What is the recommended treatment for bladder trauma?

Management of Bladder Trauma

The recommended treatment for bladder trauma depends on the type of injury, with intraperitoneal bladder ruptures requiring surgical exploration and primary repair, while uncomplicated extraperitoneal bladder ruptures can be managed non-operatively with urinary drainage via urethral or suprapubic catheter. 1

Diagnosis

• Retrograde cystography (conventional radiography or CT-scan) is the diagnostic procedure of choice for suspected bladder injuries with a 95.9% accuracy rate 1, 2
• Gross hematuria is present in 77-100% of bladder injuries and should prompt investigation 1, 2, 3
• Intravenous contrast-enhanced CT scan with delayed phase is less sensitive and specific than retrograde cystography 1
• Direct inspection of the intraperitoneal bladder should be performed during emergency laparotomy when bladder injury is suspected 1

Classification and Treatment

Intraperitoneal Bladder Rupture (30-40% of cases)

• Requires surgical exploration and primary repair 1
• Laparoscopy might be considered for isolated injuries in hemodynamically stable patients with no other indications for laparotomy 1
• During damage control procedures for severe ruptures, urinary diversion via bladder and perivesical drainage or external ureteral stenting may be used 1

Extraperitoneal Bladder Rupture (60% of cases)

• Uncomplicated extraperitoneal bladder injuries can be managed non-operatively with urinary drainage via urethral or suprapubic catheter 1
• Complex extraperitoneal ruptures (bladder neck injuries, lesions associated with pelvic ring fracture, vaginal or rectal injuries) should be explored and repaired 1
• Surgical repair should be considered during laparotomy for other indications or during surgical exploration of the prevesical space for orthopedic fixations 1

Bladder Contusion

• Requires no specific treatment and can be observed clinically 1

Post-Treatment Management

• In adult patients, urinary drainage with urethral catheter (without suprapubic catheter) after surgical management is mandatory 1
• For pediatric patients, suprapubic cystostomy is recommended 1
• CT scan with delayed phase imaging is the method of choice for follow-up of bladder injuries 1
• Patients whose catheter remains in place for greater than 14 days have higher complication rates (21%) compared to those whose catheter is removed within 14 days (0% complications) 3

Special Considerations

• Pelvic fractures are present in 93% of bladder trauma cases, requiring coordination with orthopedic surgeons 3, 4
• Additional solid organ injuries are present in 39% of cases, necessitating a multidisciplinary approach 3
• The overall mortality rate for bladder rupture is approximately 5-8%, with deaths primarily due to associated injuries rather than the bladder injury itself 4, 5
• Return to sport activities should be allowed only after microscopic hematuria has resolved 1

Pitfalls to Avoid

• Failure to perform retrograde cystography in patients with gross hematuria and pelvic fractures may lead to missed diagnoses 1, 2
• Relying solely on CT without proper bladder distension and delayed imaging can miss bladder injuries 1, 2
• Prolonged catheterization (>14 days) increases complication rates and should be avoided when possible 3
• Inadequate follow-up imaging may miss complications such as fistula formation or strictures 1

By following these evidence-based guidelines, clinicians can optimize outcomes for patients with bladder trauma while minimizing complications and mortality.