Bladder Trauma - Detailed Overview

Epidemiology and General Principles

• Pelvic fracture is associated with 83-95% of bladder injuries
• Conversely, bladder injury occurs in only 5-10% of pelvic fractures (some sources cite 10% of abdominal trauma with pelvic fracture)
• 90% of bladder ruptures are associated with pelvic fractures
• Gross hematuria is present in 75-100% of all bladder injuries - it is the cardinal sign

Etiology / Causes

1. Non-Iatrogenic

2. Iatrogenic

3. Spontaneous Rupture

Classification

By Anatomic Location

• Peritoneum remains intact
• Urine extravasates into the retropubic/perivesical space
• Results in flame-shaped extravasation of contrast on cystogram
• If fascial planes are disrupted, contrast can spread to retroperitoneum, scrotum, penis, anterior abdominal wall, and thighs
• Less immediately dangerous than intraperitoneal

• Peritoneum over the bladder is violated
• Urine extravasates freely into the peritoneal cavity
• Typically results from blunt trauma to a full bladder, causing rupture at the dome
• Contrast outlines loops of bowel on cystogram
• Carries risk of urinary peritonitis, ileus, sepsis, azotemia, and death if not treated promptly

• Both intraperitoneal and extraperitoneal components

AAST Grading Scale for Bladder Trauma

Clinical Features

• Intoxicated patients - high index of suspicion even with mild trauma
• Women: vaginal speculum examination essential - vaginal lacerations or traumatic bladder-vaginal communication can be missed with catastrophic consequences
• Bladder augmentation patients - spontaneous rupture can mimic abdominal sepsis

Imaging / Diagnosis

Gold Standard: Retrograde Cystography

1. Retrograde filling with a minimum of 300-400 mL of contrast or until patient tolerance
2. Imaging at maximal fill
3. Post-drainage views mandatory - small extravasation can be missed with a full bladder

Important: Antegrade distention by clamping a urethral catheter after standard CT with delayed imaging is NOT adequate - this does not provide sufficient distention and will miss ruptures.

Ultrasound is not effective for diagnosing bladder rupture.

CT Cystogram Findings

Indications for Retrograde Cystography

• Gross hematuria + pelvic fracture (~30% of these patients have bladder injury)
• Pubic symphysis diastasis + obturator ring fracture + clinical findings suggestive of bladder injury
• Suspected bladder injury by any mechanism

Management

Extraperitoneal Bladder Rupture

• Urethral catheterization with free bladder drainage for 10-14 days
• Use a large catheter (22 Fr) to ensure adequate drainage
• Antibiotics to reduce risk of infected pelvic hematoma or abscess
• Follow-up cystogram at 2 weeks to confirm healing before catheter removal
• If not healed after 4 weeks of catheter drainage, consider operative repair

Indications for Operative Repair of Extraperitoneal Injury

Intraperitoneal Bladder Rupture

• Exception: Very small injuries without significant fluid extravasation in clinically stable patients may be attempted with catheterization and close monitoring, with cystogram at 2 weeks to confirm healing.

Surgical Technique

1. Identify anterior bladder wall in the midline
2. Extend the cystotomy to examine integrity of bladder neck and ureteral orifices
3. Assess ureters - use IV indigo carmine, methylene blue, fluorescein, or retrograde ureteral catheterization
4. Two-layer repair with slowly absorbable suture (e.g., 2-0 Vicryl to 4-0 Vicryl):
   • Layer 1: Mucosa + muscularis
   • Layer 2: Muscularis + serosa
5. Achieve watertight closure
6. Place closed suction drain in pelvis
7. Leave Foley catheter for drainage (suprapubic tube rarely needed unless complex laceration or concurrent spinal cord injury)
8. If concomitant pelvic injuries: use tissue interposition flaps to separate suture lines

• Can be closed intravesically using absorbable suture by entering through the anterior bladder wall
• Avoid disturbing pelvic hematoma if possible

Iatrogenic Bladder Injury - Special Considerations

Intraoperative Recognition

• If recognized at time of TURBT: stop procedure, achieve hemostasis, catheterize
• If recognized during open/laparoscopic surgery: repair immediately in two layers

Risk Factors for Iatrogenic Injury

• Operating within or near the bladder (endoscopic surgery)
• Prior surgery, radiation therapy, or tumor mass effect causing anatomic distortion
• Pelvic organ prolapse (vaginal approach)
• Fixed pelvic space limiting exposure and retractor placement

Fistula Prevention

Complications

Summary Algorithm

Suspected Bladder Trauma
        |
        ↓
Hemodynamic stabilization → Rule out urethral injury first (retrograde urethrogram if concerned)
        |
        ↓
Retrograde Cystogram (minimum 300-400 mL contrast) + post-drainage views
        |
   _____________
  |             |
Negative      Positive
  |             |
No rupture    Classify: Extraperitoneal vs Intraperitoneal
              |                    |
        Extraperitoneal      Intraperitoneal
              |                    |
        Simple? ——→ Yes       SURGICAL REPAIR
              |
         Catheter 10-14 days
         + Antibiotics
         + Cystogram at 2 wks
              |
        Complicated? ——→ SURGICAL REPAIR
        (bladder neck, rectum, vagina, bony spicules,
         clot obstruction, ORIF setting, failed conservative Rx)

Key Points Summary

• Bladder rupture is rarely isolated - always assess for associated injuries
• Pelvic fracture is present in 83-95% of bladder injuries
• Gross hematuria (>95%) is the cardinal sign; always investigate thoroughly
• Retrograde cystography with 300-400 mL contrast is the gold standard; passive/antegrade filling is unacceptable
• Extraperitoneal rupture: managed conservatively with catheter drainage (10-14 days) in uncomplicated cases
• Intraperitoneal rupture: requires surgical repair in nearly all cases
• Operative repair uses two-layer watertight closure with absorbable suture
• Vaginal speculum exam is mandatory in women - vaginal laceration with bladder injury can form devastating fistula
• Suprapubic tube is rarely needed except in complex cases or spinal cord injury