Bladder Injury

Bladder injury is classified anatomically as:

Extraperitoneal rupture

Usually associated with pelvic fracture.

Intraperitoneal rupture

Usually involves the bladder dome after blunt trauma to a distended bladder.

Combined rupture

Contains both components.

This distinction directly determines treatment.

The most important feature is:

Visible haematuria after significant pelvic trauma.

Other findings include:

• Suprapubic pain
• Inability to void
• Lower abdominal tenderness
• Reduced urine output
• Pelvic fracture

Intraperitoneal urinary leakage can cause:

• Abdominal distension
• Peritonism
• Rising serum creatinine because urinary creatinine is reabsorbed through peritoneum

CT cystography or conventional retrograde cystography is required when bladder rupture is suspected.

The bladder must be actively filled retrogradely with approximately 300 to 350 mL dilute contrast. Simply waiting for IV contrast to collect in the bladder during routine CT is inadequate.

Absolute high risk presentation includes:

Visible haematuria plus pelvic fracture.

Imaging pattern

Extraperitoneal rupture:

Contrast remains around the bladder and pelvic tissues.

Intraperitoneal rupture:

Contrast surrounds bowel loops and enters peritoneal recesses.

Uncomplicated extraperitoneal rupture

Treat with continuous urethral catheter drainage.

Most heal without operation.

Follow healing with cystography before catheter removal in conservatively treated traumatic injuries.

Complicated extraperitoneal rupture

Repair surgically with:

• Bladder neck involvement
• Bone fragment penetrating bladder
• Rectal or vaginal injury
• Bladder wall entrapment
• Exploration already required for another pelvic indication.

Intraperitoneal rupture

Perform surgical repair because free intraperitoneal urine can cause:

• Peritonitis
• Sepsis
• Metabolic disturbance.

At operation:

• Inspect entire bladder
• Inspect ureteric orifices when injury is near trigone
• Debride devitalised edges only as necessary
• Close with absorbable suture

A watertight single or two layer closure is acceptable.

Penetrating bladder injury

Explore surgically in most cases.

Look carefully for both entry and exit injuries.

Associated bowel and rectal injury is common.

Postoperative catheter

Maintain continuous bladder drainage.

After uncomplicated repair, catheter removal after approximately 5 to 10 days can be appropriate in a healthy patient. More complex injury requires longer drainage and cystographic confirmation before removal.