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Emergency and Acute Medicine – Bladder Injury
Overview and Definitions
Bladder injury most commonly results from blunt trauma. Approximately 10% of patients with pelvic fractures sustain significant bladder injury, and 80–90% of bladder ruptures are associated with pelvic fractures. Overall mortality ranges from 17–22%, increasing to nearly 60% in combined intraperitoneal and extraperitoneal ruptures.
Etiology and Classification
Trauma accounts for about 82% of bladder injuries. Blunt mechanisms include motor vehicle accidents (87%), falls (7%), and assault (6%). Penetrating injuries are most often due to gunshot wounds (85%) and stabbings (15%). Iatrogenic causes account for 14% and include TURP, urologic, gynecologic, obstetric, abdominal, and orthopedic hip procedures, biopsies, indwelling Foley catheters, and IUD placement. Intoxication accounts for 2.9%, and spontaneous rupture occurs in less than 1%.
Extraperitoneal rupture (62%) is usually associated with pelvic fractures and results from blunt force or bone fragments. Intraperitoneal rupture (25%) occurs from direct compression of a distended bladder, typically involving the bladder dome. Combined intraperitoneal and extraperitoneal rupture (12%) carries the highest mortality due to associated injuries. Bladder contusion involves injury to the endothelial lining or muscularis with an intact bladder wall and may cause gross hematuria with normal imaging; it usually resolves without intervention.
In children, the bladder is intra-abdominal until late adolescence, making intraperitoneal rupture more common and overall bladder injury more frequent due to a less rigid pelvis.
Clinical Presentation
The classic triad includes gross hematuria, suprapubic pain, and difficulty voiding. History should focus on traumatic mechanism or recent procedures. On examination, the urethral meatus must be inspected; if blood is present, Foley catheter placement should be deferred until a retrograde urethrogram is performed, as concomitant urethral injury occurs in 10–29% of cases.
Evaluation and Diagnostic Testing
Initial evaluation includes urinalysis, which shows gross hematuria in 95–100% of significant injuries and microscopic hematuria in about 5%. BUN may be elevated due to intraperitoneal urine resorption, and electrolyte abnormalities such as hyperkalemia or hypernatremia may be present.
Retrograde cystography or CT cystography is the diagnostic modality of choice, with sensitivity around 95% and specificity near 100%. If urethral injury is suspected, a retrograde urethrogram is performed first. Proper cystography requires adequate bladder distension with diluted contrast and postdrainage imaging, as up to 10% of ruptures are detected only after bladder emptying. Extraperitoneal ruptures show teardrop- or star-shaped extravasation, whereas intraperitoneal ruptures demonstrate contrast outlining bowel loops or filling paracolic gutters. FAST examination showing free pelvic fluid should heighten suspicion for bladder injury.
Differential Diagnosis
Consider peritoneal trauma, urethral injury, and renal or ureteral trauma.
Management
Prehospital bladder catheterization should be avoided. Initial management follows standard ABCs with early urologic consultation. Extraperitoneal nonpenetrating ruptures may be managed with Foley catheter drainage (20F or larger) for approximately 14 days, with most lacerations sealing within 3 weeks; surgical repair is recommended if the patient is undergoing pelvic or abdominal surgery for other injuries. Intraperitoneal ruptures require surgical exploration and repair. Bladder contusions require no specific intervention. Broad-spectrum antibiotics are indicated for intraperitoneal rupture.
Disposition and Follow-Up
Admission is required for patients with associated major trauma or those needing surgical intervention. Bladder contusions without rupture and without other injuries may be discharged. Most bladder ruptures require admission, and discharge should occur only after urologic clearance. Urology follow-up is required for all outpatient-managed injuries, with Foley catheter removal typically at 14 days for conservatively managed extraperitoneal ruptures.
Clinical Insights and Common Errors
Free pelvic fluid on CT or ultrasound should prompt concern for bladder injury. Unresponsive, intoxicated, or altered patients require careful evaluation. Any penetrating injury to the lower abdomen with hematuria warrants cystography.
Overview and Definitions
Bladder injury most commonly results from blunt trauma. Approximately 10% of patients with pelvic fractures sustain significant bladder injury, and 80–90% of bladder ruptures are associated with pelvic fractures. Overall mortality ranges from 17–22%, increasing to nearly 60% in combined intraperitoneal and extraperitoneal ruptures.
Etiology and Classification
Trauma accounts for about 82% of bladder injuries. Blunt mechanisms include motor vehicle accidents (87%), falls (7%), and assault (6%). Penetrating injuries are most often due to gunshot wounds (85%) and stabbings (15%). Iatrogenic causes account for 14% and include TURP, urologic, gynecologic, obstetric, abdominal, and orthopedic hip procedures, biopsies, indwelling Foley catheters, and IUD placement. Intoxication accounts for 2.9%, and spontaneous rupture occurs in less than 1%.
Extraperitoneal rupture (62%) is usually associated with pelvic fractures and results from blunt force or bone fragments. Intraperitoneal rupture (25%) occurs from direct compression of a distended bladder, typically involving the bladder dome. Combined intraperitoneal and extraperitoneal rupture (12%) carries the highest mortality due to associated injuries. Bladder contusion involves injury to the endothelial lining or muscularis with an intact bladder wall and may cause gross hematuria with normal imaging; it usually resolves without intervention.
In children, the bladder is intra-abdominal until late adolescence, making intraperitoneal rupture more common and overall bladder injury more frequent due to a less rigid pelvis.
Clinical Presentation
The classic triad includes gross hematuria, suprapubic pain, and difficulty voiding. History should focus on traumatic mechanism or recent procedures. On examination, the urethral meatus must be inspected; if blood is present, Foley catheter placement should be deferred until a retrograde urethrogram is performed, as concomitant urethral injury occurs in 10–29% of cases.
Evaluation and Diagnostic Testing
Initial evaluation includes urinalysis, which shows gross hematuria in 95–100% of significant injuries and microscopic hematuria in about 5%. BUN may be elevated due to intraperitoneal urine resorption, and electrolyte abnormalities such as hyperkalemia or hypernatremia may be present.
Retrograde cystography or CT cystography is the diagnostic modality of choice, with sensitivity around 95% and specificity near 100%. If urethral injury is suspected, a retrograde urethrogram is performed first. Proper cystography requires adequate bladder distension with diluted contrast and postdrainage imaging, as up to 10% of ruptures are detected only after bladder emptying. Extraperitoneal ruptures show teardrop- or star-shaped extravasation, whereas intraperitoneal ruptures demonstrate contrast outlining bowel loops or filling paracolic gutters. FAST examination showing free pelvic fluid should heighten suspicion for bladder injury.
Differential Diagnosis
Consider peritoneal trauma, urethral injury, and renal or ureteral trauma.
Management
Prehospital bladder catheterization should be avoided. Initial management follows standard ABCs with early urologic consultation. Extraperitoneal nonpenetrating ruptures may be managed with Foley catheter drainage (20F or larger) for approximately 14 days, with most lacerations sealing within 3 weeks; surgical repair is recommended if the patient is undergoing pelvic or abdominal surgery for other injuries. Intraperitoneal ruptures require surgical exploration and repair. Bladder contusions require no specific intervention. Broad-spectrum antibiotics are indicated for intraperitoneal rupture.
Disposition and Follow-Up
Admission is required for patients with associated major trauma or those needing surgical intervention. Bladder contusions without rupture and without other injuries may be discharged. Most bladder ruptures require admission, and discharge should occur only after urologic clearance. Urology follow-up is required for all outpatient-managed injuries, with Foley catheter removal typically at 14 days for conservatively managed extraperitoneal ruptures.
Clinical Insights and Common Errors
Free pelvic fluid on CT or ultrasound should prompt concern for bladder injury. Unresponsive, intoxicated, or altered patients require careful evaluation. Any penetrating injury to the lower abdomen with hematuria warrants cystography.
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