranially into the right anterior pararenal space and retroperitoneum. Multiple gas bubbles in the right perivesical and iliac fossa regions in relation to a history of difficult catheterisation. Extravesical location of the distal end of the catheter due to a defect in the right lateral bladder wall corresponding to the old location of the recently operated bladder neoplasia. Findings which, taken together, suggest extraperitoneal bladder rupture.

Fig 16: Figure 16. Case 4. CT-cystography. Opacified and poorly distended bladder due to contrast extravasation into the right perivesical and Retzius spaces. Contrast extends cranially into the right anterior pararenal space and retroperitoneum. Multiple gas bubbles in the right perivesical and iliac fossa regions in relation to a history of difficult catheterisation. Extravesical location of the distal end of the catheter due to a defect in the right lateral bladder wall corresponding to the old location of the recently operated bladder neoplasia. Findings which, taken together, suggest extraperitoneal bladder rupture.

5.- An 89-year-old patient underwent a surgery 2 days ago for urothelial adenocarcinoma resection. He presented with general malaise, difficulty urinating, fever, abdominal distension and hypogastric pain. Blood tests showed a slight increase in acute phase reactants and worsening renal function.

CT-cystography. Opacified urine occupying the Retzius space with the presence of extraluminal gas bubbles adjacent to the anterosuperior wall of the bladder where a parietal defect is identified. Findings in relation to extraperitoneal bladder rupture.

Fig 17: Figure 17. Case 5. CT-cystography. Opacified urine occupying the Retzius space with the presence of extraluminal gas bubbles adjacent to the anterosuperior wall of the bladder where a parietal defect is identified. Findings in relation to extraperitoneal bladder rupture.