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Bladder Injury, Emergency Medicine

Basics

Description

- Classification: - Extraperitoneal bladder rupture (62%): - Associated with pelvic fractures - Caused by blunt force or fracture fragments

- Bladder contusion: - Damage to endothelial lining or muscularis layer with intact bladder wall - Gross hematuria after extreme physical activity (long-distance running) - Gross hematuria with normal imaging - Usually resolves without intervention

- Retrograde cystography and retrograde CT cystography are the methods of choice to diagnose a ruptured bladder. Both studies have reported sensitivity and specificity of 95% and 100% respectively. - If urethral injury is suspected, the cystogram is performed after a RUG. - Cystography technique: - Kidneys/ureter/bladder (KUB) scout film - Infuse 100 mL of diluted contrast via Foley into bladder. Contrast material needs to be diluted: 30% or 6:1 saline; otherwise it is too dense. - Plain film is repeated to evaluate early extravasation. - If initial film is normal, fill rest of bladder with diluted contrast: - Min. 300-350 mL total for adult - 3-5 mL/kg or 60 mL + (age in yr — 30) for children or until discomfort

  • Blunt trauma is the most common mechanism.
  • 10% of pelvic fractures have serious bladder injury.
  • 80-90% of bladder ruptures have pelvic fracture.
  • Mortality: 17-22% overall; 60% if combined intraperitoneal/extraperitoneal rupture

Etiology

  • Mechanism:Trauma, 82%Blunt trauma: Motor vehicle accident (MVA; 87%), falls (7%), assault (6%)Penetrating: Gunshot wound (GSW) (85%), stabbings (15%)Iatrogenic 14%: TURP and urologic procedures, gynecologic procedures, obstetric procedures, abdominal procedures, hernia repair, intrauterine device (IUD), orthopedic hip procedures, biopsies, indwelling FoleyIntoxication 2.9%Spontaneous <1%
  • Classification:Extraperitoneal bladder rupture (62%):Associated with pelvic fracturesCaused by blunt force or fracture fragmentsIntraperitoneal bladder rupture (25%):Direct compression of distended bladderCaused by rupture of the dome of the bladderCombined extraperitoneal and intraperitoneal rupture (12%):Highest mortality owing to associated injuriesBladder contusion:Damage to endothelial lining or muscularis layer with intact bladder wallGross hematuria after extreme physical activity (long-distance running)Gross hematuria with normal imagingUsually resolves without intervention
  • In children, the bladder is an intra-abdominal organ and descends into the pelvis by age 20 yr.
  • Intraperitoneal rupture is more common in children than adults because the bladder is an abdominal organ.
  • Bladder injury is more common in children than in adults because the pediatric bony pelvis is less rigid and transmits more force to adjacent structures.

Diagnosis

Signs and Symptoms

Triad:

  • Gross hematuria
  • Suprapubic pain
  • Difficulty voiding

History

Establish potential mechanism.

Physical Exam

Evaluate urethral meatus-if blood is present, do not insert Foley catheter until retrograde urethrogram (RUG) is performed (concomitant urethral and bladder injuries occur in 10-29% of patients).

Essential Workup

  • History of trauma or procedures
  • Evaluate urethral meatus for blood.
  • Urinalysis (UA)
  • Retrograde cystography

Diagnosis Tests & Interpretation

Lab

  • UA:Gross hematuria in 95-100% of patients with significant bladder or urethral traumaMicroscopic hematuria in 5%
  • BUN and creatinine:The BUN can be elevated from resorption of urine within the peritoneum.
  • Electrolytes:Hyperkalemia and hypernatremia may result from resorption of urine within the peritoneum.

Imaging

  • Retrograde cystography and retrograde CT cystography are the methods of choice to diagnose a ruptured bladder. Both studies have reported sensitivity and specificity of 95% and 100% respectively.
  • If urethral injury is suspected, the cystogram is performed after a RUG.
  • Cystography technique:Kidneys/ureter/bladder (KUB) scout filmInfuse 100 mL of diluted contrast via Foley into bladder. Contrast material needs to be diluted: 30% or 6:1 saline; otherwise it is too dense.Plain film is repeated to evaluate early extravasation.If initial film is normal, fill rest of bladder with diluted contrast:Min. 300-350 mL total for adult3-5 mL/kg or 60 mL + (age in yr — 30) for children or until discomfortIt is essential to have a bladder full of contrast for diagnosis; it is not sufficient to place contrast and clamp Foley in antegrade fashion.Cystogram films taken in AP, lateral, and oblique views (oblique may be difficult in trauma and CT is often used)Empty bladder and obtain a postdrainage film unless CT cystography obtained.Postdrainage film is essential without CT cystography-10% of bladder ruptures are seen only on postdrainage film; a distended bladder may hide extravasation.
  • Cystography interpretation:Extraperitoneal rupture: Tear drop- or star-shaped formIntraperitoneal rupture: Outlining of bowel or contrast within the paracolic gutters

Diagnostic Procedures/Surgery

  • FAST scan:Free pelvic fluid should raise concern for bladder injury.

Differential Diagnosis

  • Peritoneal trauma
  • Urethral trauma
  • Renal or ureteric trauma

Treatment

Pre-Hospital

Do not attempt bladder catheterization in the field.

Initial Stabilization/Therapy

  • ABCs
  • Early urologic consultation

Ed Treatment/Procedures

  • Urologic consultation is needed when bladder rupture is diagnosed.
  • Extraperitoneal nonpenetrating ruptures may be managed by catheter drainage:20F Foley or larger for 14 days80% of lacerations will seal in 3 wk.If patient is undergoing abdominal or pelvic surgery for other injury, surgical repair is recommended.
  • Intraperitoneal ruptures require surgical exploration.
  • Bladder contusions do not need any specific interventions.

Medication

Broad-spectrum antibiotics for intraperitoneal rupture

Follow-Up

Disposition

Admission Criteria

  • Concurrent major trauma requiring admission or observation
  • Surgical intervention required

Discharge Criteria

  • Bladder contusion with no rupture or other major trauma requiring admission
  • Most cases of bladder rupture will require admission; discharge only after clearance by urology and no other associated injuries.

Issues for Referral

Any bladder injury managed as an outpatient should have urologic referral.

Followup Recommendations

Follow-up to be arranged with urology:

  • Extraperitoneal bladder rupture with Foley catheter management will have Foley removal in 14 days.

Pearls and Pitfalls

  • Any free fluid on CT or US exam should raise suspicion for bladder injury.
  • Unresponsive, altered, and intoxicated patients warrant careful exam.
  • Penetrating injuries to lower abdomen with any degree of hematuria warrant cystography.

Additional Reading

  • Marx JA, Hockberger RS, Walls RM, et al., eds. Rosens Emergency Medicine Concepts and Clinical Practice. 8th ed. St. Louis, MO: Mosby; 2013.
  • Ramchadani P, Buckler PM. Imaging of genitourinary trauma. AJR Am J Roentgenol. 2009;192(6):1514-1523.
  • Uptodate.com
  • Wein AJ, Kavoussi LR, Novick AC, et al., eds. Cambell-Walsh Urology. 10th ed. Philadelphia, PA: WB Saunders; 2012.

See Also (Topic, Algorithm, Electronic Media Element)

  • Pelvic Fracture
  • Urethral Trauma
  • Trauma, Multiple

Codes

ICD9

  • 665.50 Other injury to pelvic organs, unspecified as to episode of care or not applicable
  • 867.0 Injury to bladder and urethra, without mention of open wound into cavity
  • 867.1 Injury to bladder and urethra, with open wound into cavity

ICD10

  • S37.20XA Unspecified injury of bladder, initial encounter
  • S37.23XA Laceration of bladder, initial encounter
  • S37.29XA Other injury of bladder, initial encounter
  • O71.5 Other obstetric injury to pelvic organs

SNOMED

  • 77165001 Injury of bladder (disorder)
  • 262907000 Traumatic rupture of bladder
  • 269160003 Closed injury of bladder (disorder)
  • 210216000 Open injury of bladder (disorder)
  • 237330001 Bladder injury - obstetric (disorder)