Bladder trauma

By: Roshini Dsouza

 Objectives
• Meaning
• Epidemiology
• Types
• Etiology/incidence
• Mechanism of injury
• Diagnostic studies
• Management
• Follow up
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Meaning
Injury to the bladder
caused by a blunt and/or
penetrating traumatic
mechanism.
 Epidemiology
• Identified in 1.6% of patients with
blunt abdominal injury.
•25% have associated urethral
trauma.
•10% of patients with pelvic injury
•Also consider bladder injury in all
patients with pelvic fractures.
•Elderly are most likely to sustain
pelvic fractures ADD A FOOTER 4
 based on the extent and location
of the injury
1. Intraperitoneal;
2. Extraperitoneal;
3. Combined intra-
extraperitoneal
Classification of bladder trauma
based on mode of action
1. Non-iatrogenic trauma
a. blunt
b. penetrating
2. Iatrogenic trauma

Types
a. external
b. internal
c. foreign body

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 Etiology
1.Contusions:

•Mucosal or muscularis
hematoma.
•Retrograde cystography: no
urine extravasation

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Bladder injury etiology continued ……………
Etiology
2. Intraperitoneal
rupture (40% of all
ruptures)
•Bladder distended at time of injury
•Typically from blunt trauma
•Increase in intra-vesicular pressure
leads to rupture at bladder dome
•Retrograde cystography: urine
extravasation into the peritoneum.
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Bladder injury etiology continued ……………
Etiology
3. Extraperitoneal
rupture (55% of all
ruptures):
•Anterolateral wall most susceptible
to injury where it attaches to fascia.
•Almost all have associated pelvic
fractures.
•Retrograde cystography: urine may
extravasate into the retroperitoneal
space, the abdominal wall, or
surrounding soft tissues
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Bladder injury etiology continued ……………
Etiology
4. Blunt Trauma
• Deceleration injuries usually
produce both bladder trauma
(rupture) and pelvic fractures
(which can cause bladder
perforation).
• Accordingly, approximately 10% of
patients with pelvic fracture also
have significant bladder injury

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Bladder injury etiology continued ……………
Etiology
5.Penetrating Trauma
• Both gunshot and stabbing are
examples of penetrating trauma

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Bladder injury etiology continued ……………
Etiology
6. Obstetric Trauma
• During prolonged labor or a
difficult forceps delivery, persistent
pressure from the fetal head against
the mother's pubis can lead to
bladder necrosis.
• Direct laceration of the urinary
bladder is reported in 0.3% of
women undergoing a cesarean
delivery.
• Previous cesarean deliveries with
resultant adhesions are a risk factor
for such, as undue scarring may
obliterate normal tissue planes.
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Bladder injury etiology continued ……………
 Etiology
7.Gynecologic Trauma
• Bladder injury may occur during
vaginal or abdominal
hysterectomy.

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Bladder injury etiology continued ……………
 EBP
Rashmi S. Desai, Sunil Kumar K(2016). To determine frequency and nature
of urological injuries in obstetric and gynecological procedures and their
consequences and mode of management in a tertiary care hospital SDM
Medical college and hospital, Dharwad, India. A retrospective study of all
obstetric and gynecological surgeries over a period of 11 years from
January 2004 to December 2014. : Out of 18,250 patients undergoing various
surgeries, 37(0.2%) patients had bladder injury and 4(0.02%) patients had
ureteric injury. In gynecologic procedures, the incidence of bladder injury
was highest in radical hysterectomy (2 out of 79, 2.5%) followed by
TLH/LAVH (4 out of 299, 1.3%), NDVH (7 out of 490, 1.4%) TAH (5 out of
1360, 0.37%), laparotomy (1 out of 347, 0.29%) and vaginal hysterectomy (3
out of 1529, 0.2%). Three ureteric injuries were noted in cases of
TLH/LAVH (3 out of 299) and one in case of TAH (1 out of 1360, 0.07%.
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 Etiology
8.Urologic Trauma
• Perforations of the bladder
during bladder biopsy,
transurethral resection of the
prostate (TURP), or
transurethral resection of
bladder tumor (TURBT) are not
uncommon.
• The incidence of bladder
perforation with bladder biopsy
is reportedly as high as 36%.

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Bladder injury etiology continued ……………
 Etiology
9.Orthopedic Trauma
• Orthopedic hardware can easily
perforate the urinary bladder,
particularly during internal
fixation of pelvic fractures
during the setting of cement
substances used to seat
arthroplasty prosthetic

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Bladder injury etiology continued ……………
EBP
Urologic Injuries in Pelvic Ring Disruptions
The overall incidence of lower urinary tract disruptions after fractures of the pelvic ring ranges
from 7% to 25%.Conversely, pelvic ring fractures are present in 83% to 97% of patients with lower
urinary tract disruptions after blunt trauma. The incidence of isolated bladder injury ranges from
6% to 11%, whereas the incidence of isolated urethral injuries ranges from 4% to 14% of patients with
pelvic ring fractures. Urethral injuries are far more common in men than in women with the
reported incidence as high as 25% after pelvic fracture. The rarity of female urethral injuries can be
attributed to the short length of the female urethra, and its lack of attachment to the pubis. This
increased mobility results in less shearing stresses on the urethra.4,16 A recent article, however,
documented an incidence of urethral disruptions in 4.6% of female patients with pelvic fractures.30
Thus, the possibility of urethral injury in female patients should not be ignored. Ureteral injury has
been associated with acetabular fractures but not with pelvic ring disruptions.Simultaneous bladder
and urethral injury occurs in 0.5% to 2.5% of pelvic fractures. More importantly, as much as 35% of
bladder disruptions may be associated with urethral disruption and as much as 41% of urethral
disruptions may be complicated by bladder injury. This has an important implication in the workup
of these injuries.

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 Etiology
10. Idiopathic Bladder Trauma
• Patients diagnosed with
alcoholism and individuals who
chronically imbibe a large
quantity of fluids are susceptible
to idiopathic bladder injury.
• This type of injury may result
from a combination of bladder
overdistention and minor
external trauma, such as that
from a minor stumble or fall.

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Bladder injury etiology continued ……………
 Bladder
Contusion:

Mechanism
of injury: Bladder contusion is an incomplete or partial-
thickness tear of the bladder. This produces a
hematoma within the bladder at the location of
injury. Bladder contusion is relatively benign.
It is self-limiting and requires no specific
therapy, except for rest until hematuria
resolves

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Mechanism of injury continued……………..
 Extraperitoneal Bladder Rupture

The mechanism of injury was believed to be direct perforation by bony

fragment or disruption of the pelvic girdle. It is now thought that pelvic
fracture is likely co-incidental and that bladder rupture most often is a
direct result of deceleration injury and fluid inertia coupled with the
shearing force created by pelvic ring deformation.
Intraperitoneal Bladder Rupture
Classic intraperitoneal rupture is described as large horizontal
tears in the bladder dome. This is the least supported area of the
bladder and only portion of the organ covered by peritoneum. In
such cases, the mechanism of injury is a sudden large increase in
intravesical fluid pressure that overcomes the mechanical strength of the
bladder wall. This is more likely to occur at greater bladder
volumes, as the detrusor muscle fibers are more widely separated
along the thinned and stretched bladder wall, offering a lower resistance
to spikes in intravesical fluid pressure.

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 Diagnostic imaging with cystogram
Combination of will reveal contrast outlining the
abdominal viscera and peri-vesical

Intraperitoneal and space. Often times this may be

observed in penetrating trauma,
where the bladder is traversed by a

Extraperitoneal high-velocity bullet, impaled by a

knife, or penetrated by another
foreign body. This through-and-
Ruptures through injury creates a combined
intraperitoneal and extraperitoneal
bladder rupture.

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 Classification of bladder injury according to AAST

Grade 1 - Contusion

Grade 2 - Intraperitoneal bladder wall laceration

Grade 3 – Intersticial injury

Bladder injury Grade 4 - Extraperitoneal bladder wall laceration
classification - simple

- complicated
Grade 5 – combination of injuries intraperitoneal and
extraperitoneal
Extraperitoneal
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bladder wall laceration 22
Bladder trauma symptoms

Gross
Lower Nausea,
hematuria most Paralytic ileus
abdominal pain vomiting
common signs

Bruises over
Inability to Hemorrhagic
Peritonitis the suprapubic
void shock
region

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Diagnostic Studies

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 • Obtain an urinalysis:
hematuria will be present in 95% of
cases.

• Creatinine and blood urea

Lab tests nitrogen (BUN), May be elevated

due to urine absorption after
intraperitoneal rupture.

• Helps assess for renal injury

risk with nephrotoxic agents such as
IV contrast
Imaging tests
Highly consider obtaining
Abdomen and pelvis
Not sensitive enough
computed tomography (CT) Plain film retrograde
to detect all bladder
with IV contrast to assess for cystogram
injuries
associated life-threatening
injuries

Perform if gross Before retrograde

hematuria and CT cystogram, perform a
does not show cause retrograde
for hematuria, such as urethrogram to ensure
renal injury. no urethral injury.

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Cystography

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Sagittal CT cystogram
demonstrates bladder
rupture, with contrast
confined to an
extraperitoneal location
MANAGEMENT:
• Initial assessment: focus on the primary survey, as described in
Advanced Trauma Life Support (ATLS), aimed at recognizing and
treating immediate life threats
• Secondary survey: once patient is stabilized, assess for related
injuries
• Treatment is guided by the injury pattern and the patient’s
hemodynamic status
• Many patients will have coexisting pelvic fractures requiring
admission
• Bladder repairs are not emergent and should be managed
expectantly until life-threatening injuries are addressed
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 Ø Supportive care

Bladder
contusions (no
urine Ø Consider placement of Foley
catheter for continuous drainage of
extravasation bladder

on retrograde
cystogram): Ø If foleys contraindicated to avoid
further injury a suprapubic approach
performed under the ultrasound guidance

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Extraperitoneal bladder ruptures
Ø Expectant management with continuous bladder
drainage
Prophylactic antibiotics are typically recommended while
Foley catheter is in place.
Ø Bladder neck injury requires surgical repair

Ø Coexisting rectal or vaginal injury requires surgical

repair.
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 Intraperitoneal bladder ruptures

Ø Need operative repair.

Ø Bacterial peritonitis
possible if not repaired.
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Medications
Fentanyl 1-2 mcg/kg IV, if concern for hemodynamic instability
or early in resuscitation because of short-acting duration (typical adult
dosage 50-100 mcg IV).
Morphine 0.1 mg/kg IV (typical adult dosage 4-10 mg IV).
Use longer-acting opiate, once hemodynamically stable.
Prophylactic antibiotics typically recommended for bladder
ruptures.
No consensus on antibiotics in the literature.
Recommend covering gram-negative and anaerobic organisms.
Ampicillin/sulbactam 3 g IV every 6 hours.
Fluoroquinolone (or third-generation cephalosporin) AND
metronidazole 500 mg IV every 8 hours.
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 SURGICAL MANAGEMENT:

Ø Intraperitoneal
Ø Extraperitoneal
Bladder Rupture
Extravasation repair.
repair.

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 Ø Continue intravenous antibiotics
through the hospital stay, based on the
surgical findings.
Postoperative
management Ø Remove the pelvic drain when its
output has minimized, generally after 48 to

following 72 hours.

bladder Ø Maintain the indwelling urethral and

trauma repair
suprapubic catheters for at least 10 to 14
days.

is as follows: Ø Obtain a cystogram before catheter

removal to confirm healing and rule out a
leak.
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Prognosis

Ø Morbidity and mortality are Ø Most extraperitoneal ruptures

typically due to associated injuries. heal without surgical intervention
within 10 days.

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COMPLICATIONS
Potential complications of bladder surgery:
Ø Persistent or recurrent urinary extravasation.
Ø Wound dehiscence.
Ø Hemorrhage.
Ø Pelvic abscess.
Ø Intraabdominal infection.
Ø Urinary tract infection.
Ø Low bladder capacity.
Ø Urinary urgency.

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General Complications:
Abdominal Fistula if rectum Incontinence if
compartment or vagina also associated nerve
syndrome. injured. damage.

Intra-abdominal
Peritonitis. Sepsis.
abscess.

Urine
extravasation.

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FOLLOW-UP

Continuous bladder drainage is required to prevent elevated

intravesical pressure and to allow the bladder to heal.

Conservatively treated bladder injuries (traumatic or external

iatrogenic bladder trauma) are followed by planned
cystography scheduled to evaluate bladder healing, with
catheter removal in case of absence of contrast extravasation.

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FOLLOW-UP
o The first cystography is planned 7-14 days
after injury, depending on the extent of the laceration,
and should be repeated thereafter in the case of an
ongoing leakage.
o After operative repair of a simple injury in a
healthy patient, the catheter can be removed after 7-10
days without need for a control cystography

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FOLLOW-UP
After repair of a complex injury (trigone involvement,
ureteric reimplantation) or in the case of risk factors
of wound healing (e.g. use of steroids, malnutrition),
control cystography is advised.
For conservatively treated internal iatrogenic bladder
trauma, a catheter duration of 5 and 7 days for
extraperitoneal and intraperitoneal perforations,
respectively, has been proposed.
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References
• Bradley C Gill, M. (2019). Bladder Trauma Guidelines. WebMD
LLC.
• N.D. Kitrey (Chair), N. D. (2016). EAU Guidelines on Urological
trauma. UROLOGICAL TRAUMA - LIMITED UPDATE
MARCH 2016.
• www.uptodate.com.

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Thank You!