What are the clinical features, diagnosis, and management of bladder trauma?

Bladder Trauma: Clinical Features, Diagnosis, and Management

Retrograde cystography is the diagnostic procedure of choice for suspected bladder injuries and should be performed in all hemodynamically stable patients with gross hematuria and mechanism concerning for bladder injury, or in those with pelvic ring fractures. 1

Types of Bladder Injuries

• Bladder injuries occur in approximately 1.6% of blunt abdominal trauma victims and are classified into several types 1:

  • Intraperitoneal bladder rupture (IBR) - 30% of cases
  • Extraperitoneal bladder rupture (EBR) - 60% of cases
  • Combined bladder rupture (CBR) - 5-12% of cases
  • Bladder contusion

• Bladder injuries are more common following blunt trauma (65-86%) than penetrating trauma (14-35%) 1

• Due to the bladder's protected position within the pelvis, 60-90% of patients with bladder injury have associated pelvic fractures 1

Clinical Features and Presentation

• Gross hematuria is the most common sign of bladder injury, present in 77-100% of cases 1, 2

• Other clinical features include:

  • Suprapubic or abdominal pain 2
  • Difficulty in voiding or inability to void 2
  • Abdominal distention 1
  • Suprapubic tenderness 3

• In patients with pelvic fractures, the presence of gross hematuria is associated with bladder injury in approximately 30% of cases 1

Diagnostic Approach

• Retrograde cystography (conventional radiography or CT-scan) is the diagnostic procedure of choice for bladder injuries 1

• Retrograde cystography should always be performed in hemodynamically stable or stabilized patients with suspected bladder injury 1

• Intravenous contrast-enhanced CT-scan with delayed phase is less sensitive and specific than retrograde cystography in detecting bladder injuries 1

• In a study of bladder injury diagnosis, retrograde cystogram had an accuracy rate of 95.9%, while standard CT had only 60.6% accuracy 4

• Direct inspection of the intraperitoneal bladder should always be performed during emergency laparotomy in patients with suspected bladder injury 1

• In pelvic bleeding amenable to angioembolization associated with suspected bladder injuries, cystography should be postponed until completion of the angiographic procedure 1

Differentiating Features

• Intraperitoneal rupture: Urine extravasation into the peritoneal cavity, often causing peritonitis 1

• Extraperitoneal rupture: Urine extravasation confined to the pelvis, almost exclusively associated with pelvic fractures 1, 2

• Combined rupture: Features of both intraperitoneal and extraperitoneal rupture 1

• Bladder contusion: Diagnosis of exclusion, with hematuria but no extravasation on imaging 2

Management

• The management approach differs based on the type of bladder injury:

• For intraperitoneal bladder rupture:

  • Surgical exploration and primary repair is the standard of care 1, 5
  • Typically requires a two-layer closure of the bladder wall 6

• For extraperitoneal bladder rupture:

  • Non-operative management with urinary drainage via urethral catheter is recommended if there are no other indications for laparotomy 5, 6
  • Some complex extraperitoneal ruptures may require surgical intervention (38% in one study) 6

• For combined bladder rupture:

  • Surgical repair is typically required 1

• Urinary drainage:

  • Most patients can be managed with urethral catheter drainage alone 6
  • Suprapubic catheter may be needed in complex cases or when urethral injury is suspected 5

• Duration of catheter drainage:

  • Typically 7-14 days for repaired bladder injuries 1
  • Cystography should be performed before catheter removal to confirm healing 1

Follow-up and Monitoring

• CT scan with delayed phase imaging is the method of choice for follow-up of bladder injuries 1

• Follow-up cystography is recommended before catheter removal to confirm healing 1, 6

• Return to sport activities should be allowed only after microscopic hematuria is resolved 1

Special Considerations

• Mortality in bladder trauma is usually due to associated injuries rather than the bladder injury itself 6, 3

• The overall mortality rate for bladder rupture is approximately 5-8% 6, 3

• Intraperitoneal ruptures carry a higher risk of death compared to extraperitoneal ruptures (odds ratio 12.4) 7

• In cases with associated urethral injuries, management of the urethral injury should take precedence to establish urinary drainage 5

• Most simple bladder injuries can be managed by trauma surgeons, but complex injuries should involve consultation with a urological surgeon 6