Is the bladder located within the peritoneum?

Anatomical Position of the Bladder in Relation to the Peritoneum

The urinary bladder is not located within the peritoneum but is predominantly an extraperitoneal organ with only its superior surface (dome) covered by peritoneum. 1

Anatomical Relationship Between Bladder and Peritoneum

The bladder has a complex relationship with the peritoneum:

• Superior Surface (Dome): The only portion of the bladder that has peritoneal covering
• Anterior, Lateral, and Base: Entirely extraperitoneal
• Posterior Surface:
  • In males: Separated from the rectum by the rectovesical pouch
  • In females: Separated from the uterus by the vesicouterine pouch 1, 2

Peritoneal Spaces Around the Bladder

The bladder is surrounded by specific anatomical spaces:

• Perivesical Space: Contains the bladder, urachus, and obliterated umbilical arteries, surrounded by umbilicovesical fascia 3
• Prevesical Space: Larger space anterior and lateral to the umbilicovesical fascia 3
• Paravesical Spaces: Extraperitoneal spaces adjacent to the bladder 3, 4

Clinical Significance

Understanding the extraperitoneal position of the bladder is critical for:

1. Bladder Injury Classification and Management

• Intraperitoneal Bladder Rupture (30% of cases):

  • Occurs when the injury affects the dome of the bladder where it's covered by peritoneum
  • Requires immediate surgical repair 1, 2

• Extraperitoneal Bladder Rupture (60% of cases):

  • Occurs in the portions of the bladder not covered by peritoneum
  • Often associated with pelvic fractures
  • Can usually be managed non-operatively with catheter drainage 1

• Combined Intraperitoneal and Extraperitoneal Ruptures (10% of cases) 1

2. Diagnostic Implications

• Retrograde cystography (CT or conventional) is critical for determining whether bladder injuries are intraperitoneal or extraperitoneal 1
• The location of fluid collections around the bladder can help differentiate between intraperitoneal and extraperitoneal pathologies 4

3. Surgical Considerations

• During laparoscopic procedures, the bladder peritoneum can be used as a flap for pelvic cavity closure 5
• Understanding the peritoneal reflections is essential for proper surgical approach to the bladder 6, 7

Common Pitfalls in Clinical Practice

• Misclassification of bladder ruptures: Failing to distinguish between intraperitoneal and extraperitoneal ruptures can lead to inappropriate management 1, 2
• Delayed diagnosis: Bladder injuries may not be recognized early unless specifically investigated 1
• Inadequate imaging: Not obtaining proper imaging studies like retrograde cystography when bladder injury is suspected 1, 2

Understanding the extraperitoneal nature of most of the bladder is crucial for proper diagnosis and management of bladder injuries, as treatment approaches differ significantly between intraperitoneal and extraperitoneal bladder ruptures.