Extraperitoneal bladder rupture

Cystogram shows two small areas of extraperitoneal bladder leakage: anterior left upper and anterior right lower. 

Small splenic lacerations. 

Extensive left pelvic fractures: displaced communited sacrum, anterior subluxed pubic body, inferior pubic ramus, buckling of superior pubic ramus. 

Large amount of extraperitoneal blood products in pelvis, left retroperitoneum, and along the course of left ureter. Right ureter and pelvis are minimally dilated. 

Diminished contrast in the left kidney on delayed views. However, left kidney is excreting contrast and right is not, so this is of unclear significance and there could be some subtle delayed nephrogram on the right despite the blood products about the left ureter (based on portal venous phase). Left ureter patent without extravasation. Bladder suboptimally evaluated. 

Left flank subcutaneous hematoma. 

Typical findings of extraperitoneal bladder rupture following severe pelvic trauma. This case highlights the importance of performing a proper cystogram following trauma, as the bladder was suboptimally evaluated on the original delayed images.  I would imagine that even later delays with more bladder volume may not have confidently shown the small areas of leakage anteriorly. The blood tracking along the left ureter was likely related to pelvic fractures rather than injury of the left ureter.

The pattern of asymmetry of renal enhancement and excretion of contrast on the delayed images is unexpected and. The right kidney appears to have a persistent nephrogram, typically seen in the setting of uncertain significanceacute renal injury, but without a definite cause. It The left kidney has expected excretion of contrast despite blood products surrounding the left ureter. It would be reasonable to recommend laboratory and/or functional imaging follow-up depending on clinical concern.