BLADDER TRAUMA

Bladder injuries may be secondary to blunt or penetrating trauma. Bladder rupture from blunt trauma is typically associated with pelvic fracture and gross hematuria. Thus, combining these two findings (hematuria + pelvic fracture) warrants retrograde plain film or CT cystography to evaluate for bladder injury.15 The bladder must be filled with at least 300cc of contrast and images with the bladder distended and the bladder emptied of contrast must be obtained to fully evaluate for contrast extravasation or intramural hematoma. Some of these bladder injuries may be small and additional views or further image reconstruction may be required in order to fully evaluate. Penetrating bladder injury must be excluded when the trajectory of the penetrating object is near the pelvis or lower abdomen.20 If possible, retrograde (plain film or CT) cystography should be performed before exploratory laparotomy. However, when imaging is not possible before abdominal exploration, large intraperitoneal bladder injuries can be rapidly excluded by filling the bladder in a retrograde fashion until distended (300 mL is usually sufficient in most patients) with sterile saline or dilute methylene blue via the Foley catheter and inspecting for leakage of the fluid into the peritoneal cavity. Unfortunately, extraperitoneal injuries cannot be reliably excluded using this technique.

While intraperitoneal bladder rupture must be repaired, most simple extraperitoneal injuries can be managed non-operatively with Foley catheter drainage for 10-14 days, depending on the extent of the damage (Figure 5). Conversely, complex extraperitoneal injuries will benefit from immediate repair. Examples of complex extraperitoneal bladder injury include pelvic fractures with bone fragments in the bladder lumen, concurrent rectal or vaginal lacerations, bladder neck injuries, severe gross hematuria with clot obstruction of the catheter, and when the patient is undergoing open repair of concurrent abdominal pelvic injuries in the stable patient.15 Bladder repair is performed using a two-layer closure with absorbable sutures and at least 2 weeks of bladder catheter drainage. It is safe to place a drain adjacent to a bladder repair, as long as the drain is in a dependent position and not immediately abutting the suture line. If the patient has concomitant injuries requiring bowel resection and anastomoses, care must be taken to avoid placing these in close proximity to the bladder repair. Fluid can be sent from the drain postoperatively to measure creatinine levels and assess for bladder leak. (See Bladder Injuries in Appendix A: Urological Diagnosis and Treatments.) It is important to note that bladder injury from penetrating trauma has a high incidence of concurrent rectal injury,23 and a rectal exam and proctoscopy are indicated.

Figure 5. Intraperitoneal Bladder Rupture. (Images courtesy of ZRM)