Basics
Description
- 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 Foley
- Intoxication 2.9%
- Spontaneous <1%
- Classification:
- Extraperitoneal bladder rupture (62%):
- Associated with pelvic fractures
- Caused by blunt force or fracture fragments
- Intraperitoneal bladder rupture (25%):
- Direct compression of distended bladder
- Caused by rupture of the dome of the bladder
- Combined extraperitoneal and intraperitoneal rupture (12%):
- Highest mortality owing to associated injuries
- 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
- 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 trauma
- Microscopic 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 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
- It 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 form
- Intraperitoneal 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 days
- 80% 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)