Bladder trauma

Background

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.

Anatomy of the male bladder, showing transitional epithelium and part of the wall in a histological cut-out.

Clinical Features

• Suprapubic pain, blood at meatus, urinary retention
• Gross hematuria is present in 95% of significant bladder injuries
  • Pelvic fracture + gross hematuria = bladder rupture
  • <1% of all blunt bladder injuries p/w UA with <25 RBCs/HPF
• Bladder Rupture
  • Extraperitoneal
    • Associated with pelvic fracture and laceration by bony fragments
    • Leakage of urine into perivesicular space
    • "Tear drop" shape on imaging
  • Intraperitoneal
    • Associated with compressive force in presence of full bladder

Evaluation

Male with scrotal gunshot wound. Axial image of the pelvis during CT cystogram demonstrates contrast extravasating through a perforation in the posterior wall of the bladder (arrow).

• Imaging
  • Retrograde cystogram (CT or plain film) indicated for:
    • Gross hematuria
    • Inability to void
    • Pelvic fracture in associated with microscopic hematuria
    • Clinical suspicion of bladder injury
    • Penetrating injuries of the buttock, pelvis, or lower abdomen with any hematuria
  • CT A/P with IV contrast NOT sensitive enough for bladder rupture: bladder must be distended with 350mL contrast

Differential Diagnosis

Genitourinary Trauma

• Urinary system
  • Renal trauma
  • Ureter trauma
  • Bladder trauma
  • Urethral trauma
    • Traumatic foley catheter removal
• Genital
  • Penile trauma
    • Traumatic foley catheter removal
  • Testicular trauma
  • Vaginal trauma
• Other
  • Child abuse
  • Pelvic fracture (often accompanies)
  • Sexual assault

Management

• Extraperitoneal Rupture
  • Nonoperative management with bladder cathether drainage (Foley vs suprapubic catheter)
• Intraperitoneal Rupture
  • Operative management

See Also

• GU Trauma