Bladder injuries can result from blunt, penetrating, or iatrogenic trauma.[1, 2] The probability of bladder injury varies according to the degree of bladder distention; a full bladder is more susceptible to injury than is an empty one. Management varies from conservative approaches that center on maximizing bladder drainage to major surgical procedures aimed at directly repairing the injury.
For patient education information, see Blood in the Urine, Intravenous Pyelogram, Cystoscopy, and Foley Catheter.
Although uniformly fatal historically, timely diagnosis and appropriate management now provide excellent outcomes. Early clinical suspicion, coupled with appropriate and reliable radiologic studies, facilitate prompt intervention and the successful management of bladder trauma.
Aside from iatrogenic injuries, patients with signs and symptoms of bladder injury will likely relay a history typical for pelvic trauma. This is fairly straightforward, and generally includes motor vehicle collisions, deceleration injuries, or assaults to the lower abdomen. If the patient is unconscious, family members or emergency services personnel may be able to provide the history.
Typical histories in patients with bladder trauma include the following:
Frequency of bladder rupture varies according to the mechanism of injury, as follows:
Approximately 60%-85% of bladder injuries result from blunt trauma, while 15%-40% are from penetrating injury. The most common mechanisms of blunt trauma are motor vehicle collision (87%), fall (7%), and assault (6%). In penetrating trauma, the most frequent culprit is gunshot wound (85%), followed by stabbing (15%).
Approximately 10%-25% of patients with pelvic fracture also have urethral trauma. Conversely, 10%-29% of patients with posterior urethral disruption have an associated bladder rupture.
Extraperitoneal bladder perforation accounts for 50%-71% of bladder rupture, while 25%-43% are intraperitoneal, and 7%-14% are combined.[6, 7] The incidence of intraperitoneal bladder rupture is significantly higher in children because of the predominantly intraabdominal location of the bladder before puberty.
Combined intraperitoneal and extraperitoneal rupture accounts for approximately 10% of all perforating traumatic bladder injuries. Mortality rates in these patients approach 60% while only 17%-22% of overall bladder injury results in death. This emphasizes the severity of the concomitant injuries associated with combined bladder rupture.
Among patients with bladder trauma from gunshot, an 83% incidence of associated bowel injury is reported. Colon injuries are noted in 33% of patients with stab wounds, while vascular injuries occur in nearly 82% of patients with a penetrating trauma and carry a 63% mortality rate.
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. The propensity of the bladder to sustain injury is positively associated with its degree of distention at the time of trauma. A blunt blow to the abdomen, as with a punch or kick, can rupture the bladder when full; similarly, bladder rupture has been documented in children struck in the abdomen by a soccer ball while playing the sport.[8, 9, 10]
Both gunshot and stabbing are examples of penetrating trauma. Often, these patients incur concomitant injury to other abdominal and/or pelvic organs.
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. Unrecognized bladder injuries may lead to vesicouterine fistulas and other problems.
Bladder injury may occur during vaginal or abdominal hysterectomy. Blind dissection in the incorrect tissue plane between the base of the bladder and the cervical fascia is generally the maneuver implicated in such.
Perforations of the bladder during bladder biopsy, cystolitholapaxy, 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%.
Orthopedic hardware can easily perforate the urinary bladder, particularly during internal fixation of pelvic fractures. Additionally, thermal injuries to the bladder may occur during the setting of cement substances used to seat arthroplasty prosthetics.
Patients diagnosed with alcoholism and individuals who chronically imbibe a large quantity of fluids are susceptible to idiopathic bladder injury. Previous bladder surgery is a risk factor for such, as areas of scarring are weakened and prone to rupture. In reported cases, all bladder ruptures were intraperitoneal. 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.
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 commonly results from blunt trama or extreme physical activity (eg, long-distance running). Patients typically present with gross hematuria. On cystography, the bladder usually appears normal, or it may have a teardrop shape secondary to compression by the hematoma.
Bladder contusion is relatively benign. It is self-limiting and requires no specific therapy, except for rest until hematuria resolves. Nevertheless, it should remain a diagnosis of exclusion. Persistent hematuria or unexplained lower abdominal pain requires further investigation.
Traumatic extraperitoneal rupture is usually (89%-100%) associated with pelvic fracture. Previously, 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 coincidental 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.
Extraperitoneal rupture is usually associated with fracture of the anterior pubic arch. When this occurs, the anterolateral aspect of the bladder is typically perforated by bony spicules. Forceful disruption of the bony pelvis or the puboprostatic ligaments also tears the bladder wall. In such instances, the degree of bladder injury is directly related to the severity of the fracture.
A mechanism similar to intraperitoneal bladder rupture is thought to underly some extraperitoneal bladder injuries. Specifically, this is the combination of trauma with bladder overdistention, leading to a burst injury.
The classic cystographic finding is contrast extravasation around the base of the bladder, confined to the perivesical space. Often, areas of contrast extravasation shaped like flames, feathers, or starbursts are noted adjacent to the bladder. Additionally, the bladder may assume a teardrop shape secondary to compression from a pelvic hematoma.
With a more complex injury, contrast material can extend 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, 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 through contiguous tissue planes. Sometimes, extravasation of contrast through the inguinal canal and into the scrotum or labia majora can occur. See the image below.
CT scan of extraperitoneal bladder rupture. The contrast extravasates from the bladder into the prevesical space.
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 likey 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.
Intraperitoneal bladder rupture generally occurs as the result of a direct blow to a distended urinary bladder. Deceleration injuries can also cause such phenomena. This type of injury is most common in alcoholics and victims of seatbelt or steering wheel trauma. Otherwise, it is more common in children due to the relative intraabdominal bladder position that persists until approximately 20 years of age.
Since urine will generally continue to drain into the abdomen through the open bladder wall defect, intraperitoneal ruptures may go undiagnosed for variable lengths of time. Metabolic and electrolyte abnormalities (eg, hyperkalemia, hypernatremia, uremia, acidosis) may occur as urine is reabsorbed through the peritoneal cavity. Additionally, such patients may appear anuric.
The diagnosis is established when urinary ascites are recovered during paracentesis or the leak is confirmed on imaging. Intraperitoneal rupture demonstrates contrast extravasation into the peritoneal cavity. The contrast media will often outline loops of bowel, fill the paracolic gutters, and pool under the diaphragm. See the image below.
Cystogram of intraperitoneal bladder rupture. The contrast enters the intraperitoneal cavity and outlines loops of bowel.
Diagnostic imaging with cystogram will reveal contrast outlining the abdominal viscera and perivesical space. Oftentimes this may be observed in penetrating trauma, where the bladder is traversed by a high-velocity bullet, impaled by a knife, or penetrated by another foreign body. This through-and-through injury creates a combined intraperitoneal and extraperitoneal bladder rupture. See the image below.
Cystogram of extraperitoneal bladder rupture. Note the fractured pelvis and contrast extravasation into the space of Retzius.
The high incidence of associated abdominal visceral and vascular injury mandates surgical exploration in virtually every case of combined intraperitoneal and extraperitoneal rupture. Cystography can be falsely negative in penetrating bladder injuries secondary to small-caliber wounds, although the capabilities of cross-sectional imaging with computed tomographic cystography have improved recently. However, it is often not the suspected bladder injury alone that drives the consideration for operative intervention. As a result, the diagnosis of such injuries is commonly made during exploratory laparotomy.
Clinical signs of bladder injury are relatively nonspecific. Patients often present with the triad of gross hematuria, suprapubic pain or tenderness, and difficulty urinating or inability to void.
Hematuria invariably accompanies bladder injury. Gross hematuria is the hallmark of bladder rupture but is not unique to the injury. Almost every (98%) bladder rupture is accompanied by hematuria. Gross hematuria does not always occur, however; in approximately 10% of cases, the hematuria is microscopic.
Most patients with bladder rupture complain of suprapubic or abdominal pain but many can still void. The ability to urinate does not exclude bladder injury or perforation, however.
An abdominal examination may reveal distention, guarding, or rebound tenderness. Absent bowel sounds and signs of peritoneal irritation indicate possible intraperitoneal bladder rupture. A rectal examination should be performed to exclude rectal injury, and in males, to evaluate prostate location. If the prostate is "high riding" or elevated, proximal urethral disruption should be suspected. In the setting of motor vehicle collision or crush injury, bilateral palpation of the bony pelvis may reveal abnormal laxity or mobility, indicating an open-book fracture or disruption of the pelvic girdle.
If blood is present at the urethral meatus, suspect a urethral injury. Perform retrograde urethrography to assess the integrity of the urethra. It is crucial that urethral integrity be confirmed before attempting to blindly pass a urethral catheter.
In a trauma situation, blood at the urethral meatus is an absolute indication for retrograde urethrography. Approximately 10-20% of men with posterior urethral injury have an associated bladder injury. Therefore, it is critical that no attempt at blind passage of a urethral catheter is made. Doing such may tear a partially disrupted urethra and convert it into a completely disrupted urethra. Only after urethral injury is excluded should urethral catheter placement be attempted. In the setting of a posterior urethral injury, placement of a suprapubic (cystotomy) tube, via an open or percutaneous approach, is generally pursued. Otherwise, direct inspection of the bladder during surgical exploration, if indicated, can be carried out.
In adults, the bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the space of Retzius. The dome of the bladder is covered by peritoneum and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia as well as by true ligaments of the pelvis.
In males, the bladder neck is contiguous with the prostate, which is attached to the pubis by puboprostatic ligaments. In females, pubourethral ligaments support the bladder neck and urethra.
The body of the bladder receives support from the urogenital diaphragm inferiorly and the obturator internus muscles laterally. The superior fascia of the urogenital diaphragm is continuous and includes the pelvic, obturator, and endopelvic fasciae. The inferior fascia of the urogenital diaphragm fuses with Colle's fascia and continues as Scarpa's fascia anteriorly. The dartos muscle and fascia in the scrotum as well as the fascia lata of the thigh are further continuations of this layer.
The type of extravasation (intraperitoneal or extraperitoneal) from a bladder injury depends upon the location of the laceration and its relationship with the peritoneal reflection, as follows:
With an anterosuperior perforation, urinary extravasation may be intraperitoneal, extraperitoneal (space of Retzius), or both. If the tear is posterosuperior, fluid can spread intraperitoneally and retroperitoneally, as well. With bladder rupture, the superior fascia of the urogenital diaphragm, when intact, prohibits extravasated urine from escaping the pelvis, while the inferior fascia of the urogenital diaphragm, when intact, prevents urinary extravasate from flowing into the perineum.
Posterior urethral injury is a contraindication to urethral catheter insertion. Such an injury should be suspected if blood is present at the urethral meatus, in all pelvic fractures, or if a high-riding prostate is found on digital rectal examination.
When posterior urethral injury is suspected, assess urethral intactness via retrograde urethrogram prior to any attempts at urethral catheter insertion.
A basic retrograde urethrogram is performed as follows:
After posterior urethral injury is excluded and a catheter has been inserted, the radiographic workup to assess for bladder injury may commence. However, in the presence of urethral injury, a suprapubic (cystotomy) tube must be placed, either in an open or percutaneous fashion, and primary urethral realignment attempted once the patient is stable. This can help prevent severe urethral stricture formation.
Alternatively, primary urethral realignment may be attempted at bedside via flexible cystoscopy and guidewire placement. This procedure may eliminate the need for subsequent formal urethroplasty.
In the subacute setting, the serum creatinine level can aid in the diagnosis of bladder rupture. In the absence of acute kidney injury and urinary tract obstruction, elevated serum creatinine can be indicative of a urinary tract leak with systemic reabsorption of the excreted creatinine. A creatinine level alone is not diagnostic, however, and further workup is required when clinical suspicion for bladder leak exists.
Often, computed tomography (CT) is the first test performed in patients with blunt abdominal trauma. Cross-sectional images through the pelvis provide information on the status of both the pelvic organs and bony structures. This modality, and specifically CT cystography, has also largely replaced conventional plain film or fluoroscopic cystography as the most sensitive means for identifying bladder perforation.
A CT cystogram is performed by filling the bladder with contrast via urethral catheter (once urethral injury has been excluded) and performing a non-contrast abdominopelvic CT scan to assess for extravastion. Imaging in this manner is able to detect even subtle perforations and can often clearly define whether the leaks are intraperitoneal or extraperitoneal.
The historical standard for imaging suspected bladder injury is well-performed cystography. Although the ideal examination is performed under fluoroscopy, clinical circumstances often do not permit this. In such cases, plain film cystography is performed. The study can easily be completed at bedside using portable imaging equipment.
While most trauma patients with bladder perforation have multiple injuries and CT imaging is a regular part of the trauma evaluation, this does not preclude obtaining a separate cystogram if bladder findings on the CT scan are equivocal.11 A properly performed cystogram consists of an initial kidney-ureter-bladder (KUB) film followed by both anteroposterior (AP) and oblique views of the bladder filled with contrast as well as another AP film obtained after contrast drainage.
The following procedure is recommended, if urethral injury is excluded and a urethral catheter can be placed:
In children, determine the estimated filling volume for the cystogram using the following formula:
Bladder capacity = 60 mL + [(30 mL) x (Years of Age)]
The importance of properly executed filling and post-drainage films is paramount. Injuries may be missed if the cystogram is not performed correctly. A well-performed static cystogram has 85-100% accuracy at detecting leaks.
Oblique films may be difficult to obtain in a trauma patient with pelvic fractures. As such, they may be omitted in selected cases.
The volume infused is less important than achieving adequate bladder distention. With sufficient bladder distention, intravesical pressure will rise high enough to cause extravasation of contrast even in patients with small bladder injuries. False-negative readings might otherwise occur with small puncture wounds or lacerations, which may be self-sealing because of mucosal edema or may be sealed by overlying hematomas, omentum, sigmoid colon, small bowel, or other pelvic viscera.
If the patient is immediately taken to the operating room for surgical exploration, inspection of the bladder can be performed. At this time, if urethral injury is excluded a urethral catheter can be placed. Otherwise, a suprapubic cystotomy can be made and catheter inserted in an open fashion.
Thereafter, the bladder can be thoroughly inspected for perforation and distended with irrigation to aid in doing such. The use of intravenous indigo carmine or methylene blue to dye the urine can also aid in visualizing urinary extravasation.
If surgery is delayed or not indicated, access to the bladder is obtained via urethral or suprapubic catheterization. A CT or plain film cystogram can then be obtained to ensure that a bladder injury is not overlooked.
Tissue is not generally taken for histology in the setting of bladder injury and repair. However, if bladder perforation occurs secondary to a disease process originating from or adjacent to the bladder wall, specimens may be sent for analysis. Results would be reflective of the underlying condition.
Bladder trauma produces ruptures that are classified as one of the following:
Most extraperitoneal bladder leaks can be effectively managed with maximal bladder drainage per urethral or suprapubic catheter. Depending on the presumed size of the bladder defect, the bladder should be drained for 10 to 14 days and then assessed for healing via cystogram. Approximately 85% of such injuries will heal within 7 to 10 days, at which point the catheter can be removed and trial of voiding completed.[13, 14] Overall, nearly all extraperitoneal bladder injuries heal within 3 weeks. However, if surgery is pursued for other indications, extraperitoneal bladder injuries may be repaired surgically in the same setting if the patient is stable.
Essentially every intraperitoneal bladder rupture requires surgical management.[15, 16] Such an injury will not usually heal with prolonged bladder drainage alone, as urine will continue to leak into the abdominal cavity despite the presence of a functional catheter. This results in metabolic derangements and can produce urinary ascites, abdominal distention, and even ileus. All gunshot wounds to the abdominopelvic region should be surgically explored, as the likelihood of injuries to other abdominal organs and vascular structures is high. At that time, any concurrent bladder injury can be directly repaired.
Bladders with extensive extraperitoneal extravasation are often repaired surgically. In cases where surgical exploration for other injuries is pursued, minor extraperitoneal leaks can be repaired, as well. This facilitates more rapid healing and decreases the potential for complications, as well as the necessary duration of indwelling catheter use in many cases.
In the trauma setting, closure of bladder defects is usually performed in a two-layer fashion. With iatrogenic injury, some surgeons routinely close the bladder in one layer with success. In either manner, a running suture is placed to obtain a water-tight closure. Only absorbable suture should be used on the bladder, as permanent sutures serve as a nidus for later stone formation and infection. Similar to nonoperative management of bladder leaks, an indwelling catheter is left for at least 10 to 14 days to facilitate healing of the defect. A cystogram is done prior to catheter removal.
In any trauma setting, the Advanced Trauma Life Support protocol should be followed first and foremost. With the patient stabilized in anticipation of surgical intervention, broad-spectrum antibiotics should be administered. In a non-emergent setting, informed consent should be obtained if possible, from the patient, family member, or person holding medical power of attorney, as appropriate.
A standard repair of bladder injury in the trauma setting is performed as follows:
Postoperative management following bladder trauma repair is as follows:
Potential complications of bladder surgery include, but are not limited to, the following:
Despite technically proper reconstruction, urinary extravasation through the bladder closure may occur. Generally, this will resolve with extended catheter drainage. An abdominal fascial dehiscence presents as persistent drainage from the incision site, which should not be confused with a urine leak.
Violation of a pelvic hematoma during surgery may result in severe hemorrhage. A pelvic hematoma may be seeded by bacteria or fungus at the time of injury or surgery, and subsequently become a pelvic abscess.
Lastly, necessary aggressive surgical debridement may result in a small bladder capacity, which can result in urinary urgency and urge incontinence. However, over time these symptoms may resolve, as the bladder will generally enlarge.
Traumatic bladder rupture, once uniformly fatal, is now managed successfully with or without surgery, depending upon the type of injury. It is difficult to cite a single specific rate of successful bladder repair due to the wide variety of concurrent trauma these patients often present with. Regardless, critical to the successful management of traumatic bladder rupture are a timely evaluation, accurate diagnosis, and proper management based on the location and severity of the bladder leak.
The most recent American Urological Association Guidelines on Urotrauma, published in 2014, state that "surgeons must perform surgical repair of intraperitoneal bladder rupture in the setting of blunt or penetrating external trauma" and that "clinicians should perform catheter drainage as treatment for patients with uncomplicated extraperitoneal bladder injuries."
Nevertheless, the literature contains a handful of case reports describing intraperitoneal bladder rupture managed conservatively. Two such reports describe successful treatment of small ruptures in patients with a benign abdomen, using prolonged large-diameter urethral catheter drainage and antibiotic prophylaxis. The authors warn that communication with the peritoneal cavity may persist, and advise open surgical management if clinical deterioration occurs (eg, uremia, infection) or follow-up cystography demonstrates a persistent leak.
Similarly, two recent studies found that patients who undergo open repair of extraperitoneal injuries have lower rates of persistent urine leak than patients treated with urethral catheter drainage.[19, 20] In the absence of a randomized trial comparing open repair and conservative managemen, the authors advocate performing open bladder repair in patients who will be undergoing surgery for other reasons.