Introduction

 Bladder injury is generally associated with blunt trauma and pelvic fracture

 10% of urogenital injuries involve the bladder

 Radiologic examination is of paramount importance to identify and classify

bladder injury and plan for treatment and stabilization.

 Problem:

Blunt trauma
 Deceleration injuries usually produce both bladder trauma (perforation) and
pelvic fractures. Approximately 10% of patients with pelvic fractures also
have significant bladder injuries. The propensity of the bladder to sustain
injury is related to its degree of distention at the time of trauma.
 Penetrating trauma
 Assault from a gunshot or stabbing typifies penetrating trauma. Often,
concomitant abdominal and/or pelvic organ injuries are present.
 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. Undue scarring may cause obliteration of normal
tissue planes and facilitate an inadvertent extension of the incision into the
bladder. Unrecognized bladder injuries may lead to vesicouterine fistulas and
other problems.
 Gynecologic trauma
 Bladder injury may occur during a vaginal or abdominal hysterectomy. Blind
dissection in the incorrect tissue plane between the base of the bladder and
the cervical fascia results in bladder injury. Women with no history of pelvic
radiation are at higher risk.
 Urologic trauma
 Perforation of the bladder during a bladder biopsy, cystolitholapaxy,
transurethral resection of the prostate (TURP), or transurethral resection of a
bladder tumor (TURBT) is not uncommon. Incidence of bladder perforation is
reportedly as high as 36% following bladder biopsy.
 Orthopedic trauma
 Orthopedic pins commonly perforate the urinary bladder. Thermal injuries to
the bladder wall may occur during the setting of cement substances used to
seat arthroplasty prosthetics.
 Idiopathic bladder trauma
 Patients diagnosed with alcoholism and those individuals who chronically
imbibe a large quantity of fluids are susceptible to this type of injury.
Previous bladder surgery is a risk factor. In reported cases, all bladder
ruptures were intraperitoneal. This type of injury may result from a
combination of bladder overdistention and minor external trauma (eg, a
simple fall).
 Frequency:

Frequency of bladder rupture varies according to the following mechanisms

of injury:

• External trauma (82%)

• Iatrogenic (14%)
• Intoxication (2.9%)
• Spontaneous (<1%)

Of all bladder injuries, 60-85% are from blunt trauma and 15-40% are from a
penetrating injury. The most common mechanisms of blunt trauma are motor
vehicle accidents (87%), falls (7%), and assaults (6%). In penetrating traumas,
the most frequent culprit is gunshot wounds (85%), followed by stabbings (15%).

Approximately 10-25% of patients with a pelvic fracture also have urethral

trauma. Conversely, 10-29% of patients with posterior urethral disruption have
an associated bladder rupture.

 Traumatic bladder ruptures

 Of traumatic ruptures, extraperitoneal bladder perforations account for 50-

71%, intraperitoneal accounts for 25-43%, and combined perforations
account for 7-14%. Incidence of intraperitoneal bladder ruptures is
significantly higher in children because of the predominantly intra-abdominal
location of the bladder prior to puberty.
 Combined intraperitoneal and extraperitoneal ruptures account for
approximately 10% of all traumatic bladder-perforating injuries. Mortality
rates in these patients approach 60%, as compared to 17-22% overall,
reflecting the severity of concomitant injuries associated with combined
bladder ruptures.

Etiology

 Main causes of bladder injury are penetrating and blunt trauma. Iatrogenic
causes include surgical misadventures from gynecologic, urologic, and
orthopedic operations near the urinary bladder. Less common causes involve
obstetric trauma. Spontaneous or idiopathic bladder injuries without an
obvious underlying pathology constitute the remainder.

Pathophysiology:

Bladder contusion is an incomplete or partial-thickness tear of the bladder

mucosa. A segment of the bladder wall is bruised or contused, resulting in
localized injury and hematoma. Contusion typically occurs in the following
clinical situations:

• Patients presenting with gross hematuria after blunt trauma and normal
imaging studies
 • Patients presenting with gross hematuria after extreme physical activity (ie,
long-distance running)

The bladder may appear normal or teardrop shaped on cystography. Bladder

contusions are relatively benign, are the most common form of blunt bladder
trauma, and are usually a diagnosis of exclusion. Bladder contusions are self-
limiting and require no specific therapy, except for short-term bed rest until
hematuria resolves. Persistent hematuria or unexplained lower abdominal pain
requires further investigation.

Considerations when ordering studies in trauma patients

1. IV contrast studies can cause false–positive scan results for blood.

2. The total quantity of contrast required may limit the number of contrast
studies, especially with shock.

3. Hypotensive patients are at risk for developing contrast-induced acute renal

failure.

4. Abdominal CT reveals more information but requires a hemodynamically

stable patient.

 Imaging Techniques

Retrograde Cystogram

 Retrograde cystography was considered the gold standard for detecting

bladder rupture.

 To obtain dependable results, adequate bladder distention is required.

 This requires 350-400 mL of contrast material to be sufficient.

 To correctly perform the study, postevacuation images should also be

obtained.

 False-negative findings occur, most commonly in association with penetrating

injury.

 With penetrating injury, wound margins may align well and prevent leakage.

 Other options includes fluoroscopy with the patient in the Trendelenburg

position during the examination to increase sensitivity.

 Contrast material can be instilled until discomfort occurs.

  Rarely a bladder hematoma also may block the wound orifice and prevent
leakage of contrast.

CT Cystography

 CT is the most recommended study for trauma evaluation of the bladder.

 It is fast, it can be used to evaluate other urologic organs, and it requires no

additional manipulation of the patient beyond what is needed for routine
evaluation.

 Plain abdominopelvic CT may have a high negative predictive value for

bladder rupture in a select subset of patients, even without cystography.

 This makes delaying cystography until after routine abdominopelvic CT even

more valuable.

 Overall, it is 95% sensitive and 100% specific in detecting bladder rupture.

 It is slightly less accurate when intraperitoneal rupture is present, with 80%

sensitivity and 99% specificity.

CT cystography can be used to fully classify bladder injury beyond noting

intraperitoneal versus extraperitoneal rupture

Classification System for Bladder Injury Based on Findings at CT

Cystography

Type of Injury Findings

1. Bladder contusion
2.Intraperitoneal rupture
3. Interstitial bladder injury
4. Extraperitoneal rupture
-Simple extraperitoneal rupture
-Complex extraperitoneal rupture
-Combined bladder injury
Incomplete or partial tear of the bladder
Intraperitoneal contrast material around
bowel loops, between mesenteric folds,
and in the paracolic gutters
Intramural or partial-thickness laceration
with intact serosa
Direct laceration of the bladder by bone
fragments from a pelvic fracture
-Extravasation is confined to the
perivesical space
-Contrast material extends beyond the
perivesical space and may dissect into a
variety of fascial planes and spaces
-Extravasation pattern typical for both
intraperitoneal injury and extraperitoneal
injury
Extraperitoneal bladder ruptures

Traumatic extraperitoneal ruptures usually are associated with pelvic fractures (89-
100%). Previously, the mechanism of injury was believed to be from a direct
perforation by a bony fragment or a disruption of the pelvic girdle. It is now
generally agreed that the pelvic fracture is likely coincidental and that the bladder
rupture is most often due to a direct burst injury or the shearing force of the
deforming pelvic ring.

These ruptures usually are associated with fractures of the anterior pubic arch, and
they may occur from a direct laceration of the bladder by the bony fragments of the
osseous pelvis. The anterolateral aspect of the bladder typically is perforated by
bony spicules. Forceful disruption of the bony pelvis and/or the puboprostatic
ligaments also tear the wall of the bladder. The degree of bladder injury is directly
related to the severity of the fracture.

Some cases may occur by a mechanism similar to intraperitoneal bladder rupture,

which is a combination of trauma and bladder overdistention. The classic
cystographic finding is contrast extravasation around the base of the bladder
confined to the perivesical space; flame-shaped areas of contrast extravasation are
noted adjacent to the bladder. The bladder may assume a teardrop shape from
compression by a pelvic hematoma. Starburst, flame-shape, and featherlike
patterns also are described.

With a more complex injury, the contrast material extends to the thigh, penis,
perineum, or into the anterior abdominal wall. Extravasation will reach the scrotum
when the superior fascia of the urogenital diaphragm or the urogenital diaphragm
itself becomes disrupted.

If the inferior fascia of the urogenital diaphragm is violated, the contrast material
will reach the thigh and penis (within the confines of the Colles fascia). Rarely,
contrast may extravasate into the thigh through the obturator foramen or into the
anterior abdominal wall. Sometimes, the contrast may extravasate through the
inguinal canal and into the scrotum or labia majora.

Intraperitoneal bladder rupture

Classic intraperitoneal bladder ruptures are described as large horizontal tears in

the dome of the bladder. The dome is the least supported area and the only portion
of the adult bladder covered by peritoneum. The mechanism of injury is a sudden
large increase in intravesical pressure in a full bladder. When full, the bladder's
muscle fibers are widely separated and the entire bladder wall is relatively thin,
offering relatively little resistance to perforation from sudden large changes in
intravesical pressure.

Intraperitoneal bladder rupture occurs as the result of a direct blow to a distended

urinary bladder. Resulting increase in intravesical pressure causes a horizontal tear
along the intraperitoneal portion of the bladder wall. This is the weakest part of the
bladder, since its muscle fibers are most widely separated. This type of injury is
common among patients diagnosed with alcoholism or those sustaining a seatbelt
or steering wheel injury.

Since urine may continue to drain into the abdomen, intraperitoneal ruptures may
go undiagnosed from days to weeks. Electrolyte abnormalities (eg, hyperkalemia,
hypernatremia, uremia, acidosis) may occur as urine is reabsorbed from the
peritoneal cavity. Such patients may appear anuric, and the diagnosis is established
when urinary ascites are recovered during paracentesis.

Intraperitoneal ruptures demonstrate contrast extravasation into the peritoneal

cavity, often outlining loops of bowel, filling paracolic gutters, and pooling under the
diaphragm. An intraperitoneal rupture is more common in children because of the
relative intra-abdominal position of the bladder. The bladder descends into the
pelvis usually by the age of 20 years.

Combination of intraperitoneal and extraperitoneal ruptures

Cystogram reveals contrast outlining the abdominal viscera and perivesical space.
External penetrating injuries deserve special mention. A penetrating injury of the
urinary bladder results from a high-velocity bullet traversing the bladder, knife
wounds, or impalement by various sharp objects. These may result in
intraperitoneal, extraperitoneal, or a combined bladder injury.

The high incidence of associated injury to abdominal viscera and vascular structures
mandates surgical exploration in virtually every case. Often, the cystogram is
bypassed, and the diagnosis is made during an exploratory laparotomy. Cystogram
results may be falsely negative in patients with penetrating bladder injuries
secondary to small-caliber bullet wounds. In such patients, these injuries may not
be appreciated until exploratory surgery is performed.

Clinical Manifestations

Clinical signs of bladder injury are relatively nonspecific; however, a triad of

symptoms is often present (eg, gross hematuria, suprapubic pain or tenderness,
difficulty or inability to void).

Most patients with bladder rupture complain of suprapubic or abdominal pain, and
many can still void; however, the ability to urinate does not exclude bladder injury
or perforation. Hematuria invariably accompanies all bladder injuries. Gross
hematuria is the hallmark of a bladder rupture. More than 98% of bladder ruptures
are associated with gross hematuria, and 10% are associated with microscopic
hematuria; conversely, 10% of patients with bladder ruptures have normal
urinalyses.

An abdominal examination may reveal distention, guarding, or rebound tenderness.

Absent bowel sounds and signs of peritoneal irritation indicate a possible
intraperitoneal bladder rupture.
In the setting of a motor vehicle accident or a crush injury, bilateral palpation of the
bony pelvis may reveal abnormal motion indicating an open-book fracture or a
disruption of the pelvic girdle.

If blood is present at the urethral meatus, suspect a urethral injury. Perform a

retrograde urethrogram to assess the integrity of the urethra before attempting to
blindly pass a Foley catheter.

Medical therapy:

Most extraperitoneal ruptures can be managed safely with simple catheter drainage
(ie, urethral or suprapubic). Leave the catheter in for 7-10 days, then obtain a
cystogram. Approximately 85% of the time, the laceration is sealed and the
catheter is removed for a voiding trial.

Virtually all extraperitoneal bladder injuries heal within 3 weeks. If the patient is
taken to the operating room for associated injuries, extraperitoneal ruptures may be
repaired concomitantly if the patient is stable.

Surgical therapy:

Intraperitoneal bladder rupture

Most, if not all, intraperitoneal bladder ruptures require surgical exploration. These
injuries do not heal with prolonged catheterization alone. Urine takes the path of
least resistance and continues to leak into the abdominal cavity. This results in
urinary ascites, abdominal distention, and electrolyte disturbances.

Surgically explore all gunshot wounds to the lower abdomen. Because of the nature
of associated visceral injuries, immediately take patients with high-velocity missile
trauma to the operating room, where the bladder injuries can be repaired
concomitantly with other visceral injuries.

Stab wounds to the suprapubic area involving the urinary bladder are managed
selectively. Surgically repair obvious intraperitoneal injuries, and manage small
extraperitoneal injuries expectantly with catheter drainage.

Extraperitoneal extravasation

Bladders with extensive extraperitoneal extravasation often are repaired surgically.

Early surgical intervention decreases the length of hospitalization and potential
complications, while promoting early recovery.

Preoperative details:

Follow the basic trauma protocol (advanced trauma life support [ATLS]), and
stabilize the patient. Administer broad-spectrum antibiotics, and obtain a surgical
informed consent, if possible. In the setting of emergency trauma, however, there is
often no time for a formal surgical consent from the patient.

Intraoperative details:

• Position the patient in a supine fashion.

• Create a vertical midline abdominal incision.
• Conduct a thorough inspection of the pelvic viscera, ureters, bowel, and
blood vessels.
• Note the presence of pelvic hematoma and, if present, leave undisturbed.
• Bivalve the dome of the bladder.
• Inspect the interior of the bladder.
• Identify both ureteral orifices and ensure that they are intact.
• Once the bladder injury is localized, débride all nonviable tissue.
• High-velocity missile injuries may cause extensive damage to the bladder
tissues.
• Close the bladder in a watertight fashion using 3 layers with an absorbable
suture.
• Test the integrity of the closure by inflating the bladder with saline or water.
• Place a large-bore suprapubic tube through a separate cystotomy site prior to
closing the bladder.
• Place a pelvic drain in the perivesical space.
• Close the abdomen in layers, and apply staples to the skin.

Postoperative details:

• Continue intravenous antibiotics until the patient is discharged.

• Remove the pelvic drain when the drainage output is minimal, usually within
48-72 hours.
• Leave in the SPT and indwelling urethral catheters until an x-ray cystogram is
performed.
• Discharge the patient when he or she shows diet toleration and is
ambulatory, afebrile, and relatively pain-free.

Follow-up care:

• Instruct the patient to return in 7-10 days for staple removal, and check the
wound at that time.
• Obtain the x-ray cystogram 10-14 days after surgery.
• If the cystogram finding is normal, remove the urethral catheter.
• Perform a voiding trial via the SPT.
• Remove the SPT when the patient passes the voiding trial.
• Advise the patient to return to normal activity within 4-6 weeks after surgery.

• Potential complications of bladder surgery

o Urinary extravasation
o Wound dehiscence
o Hemorrhage
 o Pelvic infection
o Small-capacity bladder
o De novo urge incontinence

• Other complications

o Despite technically proper reconstruction, urinary extravasation

through the bladder closure may occur. This usually responds to
extended catheter drainage.
o Abdominal fascial dehiscence presents as persistent drainage from the
incision site.
o Violation of pelvic hematomas during surgery results in severe
hemorrhage.
o If infected, pelvic hematomas become pelvic abscesses.
o Aggressive surgical débridement of the bladder may result in a small
bladder, giving rise to bladder spasms and urge incontinence. Over
time, the bladder may gradually enlarge to more physiologic volumes.
 Republic of the Philippines
Tarlac State University
College of Nursing
Tarlac City

BLADDER
TRAUMA
Submitted by:
Group C1
Dizon, Clarence
Dizon, Sylyn
Justo, Charlon
Jeanica, Pineda
Querido, Ritchen
Razon, Maritess
Saludez, Pearl Grace
Santos, Sharen

Submitted to:
Susan Z. Maglaqui, RN