Bladder Injury During Caesarean Delivery

Bladder injury during caesarean delivery is a cut, tear or burn of the bladder during entry to the abdomen, development of the bladder flap, opening of the lower segment or closure. It results from adhesions, a previous caesarean section, a low placenta, obstructed labour, emergency surgery and a low incision. It matters because recognised injuries repair well, but missed injuries cause fistula, urinary ascites and infection.

• Risk factors: previous caesarean section, adhesions, placenta accreta spectrum, placenta previa, obstructed labour, emergency surgery in the second stage, hysterectomy.
• Dome injuries are the commonest and heal best.
• Trigone injuries need ureteric checks.

During surgery the surgeon sees urine in the field, the bladder wall or catheter balloon, or gas in the urinary bag. After surgery, women have haematuria, low urine output, abdominal distension, leaking urine from the wound or vagina, and fever.

• Blood-stained urine or gas in the catheter bag.
• Clear fluid in the wound or vagina.
• Differential diagnosis: ureteric injury, bladder oedema, wound seroma, vesicouterine fistula, urinary tract infection, urinary retention.
• Complications: vesicouterine or vesicovaginal fistula (Youssef syndrome with menouria), urinary ascites, peritonitis, pelvic abscess, urinary tract infection, bladder dysfunction, ureteric injury, repeat surgery.

The diagnosis is made at operation by inspection and testing, or later by imaging.

• Intraoperative: inspect the bladder wall; fill the bladder retrograde with 300 mL sodium chloride 0.9 percent (mixed with methylene blue) through the catheter and look for leak; check ureteric jets or place stents if the trigone is involved.
• Postoperative: urine dipstick for blood, urinalysis, creatinine (a rise suggests reabsorption of urine); ultrasound for free fluid.
• Cystogram (CT cystogram with 300 mL contrast) for leaks or fistula; fluid creatinine from drain or abdomen (higher than serum confirms urine).
• Dye test with methylene blue in the bladder and a tampon in the vagina for a fistula.

The principle is two-layer repair at the time of surgery, catheter drainage and checking of the ureters.

• Supportive: keep the bladder drained with a large Foley catheter (16 to 18 French) for 7 to 10 days after a simple dome repair and 10 to 14 days for complex or trigone injuries; fluids to keep urine output above 1 mL/kg/hour; monitor urine for blood and clots; avoid constipation.
• Pharmacological: cefazolin 2 g IV as a single dose before incision, then cefazolin 1 g IV 8-hourly for 24 hours; oxybutynin 5 mg oral 8-hourly for bladder spasm (while catheterised); cefalexin 250 mg oral at night while the catheter is in place; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours).
• Procedures: repair in two layers with 3/0 polyglactin (mucosa and muscularis in one running layer, serosa in a second layer), away from the ureteric orifices; ureteric stents or a cystoscopy for trigone injuries; cystogram before removing the catheter for complex repairs (leak shown by contrast); drain the pelvis in large injuries; delayed repair of a vesicouterine or vesicovaginal fistula after 8 to 12 weeks when tissue is healthy.
• Red flags: haematuria, falling urine output, abdominal distension, rising creatinine, wound or vaginal leak of urine, fever above 38 degrees Celsius.
• Follow-up: catheter removal after a satisfactory cystogram (for complex repairs); review at 1 week and 6 weeks; ask about leakage and urinary symptoms; plan the next caesarean section with a surgeon experienced in adhesions.