BLADDER INJURY

BLADDER INJURY - Mitchell Cahan, MD; Michael Ford, MD
BASICS
DESCRIPTION
• Injury to the bladder is the result of trauma, either blunt or penetrating.
• Rupture is associated with a full bladder and blunt injury.
• Very rarely, an operative complication or nontraumatic etiology is the cause.
• Classification
- Intraperitoneal rupture
- Extraperitoneal (retroperitoneal) rupture
• Associated ureter/urethral injury
GENERAL PREVENTION
Seat belts
Incidence
~0.5% of trauma patients (1)
Blunt injuries are associated with pelvic fracture in over 95% of cases.
RISK FACTORS
• High-energy mechanism (fall, MVA)
• Pelvic fracture
• Penetrating wound
• Prior bladder/pelvic surgery
• Pelvic radiotherapy
PATHOPHYSIOLOGY
Rupture can lead to urinoma or peritonitis
ETIOLOGY
• High-energy trauma
• Rupture due to increased pressure in nondistensible (full) bladder
• Laceration due to bone fragment or penetrating object (knife, bullet)
ASSOCIATED CONDITIONS
• Pelvic fracture
• Ureteropelvic disjunction
• Urethral injury; almost exclusively in males
• Peritonitis is unusual in bladder injury.

DIAGNOSIS
PRE HOSPITAL
Isolated bladder injury is rare. Typically patient has other serious injuries.
SIGNS AND SYMPTOMS
• Pelvic/suprapubic pain
• Blood at meatus
• Urinary retention
History
• High-energy deceleration injury (fall, MVA)
• Penetrating trauma
- Recent abdominal/pelvic surgery
Physical Exam
• Suprapubic tenderness to palpation
• Blood at meatus
• Scrotal/urethral hematoma
- Free-floating prostate
- High-riding prostate
TESTS
Lab
Blood on urinalysis
• Serum creatinine and K+ are elevated and Na+ is decreased in intraperitoneal ruptures.
• Serum labs are unchanged in extraperitoneal ruptures (3).
Imaging
• Cystography is the gold standard for diagnosis.
• High-resolution CT scans also are acceptable.
ALERT
Retrograde urethrography must be performed before placing a Foley catheter when urethral injury is suspected.
Diagnostic Procedures/Surgery
• Intraperitoneal ruptures and penetrating injuries require urgent operative management.
• Extraperitoneal ruptures may be treated with Foley catheter drainage alone.
- Consider suprapubic tube if drainage is needed for >10 days.
Pathological Findings
• Perivesicular hematoma
• Perforation at dome of bladder (in trigone, near urachus)
• Jagged tear in bladder
DIFFERENTIAL DIAGNOSIS
• Isolated urethral injury
• Isolated pelvic fracture
• Isolated ureteral injury
• Other visceral rupture
TREATMENT
PRE-HOSPITAL
• Cervical spine precautions
• Stabilize hemodynamics.
• Stabilize pelvis.
STABILIZATION
Stabilize pelvis.
GENERAL MEASURES
• Foley catheter placement
• Pain control
• Antibiotics
• Antispasmodics (Ditropan)
• Imaging diagnosis
Diet
No restrictions
Activity
No restrictions
Nursing
Foley to gravity
Physical Therapy
May be necessary for associated pelvic fractures
IV Fluids
Ringer's lactated solution or normal saline for initial resuscitation
MEDICATION (DRUGS)
• Analgesics
• Antibiotics
• Antispasmodics
First Line
• Narcotic pain control (i.e., morphine, hydromorphone); titrate to effect
• Broad-spectrum antibiotics, such as ciprofloxacin 500 mg b.i.d.
• Ditropan 5-10 mg t.i.d. p.r.n. for spasm
ALERT
There is concern about fluoroquinolones causing damage to cartilage in children.
Second Line
• Broad-spectrum antibiotics
• Antispasmodics (i.e., flavoxate)
SURGERY
• Urgent surgery is indicated for intraperitoneal bladder rupture.
• Extraperitoneal rupture usually is manageable conservatively.
FOLLOW-UP
DISPOSITION
Admission Criteria
Admit all patients with bladder rupture for surgery or observation.
Discharge Criteria
• Stable for transfer to rehab or can perform ADLs
• Extraperitoneal ruptures controlled with indwelling Foley catheter if rupture not healed
• No evidence of infection
• Pain controlled
Issues for Referral
• All bladder ruptures should be evaluated by a urologist or surgeon immediately.
• Patient should be seen in follow-up by a urologist.
PROGNOSIS
Full return to normal function
COMPLICATIONS
• Infection
• Peritonitis
• Stricture is a rare complication
• Death
REFERENCES
1. Inaba K, McKenney M, Munera F, et al. Cystogram follow-up in the management of traumatic bladder disruption. J Trauma. 2006;60(1):23-28.
2. Lunetta P, Penttila A, Sajantila A. Fatal isolated ruptures of bladder following minor blunt trauma. Ugeskr Laeger. 2005;167(49):4654-4659.