INTRODUCTION:

 The bladder is a balloon-shaped organ that stores urine, which is made in the kidneys. It is held in place by pelvic
muscles in the lower part of your belly. When it isn't full, the bladder is relaxed. Muscles in the bladder wall
allow it to expand as it fills with urine. Nerve signals in your brain let you know that your bladder is getting full.
Then you feel the need to go to the bathroom.
 The brain tells the bladder muscles to squeeze (or "contract"). This forces the urine out of your body through your
urethra.
 In adults, the empty bladder is well protected within the bony pelvis, but a full bladder may be distended to reach
the level of the umbilicus, making it more vulnerable to injury. In very young children, the bladder is an
intraabdominal organ, exposing it to injury in the setting of trauma. The weakest part of the bladder is the
peritoneal dome.
 Extraperitoneal ruptures are usually associated with pelvic fractures either due to compressive forces on the
pelvis causing rupture of the anterior or lateral bladder wall or from direct penetration of the bladder by bony
fracture fragments.
 Iatrogenic injury to the bladder may be associated with gynecological and colorectal surgery, urologic procedures,
and Foley catheter placement. Also bladder punctures occur in association with midline trocar placement below
the umbilicus during laparoscopic procedures. ensuring the bladder is empty, preferably with a catheter inserted
prior to trocar placement, helps to minimize this risk.
 Spontaneous bladder rupture is quite rare and is associated with high mortality. Cases have been reported in
association with vaginal delivery, hemophilia, malignancy, radiation, infection, and urinary retention.

EPIDEMIOLOGY:

While extraperitoneal (EP) and intraperitoneal bladder (IP) injuries occur with blunt and penetrating traumas,
iatrogenic bladder injuries are well-documented as well. EP bladder injuries account for 60% of bladder traumas,
while 30% are intraperitoneal, and 10% are combined.[1] Iatrogenic IP bladder injuries are not uncommon. The
bladder is the most frequently injured organ in obstetric/gynecologic procedures such as cesarean section and
hysterectomies, with an incidence of 13.8 cases per 1000 procedures.

ETIOLIGY:
Bladder trauma occurs in the setting of motor vehicle collisions (MVC), work-related instances, and violent crimes,
but also can be iatrogenic. Two main mechanisms of blunt bladder injury are (1) high energy blow to the lower
abdomen while the bladder is distended, which usually results in an IP injury and (2) trauma causing pelvic fractures,
which usually results in an EP bladder injury. As such, bladder trauma commonly occurs with concomitant orthopedic
and abdominopelvic visceral injuries. Researchers found traumatic bladder rupture accounts for 1.6% of blunt
abdominopelvic trauma cases.[3] There are challenges associated with consistent results regarding bladder trauma. For
example, there is evidence that approximately 85% of bladder injuries result from blunt trauma, while incident rates
can account for up to 51% of injuries result from penetrating trauma.[4][5] While the national incidence of penetrating
injuries in 2015 was less than 10%, the incidence of bladder injuries resulting from penetrating injuries can be much
higher.[4][6] Additionally, other less common etiologies of bladder trauma include iatrogenic injuries most commonly
during obstetric, gynecologic, or urologic procedures.

PATHOPHYSISOLOGY:
The bladder is located in the anterior pelvis in an adult. The dome is covered by peritoneum, and the bladder neck is
fixed to the pelvis by fascia and ligaments. IP bladder rupture occurs on the dome of the bladder and above the
peritoneal reflection, while EP bladder rupture occurs below the peritoneal reflection and on the anterior or lateral
aspects of the bladder.
Bladder contusion is a partial thickness tear of the bladder and formation of a hematoma caused by blunt trauma.
Patients with bladder contusion can present with gross hematuria. On cystography, there is no extravasation of
contrast. This is usually self-limiting, as it is a relatively benign process.EP bladder rupture is most often caused by
rapid deceleration. A combination of shearing force and direct penetration by bony spicules of a fractured pelvis is
thought to be the underlying mechanism of EP bladder rupture. Complex EP bladder rupture can cause urine leak into
the thighs, penis, perineum, or the anterior abdominal wall. Researchers found that 85% to 100% of bladder injuries
are associated with concomitant pelvic fractures.[5]
IP bladder rupture occurs most commonly on the dome of the bladder as it is the only portion covered by the
peritoneum; thus, it is the least protected area of the bladder. Contrary to EP bladder rupture, IP bladder rupture is
usually caused by a direct blow to a distended bladder, although it can also be associated with deceleration injuries.
Urine drains into the abdomen and is absorbed by the peritoneal cavity, manifesting as elevated blood urea nitrogen
and creatinine, electrolyte and metabolic derangements, and decreased urine output. Combined EP and IP bladder
rupture is less common, accounting for 5% to 8% of bladder injuries associated with pelvic fractures.
TYPES OF URINARY BLADDER TRAUMA:
Bladder rupture can be categorized into five types depending on the location and extent of the rupture:
1. Bladder contusion:
This is commonly seen but sometimes not classed as true rupture, since it involves an incomplete tear of the mucosa.
2. Subserosal bladder rupture:
Also known as interstitial rupture, this is rare. It is caused by a tear in the serosal surface.
3. Intraperitoneal bladder rupture:
Occurs in approximately ~15% (range 10-20%) of major bladder injuries, and typically is the result of a direct blow to
the already distended bladder. Cystography demonstrates intraperitoneal contrast material around bowel loops,
between mesenteric folds and in the paracolic gutters. Treatment is surgical repair.
4. Extraperitoneal bladder rupture:
Extraperitoneal rupture is the most common type of bladder injury, accounting for ~85% (range 80-90%) of cases. It is
usually the result of pelvic fractures or penetrating trauma. Cystography reveals a variable path of extravasated
contrast material. Treatment is with an indwelling Foley catheter.
5. Combined bladder rupture:
Simultaneous intraperitoneal and extraperitoneal injury. Cystography usually demonstrates extravasation patterns that
are typical for both types of injury.

CLINICAL MANIFESTATION:

 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 of a patient with trauma starts with the primary survey, which consists of the airway, breathing, circulation,
disability, and exposure. The secondary survey includes a head-to-toe exam. Findings in the secondary survey may
suggest bladder trauma includes pelvic instability, blood at the meatus, significant abdominal and pelvic pain,
suprapubic tenderness, high riding prostate, and gross hematuria. An unstable pelvic fracture is associated with a high
prevalence of massive internal bleeding into the pelvis and should be stabilized with a pelvic binder before surgical
intervention. Peritoneal signs such as rigidity, guarding, and rebound tenderness should raise the suspicion not only
for perforated viscus in the abdomen but also intraperitoneal bladder injury. The Focused Assessment with
Sonography in Trauma (FAST) exam can be used to quickly assess for pericardial, intra-abdominal, and pelvic free
fluid; however, FAST exams cannot distinguish between blood and urine. Evaluation of the genitals may reveal blood
at the urethral meatus, in which case urethral injury needs to be ruled out before inserting an indwelling catheter. A
high riding prostate on a rectal exam also concerns for urethral injury. Gross hematuria is seen in 67% to 95% of cases
and is the most classical symptom associated with bladder trauma.
DIAGNOSTIC ASSESSMENT:
Basic labs such as complete blood count, metabolic panel, coagulation panel, and urinalysis should be obtained as part
of the trauma work-up. Retrograde cystography, either computed tomography (CT) or conventional X-ray, is indicated
for hemodynamically stable patients with gross hematuria, blood at the meatus, inability to void, pelvic fracture with
microscopic hematuria, or penetrating injury to the pelvis, buttock, or lower abdomen. Conventional X-ray and CT
cystography have similar sensitivity and specificity. Intravenous contrast CT scan with a delayed phase is less
sensitive and specific than retrograde cystography in detecting bladder trauma.[9] According to the European
Association of Urology guidelines for urogenital trauma, CT cystography is preferred over traditional X-ray
cystography due to rapid turnover time and convenience. Another advantage of CT cystography over conventional
cystography is that it is superior in detecting other intra-abdominal processes and bony fragments within the
bladder.[10] Imaging findings associated with EP bladder trauma are extravasation of contrast around the base of the
bladder confined to the perivesical space and extravasation into the thighs, penis, perineum, or anterior abdominal wall
if the urogenital fascia is violated in a complex injury. In IP bladder trauma, contrast extravasates into the peritoneal
cavity, outlining the loops of bowel and filling paracolic gutters. Methylene blue or indigo carmine helps assess
suspected bladder injury or evaluate bladder repair intraoperatively.

MANAGEMENT:
According to the American Urological Association (AUA) guidelines for bladder rupture, IP bladder rupture is
repaired surgically while uncomplicated EP bladder rupture may be treated with catheter drainage. If a retrograde
urethrogram shows urethral injury, a suprapubic catheter is placed either via a percutaneous or an open approach.
Surgical intervention is indicated for IP bladder injury due to the risk of intra-abdominal sepsis. In hemodynamically
stable patients with isolated IP bladder injury, diagnostic laparoscopy with repair can be considered. Intramural
bladder hematoma is left undisturbed as releasing the tamponade effect can lead to significant hemorrhage. The
bladder lumen is inspected, any foreign body is removed, and nonviable tissue is debrided. An indwelling catheter is
placed before repair. The bladder is classically repaired in two layers with running absorbable suture. Watertight
closure is ensured with irrigation by filling the bladder in a retrograde fashion through a urinary catheter. The bladder
can also be filled in a retrograde fashion with methylene blue to identify leaks. A pelvic drain may be also be placed in
the perivesical space. The abdominal wall layers and skin are closed. Postoperatively, the patient should be placed on
broad-spectrum IV antibiotics for 24-hours in cases of penetrating injury. The pelvic drain may be removed if it has
low output. The indwelling catheter can be removed after 10 to 14 days, and a cystogram is performed before removal,
as described earlier.
Uncomplicated EP bladder injury without urethral injury is managed non-operatively with an indwelling catheter for
10 to 14 days and antibiotic prophylaxis. Before removal of the catheter, a repeat retrograde cystography is performed
to ensure healing of the injury. If extravasation continues greater than three months after the traumatic event, the
injury should be surgically repaired. Indications for operative management EP bladder injury include concomitant
vaginal or rectal injury, foreign body in the bladder wall, or orthopedic repair involving hardware.
SURGICAL MANAGEMENT:
1. Surgical repair (two-layer vesicorraphy):
 Penetrating injury.
 Blunt intraperitoneal injury.
 Blunt extraperitoneal injury with internal osteosynthetic fixation of pelvic fracture.
 Iatrogenic internal intraperitoneal injury.
 Intra-operative recognised injury.
 In case of bladder neck involvement, bony fragment(s) in the bladder, concomitant rectal injury and/or bladder
wall entrapment.
 Intraperitoneal bladder ruptures by blunt trauma, and any type of bladder injury by penetrating trauma, must be
managed by emergency surgical exploration and repair.
2. Conservative management (urinary catheter):
 Conservative management is an option for small, uncomplicated, iatrogenic intraperitoneal bladder perforations.
 In the absence of bladder neck involvement and/or associated injuries that require surgical intervention,
extraperitoneal bladder ruptures caused by blunt trauma are managed conservatively.
 Postoperative recognised extraperitoneal perforation.
 Blunt extraperitoneal perforation.
 Iatrogenic internal extraperitoneal perforation.
 Small internal intraperitoneal perforation in absence of ileus and peritonitis. Placement of an intraperitoneal drain
is optional.

PROGNOSIS:
Patients with bladder injuries may also present with a wide variety of concurrent traumatic injuries. A single-center
retrospective study at a level I trauma center found a mortality rate of 10.8% among patients with bladder rupture
undergoing laparotomy for trauma.[2] Untreated bladder rupture can lead to complications such as peritonitis, severe
sepsis, and fistulas. Successful management requires timely evaluation, accurate diagnosis, and proper management
based on the location and severity of the rupture. Most patients recover normal bladder function. Severe trauma
involving the neck of the bladder, the urethra, and/or pelvic floor muscles may lead to urinary incontinence that may
or may not be amenable to surgery.

COMPLICATION:
 Urinary incontinence
 Wound dehiscence; drainage from wound site should not be confused with urine leak
 Decreased bladder capacity from over-debridement
 Persistent urinary extravasation
 Hemorrhage can occur with violation of pelvic hemorrhage
 Pelvic abscess can develop from infected hematoma
 Intra abdominal infection
 Fistula
 Urinary tract infection
 Urinary urgency

POST OPERATIVE AND REHABILITATIVE CARE:

Patients should follow-up with their surgeon for a wound check and staple removal seven to 10 days post-operatively.
Indwelling catheters are typically removed 10 to 14 days after the surgery if there is no leak detected on repeat
cytogram, and the patient passes a voiding trial. Eastern Association of Surgery for Trauma (EAST) management of
blunt force bladder injuries management guideline does not recommend routine follow-up cystography in the absence
of signs and symptoms that suggest a urine leak for patients who underwent operative repair for simple EP and IP
bladder injury.[11] Follow-up cystography is recommended for patients at high risk for urine leak (e.g., non-operative
management of an EP bladder rupture, malnutrition, steroid use).[11] Persistent leak usually resolves with extended
catheter drainage.

NURSING MANAGEMENT:

SUMMARY:
Bladder injuries can result from blunt, penetrating, or iatrogenic trauma. [1, 2] The probability of bladder injury varies
according to the degree of bladder distention; a full bladder is more susceptible to injury than is an empty one.
Although historically, bladder trauma was uniformly fatal, timely diagnosis and appropriate management now provide
excellent outcomes. Early clinical suspicion, coupled with appropriate and reliable radiologic studies, facilitate prompt
intervention and successful management.

CONCLUSION:
Traumatic bladder rupture caused by blunt or penetrating trauma is rare and mortality is due to associated injuries. CT
scan is the investigative modality of choice. In our environment IBR is more common than EBR and requires
operative management. Most EBRs can be managed non-operatively, and then require routine follow-up cystography.
Simple traumatic bladder injuries can be managed definitively by trauma surgeons. A dedicated urological surgeon
should be consulted for complex injuries.
BIBLIOGRAPHY:

 https://www.uptodate.com/contents/traumatic-and-iatrogenic-bladder-injury
 https://wikem.org/wiki/Bladder_trauma
 https://www.ncbi.nlm.nih.gov/books/NBK557875/
 https://www.msdmanuals.com/en-in/professional/injuries-poisoning/genitourinary-tract-trauma/bladder-
trauma