What is the treatment for a ruptured bladder?

Treatment of Ruptured Bladder

Intraperitoneal bladder ruptures must be surgically repaired, while uncomplicated extraperitoneal bladder ruptures can be managed with catheter drainage alone. 1

Classification of Bladder Ruptures

Bladder injuries are classified into:

1. Intraperitoneal bladder rupture (IBR) - 15-25% of cases
2. Extraperitoneal bladder rupture (EBR) - 60-90% of cases
3. Combined bladder rupture (CBR) - 5-12% of cases
4. Bladder contusion

Diagnostic Approach

• Clinical indicators: Gross hematuria with pelvic fracture or concerning mechanism, inability to void, suprapubic pain, abdominal distention
• Imaging: Retrograde cystography (conventional or CT) is essential for diagnosis and classification

Treatment Algorithm

1. Intraperitoneal Bladder Rupture

• Mandatory surgical repair regardless of whether caused by blunt or penetrating trauma 1
• Surgical options:
  • Open surgical repair (standard approach)
  • Laparoscopic repair (appropriate for isolated injuries in hemodynamically stable patients) 1
• Repair technique: Double-layer closure using monofilament absorbable suture (single-layer for laparoscopic approach) 1
• Follow-up cystography to confirm healing in complex repairs

2. Extraperitoneal Bladder Rupture

• Uncomplicated cases: Conservative management with urethral catheter drainage for 2-3 weeks 1
• Complicated cases requiring surgical repair:
  • Bladder neck injuries
  • Bone spicules exposed in bladder lumen
  • Concurrent rectal or vaginal lacerations
  • Non-healing injuries after 4 weeks of catheter drainage
  • Cases undergoing laparotomy for other reasons 1

3. Combined Bladder Rupture

• Requires surgical repair due to the intraperitoneal component 1

4. Special Considerations

• Hemodynamic instability: Temporary urethral or suprapubic catheter placement with delayed repair 1
• Pediatric patients: Suprapubic cystostomy is recommended after surgical repair 1
• Penetrating injuries: All penetrating bladder injuries with intraperitoneal components require surgical repair 1

Post-Treatment Follow-up

• CT scan with delayed phase imaging is the method of choice for follow-up 1
• For extraperitoneal injuries managed conservatively, follow-up cystography should confirm healing before catheter removal 1
• Catheter duration:
  • Standard: 2-3 weeks for extraperitoneal injuries
  • Consider longer duration with significant concurrent injuries
  • Consider surgical repair if non-healing after 4 weeks of catheter drainage 1

Common Pitfalls and Caveats

1. Diagnostic errors: Intravenous contrast studies are inadequate for diagnosis; retrograde cystography is required 2
2. Missed associated injuries: Check for concomitant urethral injuries (present in 10-29% of male patients) 1
3. Inadequate surgical exploration: During repair, confirm integrity of bladder neck and ureteral orifices 1
4. Gunshot wounds: These commonly have associated rectal injuries requiring careful pelvic inspection and possible fecal diversion 1
5. Delayed complications: Monitor for peritonitis and sepsis in untreated intraperitoneal ruptures 1

Early and appropriate management of bladder ruptures based on their classification is crucial for preventing complications and ensuring optimal outcomes in terms of morbidity, mortality, and quality of life.