Brad Figler, MD
Hunter Wessells, MD, FACS
BASICS
DESCRIPTION
• Bladder trauma generally comprises blunt and penetrating types of injury.
• When not distended, bladder is protected from injury by bony pelvis.
• Pelvic fracture and bladder distention increase risk of traumatic injury.
• Important to distinguish between extraperitoneal (EBR), intraperitoneal (IBR), and combined EBR/IBR.
• Iatrogenic bladder injury is discussed in the section “Bladder Injury, Intraoperative.”
EPIDEMIOLOGY
Incidence
1.6% of blunt abdominal trauma
Prevalence
• Unknown
RISK FACTORS
• Motor vehicle crashes (MVCs)
• Falls
• Industrial trauma (pelvic crush injury)
• Penetrating injuries to lower abdomen
• Bladder outlet obstruction
• Alcohol intoxication (bladder distention and decreased sensorium)
• Pelvic fracture
– ∼80% of bladder injures associated with pelvic fracture
– ∼6% of patients with pelvic fracture sustain a bladder injury
• Urethral injury (present in 15% of cases)
Genetics
N/A
PATHOPHYSIOLOGY
• The bladder is generally well protected from blunt trauma unless significantly distended
• In an adult, the bladder lies in the true pelvis, but can rise to umbilicus when full
• In a child, bladder lies in abdomen and more prone to injury
• EBR or combined EBR/IBR
– Pelvic fracture leads to shearing injury from bone fragment or compression with rupture
– Direct injury from penetrating trauma
• IBR
– Blow to lower abdomen in the presence of a full bladder
ASSOCIATED CONDITIONS
• Bladder neck injury
• Pelvic fracture
• Solid abdominal organ injury
• Urethral injury
GENERAL PREVENTION
• Avoid high-risk activity
• Seatbelt proper positioning and use
DIAGNOSIS
HISTORY
• Type of blunt trauma to pelvis
– Associated injuries
• For gunshot, number, and trajectory
• Stab wounds type of knife if known
• Gross hematuria
• Alcohol use
• Past urologic history
• Complaints
– Location of lower abdominal pain
– Urinary retention
– Dysuria or voiding complaints
PHYSICAL EXAM
• Abdominal distention
• Lower abdominal/suprapubic tenderness
• Peritonitis
• Seatbelt sign
• Site/extent of abdominal/pelvic bruising
• Site/extent/trajectory of penetrating objects
• Blood at meatus
• Rectal and vaginal exam (assess integrity)
• Open pelvic fractures
ALERT
Gross hematuria is the hallmark sign of injury to the bladder.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis (UA): Blood usually present
• Serum creatinine can be elevated with IBR due to intraperitoneal resorption of urine
• Hyperkalemia, hypernatremia, uremia, acidosis can also be seen with urinary extravasation into the peritoneum
• CBC (assess for leukocytosis and anemia)
Imaging
• Indications for performing cystography:
– Blunt trauma
Pelvic ring fracture with gross or microscopic (3+ or >30 RBC/HPF) hematuria
Gross hematuria in presence of otherwise unexplained free intraperitoneal fluid
High clinical suspicion (pelvic fluid collection, inability to void, elevated serum creatinine, abdominal distention, suprapubic tenderness, intoxicated or unresponsive, poorly functioning Foley catheter, displaced obturator ring fracture, or large pubic symphysis diastasis
– Penetrating injury
Trajectory suggests bladder injury
Involvement of buttock, pelvis, or lower abdomen with any degree of hematuria
High clinical suspicion
• If ureteral injury is suspected, this should be assessed preoperatively (CT with delayed images) or intraoperatively (retrograde pyelogram/direct inspection)
• When combined upper and lower tract urologic injuries are suspected, upper tract contrast study should be performed prior to cystogram (retained bladder contrast in abdomen or retroperitoneum can obscure upper tract pathology)
Diagnostic Procedures/Surgery
• Cystogram is easy to do and highly sensitive
– CT cystogram
At least as sensitive as conventional cystography for diagnosing bladder rupture (1)
Dilute contrast to limit artifact (1:6)
Postdrainage films not necessary
Excellent visualization of bladder neck
Readily identify foreign bodies
– Conventional cystogram
Dilute contrast 1:2
Scout, AP, oblique, and postdrainage films
– For both CT and conventional cystography, fill bladder to capacity (at least 350 mL in an adult, or determine by formula: (Age in years + 2) × 30.
ALERT
CT with delayed images is inadequate for the diagnosis of bladder injuries: when bladder injury is suspected, a cystogram is mandatory (2).
Pathologic Findings
Injured tissue typically remains healthy, though there is potential for local ischemia (particularly if angio-embolization was performed for pelvic bleeding)
DIFFERENTIAL DIAGNOSIS
• Bladder contusion
• Urethral injury
• Renal or ureteral injury
TREATMENT
GENERAL MEASURES
Stabilize patient if major trauma present
MEDICATION
First Line
For nonoperative management of EBR, antibiotics with gram-positive and gram-negative coverage are recommended while catheter is indwelling
Second Line
N/A
SURGERY/OTHER PROCEDURES
• When associated with significant pelvic bleeding, open pelvic fractures, and abdominal solid organ injury, supportive care is indicated while more urgent injuries are temporized
• IBR
– Laceration is typically large (6–8 cm), at dome
– Nonoperative management generally contraindicated secondary to size of defect and morbidity of chemical peritonitis
– Should be closed in 2 layers with absorbable suture via midline incision
– Laparoscopic repair has been reported in stable patients with no other injuries (3)
– Drain is not necessary
– Foley catheter 7–10 days, with cystogram to confirm absence of extravasation
• EBR
– Nonoperative management
– Acceptable in the appropriate patient, but higher complication risk (4)
– 20-French or larger catheter
– Cystogram after 10–14 days
– Antibiotics with gram-positive and gram-negative coverage while catheter is indwelling
– Contraindications to nonoperative management:
Inadequate catheter drainage
Vaginal or rectal injury
Bladder neck injury
Concomitant urethral injury
Internal fixation of pelvic fracture
Stable and undergoing laparotomy
• Operative repair
– Midline abdominal incision or Pfannenstiel
– Avoid unnecessary pelvic dissection, as there can be significant bleeding from original trauma
– Minimal debridement to ensure healthy wound edges
– Removal of foreign bodies and bony fragments
– Assess ureteral orifices if not imaged
– 2-layer watertight closure with absorbable suture
– Drain is not necessary, but may be helpful
– Foley catheter 10–14 days, with cystogram to confirm absence of extravasation
– Suprapubic tube not necessary
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
Injuries to urethra, bladder neck, or ureters may necessitate endoscopic realignment, repair of bladder neck, or ureteral reimplant
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Prompt diagnosis and appropriate management allow excellent results and minimal morbidity.
• Complications usually are associated with delay in diagnosis and management.
COMPLICATIONS
Unrecognized injury can result in fistula, sepsis, ileus, incontinence, and stricture.
FOLLOW-UP
Patient Monitoring
• Monitor for signs/symptoms of:
– Pelvic bleeding
– Unrecognized abdominal injury
– UTI
– Urinary leak
Patient Resources
www.urologyhealth.org/urology/index.cfm?article=99
REFERENCES
1. Quagliano PVDS, Malhotra AK. Diagnosis of blunt bladder injury: A prospective comparative study of computed tomography cystography and conventional retrograde cystography. J Trauma. 2006;61(2):410–421.
2. Doyle S, Master VA, McAninch JW. Appropriate use of CT in the diagnosis of bladder rupture. J Am Coll Surg. 2005;200(6):973.
3. Kim FJ, Chammas MF Jr, Gewehr EV, et al. Laparoscopic management of intraperitoneal bladder rupture secondary to blunt abdominal trauma using intracorporeal single layer suturing technique. J Trauma. 2008;65(1):234–246.
4. Kotkin L, Koch M. Morbidity associated with nonoperative management of extraperitoneal bladder injuries. J Trauma. 1995;38(6):895–898.
ADDITIONAL READING
• Figler B, Hoffler CE, Reisman W, et al. Multi-disciplinary update on pelvic fracture associated bladder and urethral injuries. Injury. 2012;43(8):1242–1249.
• Gomez RG, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int. 2004;94(1):27–32.
See Also (Topic, Algorithm, Media)
• Bladder Injury, Intraoperative
• Bladder Trauma Algorithm 
• Bladder Trauma Image 
• Ureter, Trauma
• Urethra, Trauma (Anterior and Posterior)
CODES
ICD9
• 867.0 Injury to bladder and urethra, without mention of open wound into cavity
• 867.1 Injury to bladder and urethra, with open wound into cavity
ICD10
• S37.20XA Unspecified injury of bladder, initial encounter
• S37.22XA Contusion of bladder, initial encounter
• S37.23XA Laceration of bladder, initial encounter
CLINICAL/SURGICAL PEARLS
• Gross hematuria is hallmark of bladder injury.
• In addition to diagnosing bladder rupture, CT cystogram is useful in identifying foreign bodies and bladder neck injuries.
• CT with delayed images is inadequate for the diagnosis of bladder injuries: When bladder injury is suspected, a cystogram is mandatory.