What is the treatment for a perforated bladder?

Treatment of Perforated Bladder

The treatment of bladder perforation depends critically on whether the rupture is intraperitoneal or extraperitoneal: intraperitoneal ruptures require mandatory surgical repair, while uncomplicated extraperitoneal ruptures can be managed with catheter drainage alone. 1

Diagnostic Confirmation Required

Before initiating treatment, retrograde cystography (CT or conventional) is essential to determine both the presence and location of the injury (intraperitoneal versus extraperitoneal). 1

Treatment Algorithm by Rupture Type

Intraperitoneal Bladder Rupture

Surgical repair is mandatory for all intraperitoneal bladder ruptures, regardless of mechanism (blunt trauma, penetrating injury, or spontaneous). 1

Rationale for mandatory surgery:

• Intraperitoneal ruptures are typically large "blow-out" injuries at the bladder dome that will not heal spontaneously with catheter drainage alone 1
• Failure to repair results in bacterial translocation from bladder to peritoneal cavity, causing peritonitis, sepsis, and potentially death (reported mortality of 25% for untreated spontaneous perforations) 1, 2

Surgical technique:

• Two-layer vesicorrhaphy using absorbable monofilament suture 1
• During repair, confirm integrity of bladder neck and ureteral orifices; repair if injured 1
• Open surgery is standard, though laparoscopic repair is appropriate for isolated injuries in hemodynamically stable patients 1

Extraperitoneal Bladder Rupture

Treatment depends on whether the injury is complicated or uncomplicated:

Uncomplicated extraperitoneal ruptures:

• Manage with urethral Foley catheter drainage alone for 2-3 weeks 1
• These injuries heal with conservative management in the vast majority of cases 1
• Follow-up cystography confirms healing before catheter removal 1
• If non-healing after 4 weeks of catheter drainage, consider open repair 1

Complicated extraperitoneal ruptures requiring surgical repair: 1

• Bladder neck injuries (do not heal with catheter drainage alone) 1, 3
• Exposed bone spicules in bladder lumen from pelvic fractures 1
• Concurrent rectal or vaginal lacerations (risk of fistula formation) 1
• Very wide lacerations requiring bilateral ureteral stenting 1
• Injuries close to ureteral orifices 1
• When patient is already undergoing laparotomy for other injuries (repair can be performed quickly with minimal additional morbidity) 1

Post-Operative Urinary Drainage

Use urethral catheter alone without suprapubic cystostomy after surgical repair. 1, 3

• Urethral catheterization alone has equivalent efficacy to combined urethral and suprapubic drainage 1
• Urethral catheter alone results in shorter hospital stay and lower morbidity 1, 3
• Duration: 5-14 days for iatrogenic injuries 1; 2-3 weeks for traumatic injuries 1
• Perform cystography before catheter removal to confirm healing 1

Exceptions where suprapubic tube may be considered: 1

• Severe neurological injuries (head or spinal cord trauma)
• Patients immobilized due to orthopedic injuries
• Complex bladder repairs with tenuous closures or significant hematuria

Special Considerations for Iatrogenic Perforations

Intraoperative recognition is paramount for optimal outcomes. 4

• Obtain immediate urologic consultation when bladder injury is suspected intraoperatively 1, 4
• Prompt intraoperative repair achieves 98.4% long-term success rate 1, 4
• If urologic expertise unavailable or patient unstable, adopt "drain now, fix later" approach with delayed referral to specialized center 1

Follow-Up Protocol

• Follow-up cystography is mandatory to confirm healing in all complex repairs 1, 3
• May not be necessary for simple repairs 1
• CT with delayed phase imaging is preferred method 3

Critical Pitfalls to Avoid

• Never attempt conservative management with catheter drainage alone for intraperitoneal ruptures or bladder neck injuries - this leads to peritonitis, sepsis, fistula formation, or chronic incontinence 1, 3
• Delayed diagnosis is more common after laparoscopic surgery; maintain high index of suspicion 1
• For spontaneous perforations presenting as acute abdomen, bladder rupture should be suspected if history suggests urinary tract disorder 2
• In patients with long-term indwelling catheters, bladder perforation is a rare but serious complication requiring prompt recognition 5