Management of Bladder Injuries
The management of bladder injuries depends primarily on whether the injury is intraperitoneal or extraperitoneal, with intraperitoneal bladder ruptures requiring surgical exploration and primary repair, while uncomplicated extraperitoneal bladder injuries can often be managed non-operatively with urinary drainage. 1
Classification and Initial Assessment
Types of Bladder Injuries:
- Bladder contusion: Bruising without rupture
- Extraperitoneal bladder rupture (EBR): Rupture below the peritoneal reflection
- Intraperitoneal bladder rupture (IBR): Rupture into the peritoneal cavity
- Combined rupture: Both intraperitoneal and extraperitoneal components
Clinical Presentation:
- Gross hematuria
- Suprapubic or abdominal pain
- Difficulty or inability to void
- Signs of peritonitis (in intraperitoneal rupture)
- Often associated with pelvic fractures (especially in extraperitoneal ruptures) 2
Diagnostic Approach
- CT cystography is the preferred diagnostic modality for suspected bladder injuries 1, 3
- Retrograde filling of the bladder with contrast and imaging when filled and after drainage 4
- Perform retrograde urethrography before attempting catheterization in patients with blood at the urethral meatus after pelvic trauma 5
Management Algorithm
1. Bladder Contusion:
- Requires no specific treatment
- Clinical observation only 1
2. Intraperitoneal Bladder Rupture (IBR):
- Requires surgical exploration and primary repair (Grade of Recommendation 1B) 1
- Repair options:
- In damage control situations with severe IBR:
- Temporary urinary diversion via bladder and perivesical drainage or external ureteral stenting 1
3. Extraperitoneal Bladder Rupture (EBR):
- Uncomplicated EBR: Non-operative management with urinary drainage via urethral or suprapubic catheter (Grade of Recommendation 1C) 1
- Healing occurs within 10 days in >85% of cases 1
- Complex EBR: Requires surgical exploration and repair (Grade of Recommendation 1C) 1
- Complex EBR includes:
- Bladder neck injuries
- Injuries associated with pelvic fractures requiring internal fixation
- Injuries associated with vaginal or rectal injuries
- Complex EBR includes:
- Consider surgical repair if urine extravasation persists 4 weeks after injury 1
- Consider surgical repair during laparotomy performed for other indications 1
4. Penetrating Bladder Injuries:
- Generally require surgical exploration and primary repair 1, 3
- Gunshot wounds often have associated rectal injuries requiring fecal diversion 1
- Thorough pelvic inspection is necessary for through-and-through injuries 1
Urinary Drainage Management
Adults:
- Urethral catheter alone is sufficient after surgical management of bladder injuries (Grade of Recommendation 1B) 1
- Routine placement of a suprapubic tube is no longer recommended 1
- Suprapubic catheterization may be reserved for cases with associated perineal injuries 1
Children:
- Suprapubic cystostomy is recommended after surgical repair (Grade of Recommendation 2C) 1
Special Considerations
- In hemodynamically unstable patients, insertion of urethral or suprapubic catheter may be a temporary measure with delayed repair 1
- Evaluate catheter necessity daily and remove as early as possible to minimize complications 5
- Monitor for urinary tract infections and signs of infection including fever, cloudy urine, or change in mental status 5
- In cases where urologists are not immediately available, general surgeons can manage select cases of traumatic bladder injuries with similar outcomes 6
Follow-up
- For conservatively managed EBR, urethrography should be performed every two weeks until complete healing 1
- Document daily assessment, urine characteristics, output, and any complications 5
By following this algorithm, clinicians can effectively manage bladder injuries while minimizing morbidity and mortality.