Q. A 36-year-old male presents to A&E with acute lower abdominal pain. He was punched in the abdomen having had several pints of beer. He is stable but has been referred to you because of pain and difficulty voiding. What findings make you suspicious of urological injury?
A. The classic triad of lower abdominal pain, inability to void, and frank haematuria with a history of direct trauma to a full bladder suggest a bladder perforation.
(Note that in spinal cord injury/spina bifida patients who have augmented bladders spontaneous bladder rupture can occur without significant pain; the presenting features may be those of sepsis or vague symptoms of non-specific illness.)
Q. What are the common causes of bladder injury?
A. Pelvic fractures, blunt or penetrating trauma to a distended bladder, and iatrogenic causes (associated with lower abdominal and pelvic and endoscopic surgery).
Q. What percentage of pelvic fractures is associated with a bladder injury?
A. Approximately 5%-6%. However around 80% of bladder injuries are due to pelvic fractures.
Q. How would you assess this patient?
A. As with all trauma cases, ATLS principles guide management. It is important to have a multidisciplinary approach, consulting with emergency and general surgical colleagues if necessary.
Q. What specific investigation would you request?
A. In a stable patient, I would request a stress (retrograde) cystogram.
Q. Is there any other investigation that could be requested and might yield more information?
A. Yes, a CT stress (retrograde) cystogram.
Q. How is a stress (retrograde) cystogram performed?
A. In the absence of urethral trauma, the bladder is catheterised and filled to capacity by gravity with diluted (50:50) water-soluble contrast. At least 300 mL must be infused in adults in order to distend the bladder and adequately diagnose a perforation (otherwise blood clot or small bowel/omentum may fill the perforation and prevent extravasation of contrast). Anterior-posterior and post-drainage films are obtained. The post-drainage films are particularly important for diagnosing a posterior bladder perforation, which may be obscured by a bladder filled with contrast.
Q. Why not do an IVU and wait for the cystographic phase?
A. The bladder is a low-pressure highly compliant organ. Intravesical pressure has to be raised by adequate bladder distension (at least 300 mL in adults) or the injury may easily be missed.
Q. What classification do you use for bladder injuries?
A.
Bladder contusion
Intraperitoneal rupture (30%-40%)
Extraperitoneal rupture (50%-60%)
Combined intra- and extraperitoneal ruptures (5%-10%)
Q. What does the (CT retrograde) cystogram in Figure 8.9 show and how would you manage it?
Figure 8.9
A. Figure 8.9 is a CT (retrograde) cystogram showing an intraperitoneal bladder perforation. Contrast is seen leaking into the peritoneal cavity (note that in extraperitoneal bladder perforation contrast only extravasates into the surrounding perivesical space).
The patient should be resuscitated and put on broad-spectrum antibiotics. Intraperitoneal perforations require surgical repair and thus a lower midline laparotomy is performed to inspect the viscera and close the bladder rupture with absorbable sutures. A urethral catheter (±suprapubic catheter) and intra-abdominal drain should be placed.
Q. How would you manage extraperitoneal ruptures?
A. Generally, extraperitoneal ruptures do not require surgical repair. They are managed with a urethral catheter on free drainage for 10-14 days and antibiotics. A stress (retrograde) cystogram is then performed to ensure healing has occurred.
Q. Are there any indications to proceed with surgical repair in extraperitoneal ruptures?
A. Yes.
1. Failure of catheter to drain - e.g. clot obstruction
2. Persistent extravasation
3. Bladder neck injury
4. Patients undergoing internal fixation for pelvic fracture or laparotomy for other viscus repair (e.g. bowel, rectum, vagina) can have concurrent bladder repair
5. Bone spike puncturing bladder on imaging
Q. What complications may be seen after missed bladder perforation injury?
A. Intraperitoneal urinary extravasation can result in urinary ascites, peritonitis, ileus and systemic sepsis.
Injuries involving the bladder neck can result in incontinence or stricture. Recto-/ colovesical fistulae and vesicovaginal fistulae may also occur.
Q. How would you manage a penetrating injury to the bladder?
A. Operative exploration, closure, bladder drainage and antibiotics. Careful attention should be paid to the posterior bladder wall, the ureters and neighbouring viscera.