para>Lower rates of bladder injury in children with blunt trauma and pelvic fracture (1)[C]
RISK FACTORS
- Rapid deceleration injury
- Pelvic fracture
- Penetrating trauma to the pelvis
- Prior pelvic surgery
- Prior pelvic radiation
GENERAL PREVENTION
- Seat belts
- Void prior to driving
COMMONLY ASSOCIATED CONDITIONS
80-94% blunt bladder trauma associated with injuries to other structures
- Pelvic fracture is the most common associated injury.
- Urethral injury occurs in 15% of cases of bladder rupture (1)[C].
DIAGNOSIS
HISTORY
- Determine mechanism of injury: trauma (blunt or penetrating), surgery, or spontaneous.
- Gross hematuria and pelvic fracture (1,3)[B]
- Urinary retention (1,4)[C]
- Inability to void or oliguria (1,4)[C]
- Suprapubic pain (1,4)[C]
- Abdominal distention (1,4)[C]
PHYSICAL EXAM
- Abdominal exam: Assess for suprapubic tenderness, peritoneal signs, distention, bruising, laceration, surgical incisions, or scars (4)[C].
- Genitourinary exam: Assess for blood at the meatus, gross hematuria, ecchymosis, or hematoma (4)[C].
- Rectal exam: High-riding prostate-assess for concomitant urethral injury (4)[C].
- Vaginal Exam: Clear vaginal fluid after hysterectomy is concerning for unrecognized bladder and fistula formation.
- Catheterization to evaluate for gross hematuria (4)[C]
- If blood is seen at the meatus or a catheter cannot be easily passed, evaluate for a urethral injury with a retrograde urethrogram.
- Intraoperative findings with iatrogenic surgical injury to the bladder (1)[C]
- Gross hematuria
- Pneumaturia (air in the catheter) during laparoscopic or robotic procedure
DIFFERENTIAL DIAGNOSIS
Other urologic injury: urethral, ureteral, or renal injury causing gross hematuria
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Urinalysis may demonstrate microscopic hematuria.
- Basic metabolic panel: Elevated BUN/creatinine may be seen secondary to peritoneal absorption of urine after intraperitoneal ruptures (4)[C].
- Hemoglobin/hematocrit and PT/PTT: Evaluate in patients with gross hematuria.
- Cystogram (1,3,4)[B]
- Technique: Fill the bladder with a minimum of 300 mL of contrast or until discomfort. Need precontrast, full bladder, and postcontrast imaging with two views.
- Contusion: normal or distortion of bladder wall without extravasation
- Extraperitoneal perforation: flame-shaped perivesical contrast; teardrop deformity seen with compression from pelvic hematoma
- Intraperitoneal perforation: Contrast outlines bowel loops.
- CT cystogram: Bladder needs to be filled in a retrograde fashion similar to a cystogram. Dilute contrast should be used. Only one view is required with a full bladder. Unacceptably high rate of false-negative studies if the catheter is clamped, and IV contrast is allowed to fill the bladder in an antegrade fashion (1,3,4)[B].
- Absolute indication for a cystogram: blunt trauma, pelvic fracture, and gross hematuria (1,3,4)[B]
- Relative indication for a cystogram: blunt trauma, pelvic fracture, and microscopic hematuria or gross hematuria and a high index of suspicion (1,3,4)[C]
- Ultrasound is not an adequate study to diagnose or rule out bladder rupture (1)[C].
- Penetrating trauma usually requires operative exploration. Gross hematuria in the setting of penetrating trauma warrants either emergent exploration or a cystogram if the patient is clinically stable (1)[C].
- Intraoperatively, the bladder can be filled with methylene blue to see if there is extravasation into the operative field.
Follow-Up Tests & Special Considerations
Oliguric/anuric patient with ascites and risk factors needs to be ruled out for an intraperitoneal bladder rupture (1,3,4)[C].
TREATMENT
GENERAL MEASURES
- Place a catheter to drain the bladder.
- Control pain.
- Short course of prophylactic antibiotics
- Obtain appropriate labs and imaging studies.
- See "Surgery/Other Procedures" for details.
MEDICATION
First Line
- 3 days of prophylactic antibiotics to cover common uropathogens is recommended (i.e., ciprofloxacin 500 mg PO BID).
- Opioids as needed for pain control
- Anticholinergics/antispasmodics for bladder spasms (i.e., oxybutynin 5 mg PO TID PRN for bladder spasms)
ISSUES FOR REFERRAL
Whenever possible, urology should be consulted for all patients with bladder injury.
SURGERY/OTHER PROCEDURES
- Contusion: observation or catheter drainage until hematuria resolves (1)[C]
- Extraperitoneal bladder perforation (1,3)[C]
- Can be managed with catheter drainage alone for 10 to 14 days if otherwise uncomplicated; large-bore catheters are preferred for adequate drainage (20 to 22F).
- Indications for operative repair:
- Bladder neck injury
- Concomitant vaginal or rectal injury (concern for fistula formation)
- Bone fragments present in bladder wall (concern for poor healing)
- Orthopedic hardware required to fix pelvic fracture (concern for urine infecting hardware)
- Exploratory laparotomy for other associated injuries
- Surgical approach: exploratory laparotomy. Open the bladder and repair the defect intravesically with one- to two-layer closure of absorbable suture. Do not attempt to repair extravesically as a hematoma under tamponade may be released, causing serious bleeding.
- Intraperitoneal bladder perforation or penetrating injury (1,3,4)[B]
- Requires urgent operative repair
- D ©bridement of devitalized tissue
- Need to rule out concomitant ureteral injury either by passage of ureteral catheters or efflux of urine/methylene blue from the ureteral orifice
- Two-layer water-tight closure with absorbable suture
- Foley catheter should be left to drainage for 10 to 14 days.
- Suprapubic tube placement can be considered if concern for inadequate urethral catheter drainage but is otherwise not required (3,5)[B].
- Recommend leaving an intra-abdominal drain to control and test for a postoperative urine leak.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Trauma evaluation
- Hemodynamic stabilization and resuscitation
- All traumatic bladder injuries will require inpatient monitoring of hemodynamics, hematocrit, electrolytes, and renal function.
IV Fluids
Isotonic fluids for resuscitation
Nursing
- Ensure the catheter is draining.
- Irrigate clots as needed.
- Avoid continuous bladder irrigation if possible.
Discharge Criteria
- Pain is controlled.
- Patient able to void or catheter is draining with minimal hematuria.
- Patient can manage all injuries at home and activities of daily living.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patients with bladder perforation should undergo a cystogram prior to catheter removal around 10 to 14 days to rule out a persistent leak (3)[C].
DIET
No restrictions
PROGNOSIS
The goal is for patients to store urine and void volitionally to completion without complaint. If there is no associated neurologic injury, this is typically accomplished.
COMPLICATIONS
- Urinary tract infection
- Urine leak
- Abscess
- Fistula
- Bladder calculi
- Death (usually from other associated injuries)
REFERENCES
11 Gomez RG, Cabellos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int. 2004;94(1):27-32.22 Pereira BM, de Campos CC, Calderan TR, et al. Bladder injuries after external trauma: 20 years experience report in a population-based cross-sectional view. World J Urol. 2013;31(4):913-917.33 Morey AF, Brandes S, Dugi DDIII, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327-335.44 Morey AF, Iverson AJ, Swan A, et al. Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma. 2001;51(4):683-636.55 Parry NG, Rozycki GS, Feliciano DV, et al. Traumatic rupture of the urinary bladder: is the suprapubic tube necessary? J Trauma. 2003;54(3):431-436.
ADDITIONAL READING
Morey AF, Dugi DDIII. Genital and lower urinary tract trauma. In: Wein AJ, Kavoussi AC, Novick AW, et al, eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier Saunders; 2012.
SEE ALSO
Hematuria
CODES
ICD10
- S37.20XA Unspecified injury of bladder, initial encounter
- S37.29XA Other injury of bladder, initial encounter
- S37.22XA Contusion of bladder, initial encounter
- S37.23XA Laceration of bladder, initial encounter
- N32.89 Other specified disorders of bladder
ICD9
- 867.0 Injury to bladder and urethra, without mention of open wound into cavity
- 596.6 Rupture of bladder, nontraumatic
- 867.1 Injury to bladder and urethra, with open wound into cavity
- 998.2 Accidental puncture or laceration during a procedure, not elsewhere classified
- 596.9 Unspecified disorder of bladder
SNOMED
- Injury of bladder (disorder)
- Rupture of bladder (disorder)
- Traumatic rupture of bladder
- Contusion of bladder
CLINICAL PEARLS
- Bladder injuries are usually associated with blunt trauma and pelvic fracture.
- Gross hematuria is the most common presenting sign.
- A cystogram needs to be performed when a bladder injury is suspected.
- Bladder contusions and uncomplicated extraperitoneal injuries can be managed with catheter drainage alone.
- Intraperitoneal bladder perforations or complicated extraperitoneal injuries require urgent operative intervention.
- Catheter drainage is required until bladder is healed, usually around 10 to 14 days.
- A cystogram should be obtained prior to catheter removal to evaluate for a leak.
- Persistent leaks are most often managed conservatively with prolonged catheter drainage.