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Bladder injuries
Situations in which the bladder may be injured
TURBT ,
cystoscopic bladder biopsy, TURP, cystolitholapaxy, penetrating trauma to the
lower abdomen or back, caesarian section (especially as an emergency), blunt
pelvic trauma in association with pelvic fracture or minor trauma in
the inebriated patient, rapid deceleration injury (e.g. seat belt injury with
full bladder in the absence of a pelvic fracture), spontaneous rupture after
bladder augmentation, total hip replacement (very rare).
Types of
perforation
- Intraperitoneal perforation the peritoneum overlying the
bladder is breached allowing urine to escape into the peritoneal cavity.
-
Extraperitoneal perforation the peritoneum is intact and urine escapes into the
space around the bladder, but not into the peritoneal cavity.
Making the
diagnosis
During endoscopic urological operations (e.g. TURBT,
cystolitholapaxy), the diagnosis is usually obvious on visual inspection alone a
dark hole is seen in the bladder and loops of bowel may be seen on the other
side. No further diagnostic tests are required.
In cases of trauma, the
classic triad of symptoms and signs suggesting a bladder rupture is:
-
suprapubic pain and tenderness
- difficulty or inability in passing
urine
- haematuria
Additional signs:
- abdominal distension
-
absent bowel sounds (indicating an ileus from urine in the peritoneal
cavity)
These symptoms and signs are an indication for a retrograde
cystogram.
The diagnosis may be made only at operation for fixation of a
pelvic fracture.
Imaging studies
Retrograde cystography or CT
cystography.
- Ensure the bladder is adequately distended with contrast. With
inadequate distension a clot, omentum, or small bowel may plug the
perforation, which may not therefore be diagnosed. Use at least 400ml of
contrast in an adult and 60ml plus 30ml per year of age in children up to a
maximum of 400ml in children.
- Obtain images after the contrast agent has
been completely drained from the bladder (a post-drainage film). A whisper of
contrast from a posterior perforation may be obscured by a bladder distended
with contrast.
In extraperitoneal perforations, extravasation of contrast is
limited to the immediate area surrounding the bladder. In intraperitoneal
perforations, loops of bowel may be outlined by the contrast.
Treatment
of bladder rupture
Extraperitoneal
Bladder drainage with a urethral
catheter for ~2 weeks followed by a cystogram to confirm the perforation has
healed.
Indications for surgical repair of extraperitoneal bladder
perforation:
- If you have opened the bladder to place a suprapubic catheter
for a urethral injury
- A bone spike protruding into the bladder on CT
-
Associated rectal or vaginal perforation
- Where the patient is undergoing
open fixation of a pelvic fracture, the bladder can be simultaneously
repaired
Intraperitoneal
Usually repaired surgically to prevent
complications from leakage of urine into the peritoneal
cavity.
Spontaneous rupture after bladder augmentation
Spontaneous
bladder rupture occasionally occurs months or years after bladder augmentation
and usually with no history of trauma. If the patient has spina bifida or a
spinal cord injury, they usually have limited awareness of bladder fullness and
pelvic pain. Their abdominal pain may therefore be mild and vague in onset and
nature. Fever or other signs of sepsis may be present. Have a high index of
suspicion in patients with augmentation who present with non-specific signs of
illness. A cystogram usually, though not always, confirms the diagnosis. If
doubt exists, consider exploratory laparotomy.
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