Bladder Injury

‫ سيف شهاب احمد‬:‫اعداد الطالب‬

‫د قيس عبد الرحمن العاني‬. ‫م‬.‫أ‬: ‫بأشراف‬
‫المرحلة الرابعة‬

The objectives:
1_study bladder anatomy
2_study classification of causes of bladder injury
3_Grading of bladder injury
4_clinical feature and signs of bladder injury
5_the investigation regarding bladder injury
6_mangment of bladder injury
7_complications of bladder injury
Introduction:
Bladder injury is often linkedto a blunt trauma andEspecially with pelvic
fractures.Some series of bladder reports up to 90 per cent Ruptures that occur
with recurrent pelvic fracture. Serious related lesions are often seen when both
pelvic fractures occur Bladder rupture and mortality will occur in 12–22 per cent
of cases.

Anatomy:
Bladder is a hollow muscle organ in humans and other vertebrate pop
ulations that collects and stores urine from the kidneys prior to urination dispo
sal. The bladder is a hollow muscular (or elastic) organ that sits on the pelvic flo
or in the human being. Urine passes through the ureters into the bladder, an
d exits via the urethra. The typical human bladder will hold from 300 to 500 m
L and more.
The bladder is supplied by the vesical arteries and drained by the vesical
veins. The superior vesical artery supplies blood to the upper part of the
bladder. The lower part of the bladder is supplied by the inferior vesical
artery in males and by the vaginal artery in females, both of which are branches
of the internal iliac arteries. In females, theuterine arteries provides additional
blood supply.
Classification of bladder trauma :
• blunt
• penetrating

• external
•internal
• foreign body

Table:Classification of bladder trauma based on mode of action

Causes:
1. Blunt:
• Motor vehicle accident: 70-97% have associated
pelvic fracture
• 10-15% of all pelvic fractures have bladder injury
with or without urethral injury.

2. Penetrating injury: bullet, knife, foreign body.

3. Iatrogenic during surgery: obstetric, gynecologic, general surgical and
urologic interventions.

Types of bladder injury:

• 1.Contusion: Hematuria damage, with no bladder evidence Leakage (n
o urainary extravasation) .
• 2. Extraperitoneal rupture (65 per cent): intact peritoneum and urine
It escapes into the bladder room, but not into the bladder Cavity peritoneal. •
• 3. Intraperitoneal rupture (25%): the peritoneum that overhangs the Bl
adder breakage allows urine to flee into the peritoneal Cavity
• 4. Combined: intra and extraperitoneal (10%)
Figure above show: intrapereoneal and extra pertonial rupture of bladder

Grading of bladder injury:

Accoarding to American Association for the Surgery of Trauma Bladder Organ Injury Scale.

Bladder Injury Description Grade Injury Description:

I. Hematoma Disorder Contusion, bleeding intramural Overlap Partial thickness.

II. Overlap Laceration of the Extraperitoneal
Bladder Wall < 2 cm
III: Overlap Extraperitoneal laceration of the bladder wall
2 cm or intraperitoneal < 2 cm
IV. Overlap Intraperitoneal laceration of the lining of the bladder 2 cm .
V. Overlap Laceration extending into the neck or ureteral orifice of the bladder (trigone)

Clinical features:
The classic triad of symptoms and signs suggesting a bladder rupture
are:
1. Gross hematuria.
2. Suprapubic pain and tenderness with sometimes bruising.
3. Difficulty or inability in passing urine.

Additional signs are as follows:

1. Abdominal distension
2. Absent bowel sounds (indicating an ileus from urine in the
peritoneal cavity)
3. Fever in peritonitis
4. Urine ascites
5. Increased BUN/Cr
6. Free fluid on abdominal CT or ultrasound
7. Enlarged scrotum
Diagnosis:
1. Retrograde cystography:
a Foleys catheter is inserted and 350ml of diluted contrast in an adult and
{(age + 2) x 30} mL in children is injected to the bladder then x-ray imageis
taken.
In extraperitoneal perforations, extravasation of contrast is limited to the
immediate area surrounding the bladder (a dense
“flame-shaped”collection of contrast).
In intraperitoneal perforations, loops of bowel or the lower lateral
portion of the peritoneal cavity may be outlined by the contrast.
Intraperitoneal

Intraperitoneal bladder
rupture.

2. CT cystography:
 a “full-bladder” phase is required. CT cystography is usually more appropriate, since many trauma
patients are already undergoing CT forother abdominal, chest, head, or pelvic injuries

Management:
1. Bladder contusion
• Adequate drainage of the bladder should result in resolution
within a few days.
• Follow-up cystography is recommended to assess integrity of
the bladder wall.
2. Intraperitoneal rupture
• usually requires exploratory laparotomy, cystotomy and suturing of the
bladder wall defect, urethral catheter placement, and water-tight bladder
closure in 2 or 3 layers with absorbable suture.
• suprapubic tube may be considered for a complex bladder repair, significant
ongoing gross hematuria, or patients that will require long term catheterization.
• Antibiotics
3. Extraperitoneal rupture
A. Extraperitoneal When conditions are ideal, use bladder
drainage with a urethral catheter for about 2 weeks followed by a cystogram to
confirm the perforation has healed.
• If extravasation is noted, replace the catheter for 2 more weeks and repeat
imaging; some injuries may take up to 6 weeks to heal.
• If no urinary extravasation exists, the catheter can be removed.
• Antibiotics on day of injury until 3d after Foley removed
B. Open surgical repair (as described for intraperitoneal bladder rupture) is
recommended for any of the following scenarios.
a) If the bladder was opened to place a suprapubic catheter for a urethral injury
or Bone spike protruding into the bladder on CT.
b) Injuries to the bladder discovered intraoperatively during
nonurological surgery
c) Injuries occurring as a result of penetrating trauma
d) Poor urinary drainage due to clot obstruction.
e) Associated rectal or vaginal perforation.

The rupture is being sutured

The cystotomy is being sutured

Complications:
• Complications of bladder injury are primarily due to a delay in
diagnosis leading to azotemia, ascites, and sepsis.
• Vesical fistula when other organ injuries are present (Vesico vaginal fistula,
uretero-vesical fistula, recto-vesical fistulae).
• Bladder neck injury, if not identified and repaired, may result in incontinence.
• Persistent extravasation suggests catheter obstruction, bony
fragments, or ischemic complications of injury.