Bladder trauma

Clinical significance

Bladder trauma occurs with pelvic fractures (blunt trauma) or penetrating injuries.

Classification:

• Intraperitoneal rupture (more common in a distended bladder).
• Extraperitoneal rupture (more common with pelvic fractures).

Clinical presentation

• Lower abdominal pain.
• Hematuria.
• Inability to void.
• Peritoneal signs in intraperitoneal rupture.
• Intraperitoneal fluid in intraperitoneal rupture.

Diagnosis

• Perform CT cystography with active retrograde filling of the bladder using diluted contrast, usually 300–350 mL in an adult, to achieve adequate distension. Passive contrast accumulation during the excretory phase does not exclude rupture.
• Retrograde cystography if CT is unavailable.
• Ultrasonography for initial assessment.

Emergency management

• Simple extraperitoneal rupture is usually managed with an indwelling catheter, with follow-up imaging before removal as clinically indicated. There is no universal catheter duration or requirement for antibiotics in every patient.
• Traumatic intraperitoneal rupture requires surgical repair after initial stabilization and control of life-threatening injuries.
• Hemodynamic instability requires immediate control of life-threatening injuries. Decide the timing of bladder repair as part of the overall trauma operation rather than automatically deferring it.
• Complex extraperitoneal rupture includes bladder neck injury, an intraluminal bone fragment, rectal or vaginal injury, bladder wall entrapment, or concurrent pelvic surgery. Surgical repair is often required in these situations.

Algorithm