Management of Spontaneous Bladder Rupture at the Bladder Neck
Bladder neck injuries require surgical exploration and repair, as they are classified as complex extraperitoneal ruptures that do not heal reliably with catheter drainage alone. 1
Classification and Initial Recognition
Spontaneous bladder rupture at the bladder neck falls into the category of complex extraperitoneal bladder injury requiring different management than simple extraperitoneal ruptures. 1
Key distinguishing features of bladder neck involvement:
- Bladder neck injuries may not heal with catheter drainage alone and should be considered for surgical repair 1
- These injuries are grouped with other complex scenarios including pelvic ring fractures with bone spicules, concurrent rectal/vaginal injuries, and injuries requiring orthopedic fixation 1
Definitive Management Algorithm
Surgical Repair is Indicated
Complex extraperitoneal bladder ruptures—specifically bladder neck injuries—should be explored and repaired surgically. 1
The rationale for mandatory surgical intervention:
- Bladder neck location compromises the injury's ability to heal spontaneously 1
- Conservative management with catheter drainage (the standard for uncomplicated extraperitoneal injuries) is inadequate for this anatomic location 1
- During surgical repair, the integrity of both the bladder neck and ureteral orifices must be confirmed 1
Surgical Technique
Open surgical repair should be performed in a double-layer fashion using monofilament absorbable suture. 1, 2
Technical considerations:
- Standard fashion repair to avoid prolonged sequelae from the injury 1
- Laparoscopic approach may be considered only if the patient is hemodynamically stable and there are no other indications for laparotomy 1, 2
- Single-layer repair is acceptable during laparoscopic approach 1
Post-Operative Urinary Drainage
In adult patients, urinary drainage with urethral catheter alone (without suprapubic catheter) is mandatory after surgical management. 1, 2
- Urethral catheterization has the same efficacy as suprapubic cystostomy and results in shorter hospital stay and lower morbidity 2
- Routine suprapubic tube placement is no longer recommended 1, 2
- For pediatric patients, suprapubic cystostomy is recommended 1
Damage Control Scenarios
In hemodynamically unstable patients:
- Urethral or suprapubic catheter may be inserted as a temporary measure and bladder repair postponed 1, 2
- Urinary diversion via bladder and perivesical drainage or external ureteral stenting may be used during damage control procedures 1
Follow-Up Protocol
Follow-up cystography should be used to confirm bladder healing in complex repairs. 1
- CT scan with delayed phase imaging is the method of choice for follow-up 2
- This is particularly important for complex repairs involving the bladder neck 1
Critical Pitfalls to Avoid
Do not attempt conservative management with catheter drainage alone for bladder neck injuries. The anatomic location at the bladder neck makes spontaneous healing unreliable, and failure to repair can result in prolonged urinary extravasation, fistula formation, or chronic incontinence. 1
The evidence consistently distinguishes bladder neck injuries from simple extraperitoneal ruptures—while the latter can be managed conservatively with 85% healing within 10 days 1, 2, bladder neck involvement mandates surgical intervention regardless of whether the rupture is intraperitoneal or extraperitoneal. 1