Bladder Trauma

Bladder Trauma

David Ray Velez, MD

Table of Contents

Background
Diagnosis
Treatment

Background

Classification

  • Intraperitoneal (60% – Most Common)
  • Extraperitoneal (30%)
  • About 10% are Combined Injuries with Both Intraperitoneal and Extraperitoneal Components

Etiology

  • Most Common After Blunt Abdominal Trauma
  • 80-90% are Associated with Pelvic Fractures
    • Most Common Associated Fracture: Obturator Ring
  • Can Be Caused by Shear Forces, Sudden Compression of a Distended Bladder, or Penetrating Injury from a Pelvic Fracture

AAST Bladder Injury Scale

Bladder Trauma 1

Diagnosis

Presentation

  • Gross Hematuria – The Cardinal Sign of Bladder Injury
    • Very Reliable (95-100%)
    • < 5% of Cases Only Have Microscopic Hematuria
  • Lower Abdominal Pain
  • Oliguria (Low Urine Output)

May Be Diagnosed Intraoperatively or on Radiographic Imaging

Diagnosis

  • CT Cystography is the Standard Method for Diagnosis
    • Inject 300-400 cc of Contrast Through the Foley to Distend the Bladder and Clamp
  • Findings:
    • Intraperitoneal Leak: Contrast Outlines Loops of Bowel or Fills Cul-De-Sac
    • Extraperitoneal Leak: Flame or Starburst Pattern of Contrast Extravasation
  • Must Obtain Post-Drainage Films if Conventional Cystography (XR Fluoroscopy) is Performed – Risk for False Negatives Without
  • May Be Diagnosed by Cystoscopy in Select Circumstances

Intraperitoneal Bladder Rupture 2

Extraperitoneal Bladder Rupture 3

Treatment

Intraperitoneal Rupture: Surgical Repair

  • Debride Devitalized Tissue and Repair Primarily
  • Use Absorbable Sutures in 2 Layers – Permanent Sutures Irritate the Mucosa and Are Lithogenic
  • Foley Catheter Left Indwelling Postoperatively for 7-10 Days
  • Consider Cystogram Prior to Removal to Confirm Extravasation is Resolved Prior to Foley Removal – Debated

Extraperitoneal Rupture: Nonoperative Management with Foley Catheter

  • Nonoperative Management:
    • Foley Catheter Left Indwelling for at Least 10-14 Days
    • Cystogram Repeated Every 7-10 Days
    • Foley Removed Once Extravasation is Resolved
  • Nonoperative Management is Successful in > 85% of Cases
  • Indications for Surgical Repair:
    • Need for Pelvic Exploration for Other Causes
    • Open Pelvic Fracture with Bone Exposed in the Bladder Lumen
    • Concurrent Vaginal Injury
    • Concurrent Rectal Injury
    • Bladder Neck Injury/Avulsion
    • Persistent Hematuria/Clots Causing Catheter Obstruction

References

  1. Ojewola RW, Tijani KH, Badmus OO, Oliyide AE, Osegbe CE. Extraperitoneally Ruptured, Everted, and Prolapsed Bladder: A Very Rare Complication of Pelvic Injury. Case Rep Urol. 2015;2015:476043. (License: CC BY-3.0)
  2. Vagholkar K, Vagholkar S. Posttraumatic Haematuria with Pseudorenal Failure: A Diagnostic Lead for Intraperitoneal Bladder Rupture. Case Rep Emerg Med. 2016;2016:4521827. (License: CC BY-4.0)
  3. Kim JH, Ha YC, Kim TH, Myung SC, Moon YT, Kim KD, Chang IH. Delayed presentation of intravesical bone penetration after pelvic ring fracture. Korean J Urol. 2012 Dec;53(12):887-9. (License: CC BY-NC-3.0)