Bladder injuries are caused by either blunt or penetrating trauma to the lower abdomen, pelvis, or perineum. Blunt trauma is the more common mechanism, usually by a sudden deceleration, such as in a high-speed motor vehicle crash or fall, or from an external blow to the lower abdomen. The most frequently accompanying injury is a pelvic fracture, occurring in > 95% of bladder ruptures caused by blunt trauma. Other concomitant injuries include long bone fractures and CNS and chest injuries. Penetrating injuries, most often gunshot wounds, account for about 25% of bladder injuries.

The bladder is the most frequently injured organ during pelvic surgery. Such injuries can occur during transurethral surgery, colon resection, or gynecologic procedures (most commonly abdominal hysterectomy, cesarean section, pelvic mass excision). Predisposing factors include scarring from prior surgery or radiation therapy, inflammation, and extensive tumor burden.

Bladder injuries are classified as contusions or ruptures based on the extent of injury seen radiographically. Bladder ruptures can be extraperitoneal, intraperitoneal, or both.

Complications of bladder injuries include infection, fistula, incontinence, and bladder instability. Mortality with bladder rupture approaches 20% from the concomitant organ injuries rather than the bladder injury.

Symptoms and Signs

Symptoms may include suprapubic pain and inability to void; signs may include suprapubic tenderness, distention, and, in the case of intraperitoneal rupture, peritoneal signs.

Diagnosis

• Retrograde cystography

Diagnosis is suspected on the basis of history and physical examination findings and hematuria (gross or microscopic). Confirmation is by retrograde cystography using plain film x-rays or CT. Plain film x-rays are accurate, but CT also helps delineate concomitant intra-abdominal injuries. If urethral disruption is suspected in a male, retrograde catheter placement is avoided, pending results of urethrography.

Treatment

• Catheter drainage
• Sometimes surgical repair

All penetrating trauma and intraperitoneal ruptures from blunt trauma require surgical exploration and repair. Contusions require only catheter drainage until gross hematuria resolves. Extraperitoneal ruptures require only catheter drainage if urine is draining freely and the bladder neck is spared. If the bladder neck is involved, surgical exploration and repair are required.

Last full review/revision February 2007 by Noel A. Armenakas, MD