What is the management of bladder perforation with hematuria?

Management of Bladder Perforation with Hematuria

The management of bladder perforation with hematuria depends critically on whether the perforation is intraperitoneal or extraperitoneal: intraperitoneal ruptures require immediate surgical repair to prevent peritonitis and sepsis, while uncomplicated extraperitoneal injuries can be managed conservatively with catheter drainage alone. 1

Immediate Diagnostic Evaluation

Perform retrograde cystography (plain film or CT) immediately in any patient with gross hematuria and suspected bladder injury. 1 This is the gold standard diagnostic technique and requires proper execution:

• Instill a minimum of 300 mL of contrast (or until patient tolerance) via retrograde gravity filling to achieve maximal bladder distention 1
• Obtain at least two views: one at maximal fill and one post-drainage 1
• Never simply clamp a Foley catheter to allow IV contrast to accumulate—this inadequate technique misses bladder injuries 1, 2

CT cystography has 85-100% accuracy for diagnosing bladder perforation and allows simultaneous evaluation of other injuries. 1 Intraperitoneal injuries show contrast outlining bowel loops and filling intraabdominal spaces, while extraperitoneal injuries show contrast confined to the pelvis. 1

Management Based on Perforation Type

Intraperitoneal Bladder Rupture

All intraperitoneal bladder perforations require immediate surgical repair. 1 This is a Standard recommendation (Grade B evidence) because:

• Intraperitoneal ruptures from blunt trauma are typically large "blow-out" injuries at the bladder dome that will not heal spontaneously 1
• Failure to repair leads to bacterial translocation from bladder to peritoneal cavity, causing peritonitis, sepsis, and potentially death 1, 3
• Standard repair involves two-layer closure including mucosa with absorbable suture 1
• During repair, confirm integrity of bladder neck and ureteral orifices and repair if injured 1

Exception: Isolated uncomplicated intraperitoneal injuries without signs of infection or ileus may be managed conservatively with catheter drainage for at least 7 days in highly select cases. 1 However, this requires close monitoring and should only be attempted when surgical risk is prohibitive.

Extraperitoneal Bladder Rupture

Uncomplicated extraperitoneal bladder injuries should be managed with catheter drainage for 2-3 weeks. 1 This conservative approach is appropriate because:

• Over 85% heal within 10 days with catheter drainage alone 4
• Leaving the Foley catheter for 2-3 weeks is standard, though longer duration is acceptable with concurrent injuries 1
• Consider open repair only if non-healing persists beyond 4 weeks 1

Surgical repair is required for complicated extraperitoneal injuries including: 1

• Large extraperitoneal bladder injuries
• Bladder neck involvement
• Concurrent rectal or vaginal injury requiring operative management
• Adjacent orthopedic implants (e.g., external pelvic fixators)
• Penetrating injuries with pelvic trajectories 1, 4

Special Clinical Scenarios

Iatrogenic Catheter-Related Perforation

Bladder perforation from indwelling catheters is rare but serious. 5, 6 If perforation occurs:

• Most iatrogenic injuries are recognized intraoperatively, but if delayed, patients present with gross hematuria, abdominal pain, distention, and peritonitis 1
• Extraperitoneal catheter-related perforations may be managed conservatively with urethral drainage 5, though this requires careful monitoring
• Intraperitoneal perforations require surgical repair 6

Unstable Patients

For hemodynamically unstable patients unable to undergo immediate repair:

• Delay surgical repair until stabilization is achieved 1
• In patients deemed unfit for surgery, bilateral nephrostomy combined with urinary catheterization is the preferred temporizing measure 1
• Expedite definitive repair when medically feasible 1

Post-Repair Management

• Maintain continuous bladder drainage to prevent clot retention and overdistention 4
• Follow-up cystography should confirm healing in complex repairs but may not be necessary for simple repairs 1
• Laparoscopic repair is appropriate for isolated intraperitoneal injuries in select cases 1

Critical Pitfalls to Avoid

• Do not attribute hematuria solely to anticoagulation without ruling out structural bladder injury 4, 2
• Do not delay imaging in patients with pelvic fracture and gross hematuria—29% have bladder rupture requiring immediate diagnosis 1, 2
• Do not perform inadequate cystography by clamping Foley and relying on IV contrast accumulation 1, 2
• Do not assume microscopic hematuria excludes bladder injury in high-risk scenarios (pelvic fracture with pubic symphysis diastasis or obturator ring displacement >1 cm) 1