Pathopsysiology bladder trauma

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: y y Patients presenting with gross hematuria after blunt trauma and normal imaging findings 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 bedrest until hematuria resolves. Persistent hematuria or unexplained lower abdominal pain requires further investigation.

Extraperitoneal bladder ruptures

Traumatic extraperitoneal ruptures are usually 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 are usually 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 is typically perforated by bony spicules. Forceful disruption of the bony pelvis and/or the puboprostatic ligaments also tears 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 are also 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.

CT scan of extraperitoneal bladder rupture. The contrast extravasates from the bladder into the prevesical space.

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 usually descends into the pelvis by age 20 years.

Cystogram of intraperitoneal bladder rupture. The contrast enters the intraperitoneal cavity and outlines loops of bowel.

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.

Cystogram of extraperitoneal bladder rupture. Note the fractured pelvis and contrast extravasation into the space of Retzius.

The high incidence of associated injury to abdominal viscera and vascular structures mandates surgical exploration in virtually every case. Often, cystography is bypassed, and the diagnosis is made during an exploratory laparotomy. Cystography 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.

BLADDER TRAUMA
Fortunately traumatic injury to the bladder is uncommon. The bladder is located within the bony structures of the pelvis and is protected from most external forces. But injuries can occur as a result of blunt or penetrating trauma. The following information should help explain why timely evaluation and proper management are critical for the best outcomes. What happens under normal conditions? The bladder is a hollow, balloon-shaped organ that is located within the pelvis. The bladder stores urine the liquid waste made by the kidneys when they clean the blood. Muscular tissue within the bladder wall allows it to enlarge or shrink as urine is held or emptied. How does bladder trauma happen? When the bladder is empty, it is protected from injury from a blow to the lower abdomen by the bones of the pelvis. As it fills, the top of the bladder rises into the abdomen and makes it more vulnerable to be ruptured. In the child, the pelvic bones are not fully developed and so it is more easily injured than in the adult. If the force of the impact is great enough to fracture the bones of the pelvis, the bladder may be injured even if it is empty. Bullets or knives can also injure the bladder despite its level of fullness. What are causes of injury to the bladder? The most common way the bladder is injured is in motor vehicle accidents, falls from a high place or having a heavy object fall on the lower abdomen of a person. Automobile passengers that have a full bladder and are wearing a seat belt around the lower abdomen may have the force of the collision focus on the lower abdomen and thus the full bladder. To prevent this, wear your seat belt properly as a lap belt and always empty your bladder when planning a long car ride. What are the symptoms of bladder trauma? Virtually everyone who has a blunt injury to the bladder will see blood in the urine. Those with penetrating injury many not actually see bleeding. There may be pain below the bellybutton but many times the pain from other injuries makes the discomfort from the bladder hardly noticeable. If there is a large hole in the bladder and all of the urine leaks into the abdomen, it is impossible to pass urine. In women, if the injury is severe enough, the vagina may be torn open as well as the bladder. If this happens, urine may leak from the bladder through the vagina. Blood may also come out of the vagina in this instance. Other symptoms may include: difficulty beginning to urinate, weak urinary stream, painful urination, fever and severe back pain. How is bladder trauma diagnosed? The diagnosis of injury to the bladder is done by placing a catheter into the bladder and performing a series of X-rays. If the doctor is worried that the urethra is injured an X-ray of this organ may be done before a catheter is inserted. Before the X-rays are taken, the bladder is filled with a liquid that will make it visible on the X-rays. What are the different types of bladder injuries and how are they treated?

Contusion: Most of the time the bladder wall does not rupture but is only bruised. If this happens, merely leaving a large diameter catheter in the bladder so clots may pass is all that is necessary. Once the urine has become clear and the doctor does not need the catheter in the bladder for other reasons (accurate measurement of urine made during the day or in patients too sick to urinate on their own), it can be removed. Intraperitoneal Rupture: If the tear is on the top of the bladder, the hole will usually communicate with the abdominal cavity that holds all of the vital organs (liver, spleen and bowel). This injury should be surgically repaired. Urine that leaks into the abdomen is a serious problem. The repair is performed by making an abdominal incision and sewing the tear closed. A catheter is left in the bladder for up to 2 weeks to rest the bladder after the surgery, either through the urethra or coming directly out the abdominal wall, below the bellybutton. Extraperitoneal Rupture: If the tear is at the bottom or sides of the bladder, the urine will not leak into the abdominal cavity but into the tissues around the bladder. Patients who have complex injuries of this type should have surgical repair of the injury but in some circumstances small injuries can be treated by simply placing a large diameter catheter into the bladder to keep it empty and allow the urine and blood to drain out into a collection bag. If the catheter does not drain properly, surgical repair is required. Allowing the bladder to repair itself in this fashion usually takes at least 10 days and the catheter is not removed until an X-ray is done as described above to prove the leak has sealed. Penetrating Injuries: Patients who have injury to the bladder from a penetrating object are usually operated upon and the hole(s) is surgically repaired. Most of the time other organs in the area will be injured and need repair as well. A catheter is left in the bladder to drain the urine and blood as described above. What can be expected after treatment for injuries to the bladder? After the catheter is removed, urination should return to normal in a few weeks. Antibiotics are commonly given to the patient for a few days to eliminate any infection in the bladder from the injury or the catheter. In some patients, the bladder remains overactive for many weeks or months due to the irritation of the injury. Medication to calm this bladder over activity may be given to help the symptoms of having to pass urine frequently or the feeling that when you get the first sensation to pass urine, you think you have to get to the bathroom immediately or you might wet yourself (urgency).