Description Bladder injury can be the result of: Blunt or penetrating trauma Bladder rupture secondary to a full bladder

bladder or blunt injury Surgical complication (iatrogenic injury)

Classified as either intraperitoneal or extraperitoneal rupture Bladder contusion is injury to the mucosa or muscularis without full-thickness loss; without urine extravasation Often associated with ureter/urethral injury and/or other non-urological injuries

Epidemiology Incidence 0.5% of civilian trauma patients (1) 12% of civilian injuries in Iraq, mostly due to gunshot wounds (2) Blunt trauma with bladder injury is associated with other injuries 94% of the time (3); pelvic fracture being the most common followed by lower abdominal impact in the presence of a full bladder (4). During pelvic surgery, it is the most commonly damaged organ (5). Pediatric Considerations Children are more prone to rupture and are more likely to have intraperitoneal ruptures than adults (1). Risk Factors High-energy mechanism (fall, motor vehicle accident [MVA]) Pelvic fracture Penetrating wound Prior bladder/pelvic surgery Pelvic radiotherapy

General Prevention Seat belts: Voiding prior to automobile travel

Pathophysiology Bladder is often protected by its deep location in the bony pelvis. Contusion: Damage sustained to bladder mucosa and muscularis without loss of wall continuity (5) Intraperitoneal rupture: Increases in intravesical pressure can lead to rupture at the most weak and mobile portion, the bladder dome (6,7)

Extraperitoneal rupture: Disruption of bony pelvis can tear bladder at fascial attachments while this or other bony protrusions can perforate the bladder (6).

Pediatric Considerations Children <6 years old are more prone to bladder injury as the organ still lacks protection from the pubic symphysis (7). Etiology Alert Rare instances of intravesical vascular graft erosion have recently been reported up to 8 years post-op (9). Commonly Associated Conditions Pelvic fracture Urethral injury; almost exclusively males The cause of injury is usually high-energy trauma (motor vehicle accidents, falls). Rupture due to increased pressure in nondistensible (full) bladder Laceration due to bone fragment or penetrating object (knife, bullet) Surgical complications: Gynecologic, general surgery, and urologic operations are the most common reported causes of iatrogenic bladder injury, in decreasing order of frequency (8).

Diagnosis History Isolated bladder injury is rare. Typically, patient has other serious injuries. High mechanism deceleration injury (fall, MVA) Penetrating trauma Recent abdominal/pelvic surgery Urinary retention Preexisting bladder outlet obstruction Anatomical abnormalities Inability to void or oliguria Pain in the genital area or abdomen

Physical Exam Alert Peritonitis is unusual in bladder injury. Diagnostic Tests & Interpretation Lab Initial lab tests Immediate catheterization will likely demonstrate gross hematuria (3). Urinalysis will demonstrate blood. Basic metabolic panel: Serum blood urea nitrogen (BUN), creatinine, chloride, and potassium levels may be elevated and sodium and bicarbonate may be decreased in intraperitoneal ruptures secondary to peritoneal absorption. An increase in BUN/creatinine ratio may also be observed (5). Serum labs are unchanged in extraperitoneal ruptures (6). Follow-Up & Special Considerations If blood at the meatus or if the catheter does not pass easily, consider urethral injury and need for retrograde urethrography. Imaging Initial approach Abdominal exam: Suprapubic tenderness to palpation, guarding, distention, decreased bowel sounds, bruising Genitourinary exam: Blood at meatus, gross hematuria, clots in the urine, scrotal/urethral hematoma, free floating or high riding prostate, unstable pelvis

2 types of imaging are acceptable: Plain film cystography: Fill bladder until patient has sense of discomfort or fill with 350 mL. Use 3-film technique capturing before filling, when full, and after drainage. Contusion: No extravasation but may see distortion of bladder outline with contrast. Intraperitoneal: Contrast may be seen in cul-de-sac and paracolic gutters. Bowel loops may also be outlined. Extraperitoneal: Flame-shaped perivesical stranding of contrast (5) CT cystography: High-resolution computed tomography (CT) cystogram is also acceptable. CT or radiology with only excreted contrast is not sensitive (6). Dilute contrast material.

Alert

Absolute indication for immediate cystography: Gross hematuria with pelvic fracture as 29% of these patients will have a bladder injury (10). Relative indications: Gross hematuria without pelvic fracture, microhematuria with pelvic fracture, isolated microscopic hematuria (10)

During plain film cystography, a post-void view is mandatory as contrast in the bladder may mask extravasation. This is not required with CT cystogram. Follow-Up & Special Considerations Retrograde urethrography must be performed before placing a Foley catheter when urethral injury is suspected. Other signs of bladder injury can include free intraperitoneal fluid on CT scan or ultrasound Pathological Findings Perivesicular hematoma Perforation at dome of bladder (in trigone, near urachus) Jagged tear in bladder Intraoperative clues (11) Appearance of Foley catheter/balloon or urine in the operative field Presence of gas in catheter bag (during laparoscopy)

Differential Diagnosis Isolated urethral injury Isolated pelvic fracture Isolated ureteral injury Other visceral rupture

Treatment Contusion: Observation or 2022 French Foley catheter for 1014 days (6)[B] Intraperitoneal rupture: Immediate surgical repair (6)[C] Often intraoperative damage falls under this heading and can also be treated immediately. Extraperitoneal rupture: 2022 French Foley catheter for 1014 days (6)

Medication Analgesics Antibiotics Antispasmodics

First Line Narcotic pain control (i.e., morphine, hydromorphone); titrate to effect Broad-spectrum antibiotics like ciprofloxacin 500 mg b.i.d. Oxybutynin 510 mg t.i.d. for spasm

Second Line Alert There is concern about fluoroquinolones causing damage to cartilage in children. Additional Treatment If uncomplicated extraperitoneal bladder rupture: Can be treated with urethral catheter alone (use large bore catheter [22 French]) Exception: In pediatric patients, consider placing a suprapubic catheter as small catheters through urethra will clot and larger catheters through urethra risk future urethral stricture Catheter should remain in place for 2 weeks. Cystography is necessary prior to removal of catheter. Antibiotics should be given on day of injury and continued for 3 days after catheter removal. Needs to be treated with open repair Complicated rupture is considered when there is coexisting bladder neck injury, vaginal injury, or rectal injury. Also if open pelvic fracture, or bone fragments are present. Consider open repair if patient is scheduled for exploratory laparotomy or internal fixation of pelvic fracture (prevents urine leak on hardware). If an intraperitoneal bladder rupture or penetrating injury: Urgent operative management is necessary. Cystography should be repeated 710 days after surgery. Antibiotics are needed for 3 days. No need for suprapubic catheter as urethral catheter is sufficient, except in pediatric population (3) During pelvic surgery, iatrogenic full thickness defects are likely to be intraperitoneal, so can fix immediately with 2-layer (mucosa and muscularis) closure via absorbable suture If a complicated extraperitoneal bladder rupture: Broad-spectrum antibiotics Antispasmodics (i.e., flavoxate)

Prior to repair, be sure to confirm that ureters were not damaged concomitantly either with IV indigo carmine administration and visulation of blue dye expulsion from the ureteral orifices (UO) or by confirming easy placement of ureteral catheters through the UO (11).

General Measures Place Foley catheter Pain control Antibiotics Antispasmodics (Ditropan) Obtain imaging diagnosis

Issues for Referral A urologist or trauma surgeon should be involved with all bladder injury management. Surgery/Other Procedures Urgent surgery is indicated for intraperitoneal or bladder neck rupture Extraperitoneal rupture is usually manageable with 10 14 days of catheter drainage (2022 French).

In-Patient Considerations Initial Stabilization Cervical spine precautions Stabilize hemodynamics Stabilize pelvis Follow advanced trauma life support protocols

Admission Criteria All bladder injuries require admission for monitoring renal function and hemodynamic stability. IV Fluids Lactated Ringers for initial resuscitation, unless contraindicated (i.e., concomitant head injury) Nursing Foley to gravity Hourly urine output recorded

Discharge Criteria Stable for transfer to rehabilitation or home if can perform activities of daily living Extraperitoneal ruptures controlled with indwelling Foley catheter if rupture not healed Able to void if no catheter in place No evidence of infection

Pain controlled

Ongoing Care Follow-Up Recommendations Patient Monitoring Diet No restrictions Patient Education Regular lifestyle is expected Use of seat belts No special instructions needed Hourly urine output Hemodynamic monitoring Progressive abdominal distention

Prognosis Full return to normal function Complications Infection Urine leak and/or urinoma Abscess formation Peritonitis or sepsis Bladder calculi Vesicocutaneous or other fistulas Stricture is a rare complication Death; usually from other injuries

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