Correlation Between Pelvic Fracture and Bladder

Trauma in Hasan Sadikin General Hospital

Randhi Rinaldi1, Ahmad Agil1

1
Urology Department, Hasan Sadikin Academic Medical Center, Universitas

Padjadjaran, Bandung, Indonesia

*Corresponding: randhirinaldi@gmail.com

ABSTRACT

Introduction: Abdominopelvic trauma frequently results in genitourinary

injuries, and urinary bladder rupture is a rather common injury in blunt abdominopelvic

trauma. The purpose of this study is to determine whether pelvic fracture and bladder

trauma are related.

Methods: This study uses hospital medical data to conduct a retrospective

observational cross-sectional analysis of the relationship between pelvic injury and

bladder trauma. Nonprobability sampling was the method of choice for this study, and a

total of 62 data points were collected during a five-year period, from 2016 to 2021.

Result: A total of 73 cases (0.3%) of pelvic fractures were reported out of 317

cases of urogenital trauma in the period between 2016 and 2021. A total of 62 bladder

trauma patients—49 men (79%) and 13 women (21%)—were found among the pelvic

fracture patients. The median age was 33.39 years plus 16.87. 60% of pelvic fractures

were ramus pubis fractures, the most common type. AAST Grade 1 was the most

prevalent bladder damage, accounting for roughly 26 cases (86.7%). With a p-value of
0.001, we discovered that individuals who experience pelvic fractures have a

significantly increased chance of bladder damage (OR = 5.73).

Conclusion: This study showed a strong correlation between bladder trauma

and pelvic injury.

Keywords: Bladder trauma, pelvic fracture, fracture type

 INTRODUCTION

The bony pelvis provides a strong, protective cage to the pelvic visceral. High-

energy trauma can result in fracture and disruption of the pelvic ring which results in

lower urinary tract injury (LUTI)—injury to the bladder and/or urethra—in up to 10%

of cases.1 The mechanism of injury is thought to be due to shearing forces on the

attachments to the visceral or bony spicule penetrating injury.

The bladder is an extraperitoneal organ that is protected by the pubic bone. In

males, the bladder sits superior and anterior to the prostate, while in females, the

bladder lies anterior to the uterus. Superior and posterior to the bladder is the

peritoneum, a membranous layer that delineates the intraabdominal cavity.3

15-20% of pelvic fracture cases contain genitourinary injuries, which are

frequent side effects of abdominopelvic trauma and are more common when the pubic

symphysis is injured.4 One to six percent of individuals who experience forceful

abdominopelvic trauma gets urinary bladder rupture, which is a rather common injury.

The bladder is effectively protected from both blunt and piercing traumatic injuries

because of its deep location within the bony pelvis. Bladder rupture represents an

important injury, because the reported fatality rate after blunt trauma is substantial

(22%).5 Aim of this study is to evaluate the correlation between pelvic injury and

bladder injury specifically bladder rupture.

STUDY METHOD

This is a retrospective observational cross-sectional study evaluating the

correlation between pelvic injury and bladder trauma. The data were gathered from
hospital medical records and then analyzed to get the odds ratio between pelvic fracture

and urethral injury.

The sampling technique used in this research is nonprobability sampling with a

consecutive sampling method. In this consecutive sampling method, the researcher takes

all newly diagnosed subjects until the minimum number of subjects is met. The

determination of the sample size in this study is in accordance with the data obtained for

62 patients over a period of 5 years from 2016 to 2021.

Statistical analysis performed in this study was using chi-square. The study

result is considered statistically significant if p-value ≤0,05. The data taken were

recorded and processed through the SPSS program version 21.0 for Windows.

STUDY RESULT

Table 1. Demographic Variables of Participant

Variable N = 62

Gender

Men 49 (79%)

Women 13 (21%)

Age

Mean±STD 33.39± 16.87

Median 28.5

Range (min-max) 10-70

From 2016 to 2021, 24.443 trauma patients in all visited the emergency room.

There were 317 patients with urogenital trauma among the trauma victims. There were
73 individuals with pelvic fracture injuries among them (0.3%). 30 (9.5%) of the

patients with pelvic fractures suffered bladder damage. A total of 62 bladder trauma

patients—49 men (79%) and 13 women (21%)—were discovered, including those with

and without pelvic fractures. The average age was 33.39 ± 16.87.

Table 2. Type of Bladder Rupture Associated with Pelvic Fractures

Variabel N= 30

Type of Pelvic Fracture

Anteroposterior compression (APC) 11(34.8%)

Pubic ramus fracture 18(60.9%)

Symphiolysis 1(4.3%)

Management

Conservative management 20(66.7%)

Cystostotomy 2(6.7%)

Laparotomy exploration (LE) 1(3.3%)

Repair of Bladder 7(23.3%)

This study divided fracture types into three categories. Ramus pubis fractures

were the most typical kind of pelvic fracture (60%). 11 instances (36.6%) of APC pelvic

fracture and 1 case (4.4%) of symphiolysis were involved. Up to 20 cases or 66.7% was

seen in conservative management as the most common treatment in bladder trauma-

related pelvic injury. Another common management showed in the repair of bladder

category as many as 7 cases or 23.3%.

Table 3. The proportion of Bladder Trauma Associated With Pelvic Injury and

Non-Pelvic Injury

Variable Pelvic Fracture P-value

With Pelvic Without

Fracture Pelvic

Fracture

Bladder Trauma N = 30 N = 32

Mechanism of Injury P=0.142

Fall from height 3(10%) 5(15.6%)

Car vehicle collision 2(6.7%) 6(18.7%)

Motor vehicle collision 20(66.6%) 16(50%)

Pedestrian 5(16.7%) 2(6.3%)

Unknown mechanism 0(0%) 3(9.4%)

AAST Grading P=0.924

Grade 1 26 (86.71 (3.3%) 26 (81.2%)

Grade 2 1 (3.3%) 3 (9.4%)

Grade 3 2 (6.7%) 1 (3.1%)

Grade 4 0 (0%) 2 (6.3%)

Grade 5 0 (0%)

Outcome

Alive 28(93.3%) 32(100%) P=0.230

 Variable Pelvic Fracture P-value

With Pelvic Without

Fracture Pelvic

Fracture

Deceased 2(6.7%) 0(0.0%)

In this study, the processes of trauma were divided into five groups. There

were 8 cases of fall from height in the bladder trauma with pelvic fracture group

(12.9%), 6 cases of car accidents (9.7%), 38 cases of motor vehicle collision (61.3%), 7

cases of pedestrian (11.3%), and 3 cases of unknown cause (4.8%).

The AAST grading system is used to categorize bladder trauma. For each

pelvic fracture and case without a pelvic fracture category, the highest case had an

AAST Grade 1 of roughly 26 cases. In our analysis, conservative care accounted for

roughly 20 cases or 66.7% of all cases.

Table 4. The Risk of Bladder Trauma To Pelvic Injury

Pelvic Fracture OR CI (95%) P-Value

Variable
(+) ( -)

Bladder 5.73 <0.001*

Trauma
 (+) 30 32

(-) 40 215

With a p-value of 0.001, we discovered that individuals with pelvic fractures

have a considerably higher risk of bladder trauma (OR=5.73) than people without pelvic

fractures.

DISCUSSION

Pelvic fracture is common after severe trauma and usually accompanies other

organ injuries. About 3-8% of patients with pelvic fractures have concomitant bladder

injuries. On the other hand, up to 90% of patients with blunt bladder injuries have

concomitant pelvic fractures, with pelvic ring fractures being the most common injury

pattern.6,7

Blunt trauma accounts for 60-85%, while penetrating trauma accounts for 15-

51% of bladder injuries.8 Blunt abdominal injuries are most notably due to motor-

vehicle accidents while penetrating injuries often result from stab or gunshot wounds

(GSW). GSWs are responsible for the majority of penetrating bladder trauma compared

to stab wounds (80% versus 20%) in the United States. Stab wounds follow a more

predictable path limited to the immediate trajectory of the object.6,8

Several mechanisms of blunt bladder injury have been proposed. Direct force

to the abdomen can cause a “burst” rupture of the dome, the weakest part of the

bladder.8 A filled bladder is more susceptible to rupture because the dome rises into the
abdominal cavity, eliminating protection afforded by the bony pelvis and pelvic organs.

This leads to an IP bladder injury and urine extravasation into the peritoneal cavity,

which carries a risk for peritonitis, chemical ileus, sepsis, and even death. Although

concomitant pelvic injuries are not uncommon in IP injuries, up to 25% do not have

concomitant pelvic injuries.6,8

Bladder injuries are often associated with concomitant pelvic fractures in 85-

100% of cases. These injuries may cause an extraperitoneal bladder rupture, where urine

may leak into the perivascular space surrounding the bladder but does not enter the

intraperitoneal cavity. Pelvic ring disruptions may create a shear force disrupting

ligaments holding the bladder wall to the base of the pelvis or a counter-coup force that

results in a burst injury opposite to the site of the pelvic fracture. In 65% of cases, the

injury to the bladder is opposite the area of the fracture. Moreover, bony fragments from

a pelvic fracture may also directly lacerate the bladder surface.1,2,9

The American Association of Surgery for Trauma (AAST) developed the

Organ Injury Scale to provide a common language to facilitate clinical decision-making

and research. It is based on the degree of anatomical disruption with Grade I being mild

to Grade V being lethal. Bladder injury is graded as a contusion or partial laceration

(Grade I) to complete laceration (Grades II-V). Grade I injuries, contusions of the

bladder wall and partial thickness lacerations, can lead to self-limiting intramural

hematoma formation. These minor injuries are the most common injuries and represent

a third of all cases of bladder injury. 10,11

 Table 5: American Association for the Surgery of Trauma Bladder Organ

Injury Scale4

Bladder Injury Description

Grade Injury Description

I Hematoma Contusion, intramural

hematoma

Laceration Partial thickness

II Laceration Extraperitoneal bladder

wall laceration

III Laceration Extraperitoneal ≥ 2 cm or

intraperitoneal

IV Laceration Intraperitoneal bladder

wall laceration ≥ 2 cm

V Laceration Laceration extending into

bladder neck or ureteral

orifice (trigone)

Prompt recognition of bladder trauma can prevent severe complications due to

urinary leakage, which include sepsis, peritonitis, abscess, urinoma, fistulas, and

electrolyte disturbances through reabsorption. Morbidity and mortality from bladder

injuries have been shown to correlate with injury severity scores >15, systolic blood

pressure < 90 mmHg, and concomitant pelvic fractures. Bladder injuries are also

associated with longer hospital stays and carry a significant risk of morbidity and the

potential for an increased cost of care.7,8,12

 Gross hematuria, seen in 67-95% of cases, is the most classical symptom

associated with bladder trauma. Microscopic hematuria may be seen in 5% of cases.

Other signs such as the mechanism of injury, associated pelvic fracture, suprapubic

tenderness, low urine output, difficulty voiding, elevated creatinine, abdominal

hematoma, edema of the perineum and upper thighs, and shock should all raise the

index of suspicion for a bladder injury. 17,18 In the case of penetrating injuries,

especially GSWs, entrance and exit wounds in the lower abdomen, perineum, and

buttocks may be visualized and should be traced.5,9

Trauma patients should undergo assessment per Advanced Trauma Life

Support protocol developed by the American College of Surgeons. Hemodynamically

unstable patients should not undergo acute evaluation of bladder trauma, but rather be

taken for immediate surgical exploration. 10,13 Gross hematuria in the setting of a pelvic

fracture is an absolute indication for cystography, as bladder injury is present in 29% of

such cases. Gross hematuria refers to visible blood from the urinary tract while

microscopic hematuria can only be detected on urinalysis. Gross hematuria without

pelvic fracture and microscopic hematuria with pelvic fractures are relative indications

for cystography if there is clinical suspicion. Clinical suspicion may include mechanism

of injury, pubic symphysis diastasis, >1 cm obturator ring fracture displacement,

penetrating injuries with pelvic trajectories, inability to void, low urine output, increased

blood urea nitrogen or creatinine, abdominal distension, suprapubic pain, or urinary

ascites seen on imaging. A small number of patients with pelvic fractures (0.6-5%) will

present with microscopic hematuria. However, microscopic hematuria, in general, is a

poor predictor of bladder injury.7,8,10

 In a study by Brewer et al., of 214 patients who underwent cystography for

microscopic hematuria, none were found to have a bladder injury.14 Thus, cystography

for the presence of a pelvic fracture or microscopic hematuria alone is not

recommended.

The European Association of Urology (EAU) recommends CT cystography be

used in the context of other possible abdominal trauma, while the American Urological

Association (AUA) guidelines do not specifically address the use of CT versus X-ray.

Compared to X-ray cystography, CT is more expensive and confers greater radiation.

However, CT takes less time and includes more detail of the surrounding pelvic

structures.2,6,12

In the case of an intra-operative bladder injury, the EAU guidelines

recommend the use of cystoscopy for the evaluation of suspected bladder injuries.

Alternatively, for patients undergoing intraabdominal surgery, an indwelling urethral

catheter may be filled while the abdomen is inspected for fluid extravasation from the

bladder. While routine cystoscopy after gynecological or urological procedures is

controversial, it is warranted if bladder injury is suspected after hysterectomies, sling

operations (especially via retropubic route), or transvaginal mesh procedures.4,10,11

A bladder contusion is a diagnosis of exclusion in patients presenting with

hematuria in the setting of bladder trauma for which no observable cause is found.

Contusions do not necessitate treatment unless significant hemorrhage is present for

which a large bore catheter can be used for drainage and irrigation if required.

Interstitial bladder injuries can be managed with prolonged bladder rest with a urethral

catheter, and a repeat cystogram is not necessary. Surgical management of a bladder

injury is warranted for IP injuries since they carry the risk of sepsis, tend to be larger
injuries, and have a higher associated risk of morbidity and mortality when compared to

EP injuries.3,13

IP injuries therefore require surgical exploration, which is usually performed

through a lower midline or Pfannenstiel incision. The laceration should be sutured in

one or two layers with an absorbable running suture. After the bladder injury has been

repaired, the closure may be tested by filling the bladder in a retrograde fashion through

a urethral catheter. Furthermore, use of a colored agent, such as methylene blue, may

help to identify leaks during bladder filling. An abdominal drain may also be placed to

evaluate for post-operative urine leaks. There are no current guidelines on the optimal

length of time for catheter placement after bladder repair, but 7-14 days has been

reported and is commonly used. AUA guidelines recommend against using suprapubic

catheters following bladder repairs, as urethral catheters are sufficient in the majority of

cases. In fact, drainage with urethral catheters have been associated with shorter hospital

stays and lower morbidity compared to combined drainage with suprapubic and urethral

catheters. EP injuries are usually managed conservatively, with bladder drainage via

catheter followed by a cystogram to confirm healing of the injury.2,12

Extraperitoneal bladder injury in the setting of ORIF for pelvic fracture

requires immediate catheterization since fracture repair may be delayed several days

Immediate surgical repair of an extraperitoneal bladder injury is appropriate in the

setting of intravesical bone spicules, rectal or vaginal laceration, and bladder neck

injuries in order to minimize the risks of fistula formation, abscess, urine leak, and

incontinence. Immediate repair may also be considered for patients undergoing

exploratory laparotomy or internal fixation of their pelvic fracture to minimize urine

contamination of orthopedic hardware. Surgical repair involves two-layer (mucosa-

detrusor) primary vesicorraphy with an absorbable suture followed by the placement of

a large bore Foley catheter to ensure drainage. A transvesical approach may be useful,

as it can be difficult to identify an extraperitoneal bladder rupture from outside the

bladder. It may be necessary to resect devitalized mucosa or detrusor muscle, although

extensive mobilization of the bladder should be avoided to minimize the risk of vascular

and neurological injuries to the bladder. An important potential complication of a

bladder rupture with a pelvic fracture (even in the absence of operative repair) is

peripheral nerve injury with resulting bladder dysfunction. This may lead to lifelong

voiding dysfunction and may be more common with delayed repair and significant

pelvic fractures.3,5

Extraperitoneal bladder injuries are more commonly associated with pelvic

ring fractures, some of them needing anterior pelvic ring stabilization. This is usually

achieved with open reduction and internal fixation (ORIF), by plate and screws or

screws only, or alternatively with external fixation of the pelvis.15

In a study by Johnsen et al., cystogram revealed continued extravasation in at

least 18% of patients with EP injuries managed with catheters, suggesting confirmatory

cystography may still be of some utility. 16 The majority of ruptures heal by three weeks;

if the injury has not healed by four weeks, AUA guidelines recommend surgical repairs.

The guidelines also recommend surgery for EP bladder injuries when there is persistent

hematuria, associated pelvic organ injury, the presence of foreign bodies or projecting

bones in the bladder, ongoing urinary leak, and penetrating trauma. Other indications

may include concomitant vaginal or rectal lacerations, inadequate drainage via urethral

catheters, bladder neck injuries, and internal fixation of pelvic fractures. Concurrent

cystorrhaphy during surgical intervention for other abdominal injuries has also been
shown to reduce urologic complications, time in intensive care, and overall hospital

stay. Similarly, EAU guidelines recommend concomitant cystorrhaphy during

laparotomy to decrease infective complications.6,8,17

CONCLUSION

Despite being rare, bladder injuries entail a high risk of morbidity and fatality

if not identified and treated right once. This study demonstrated a strong relationship

between pelvic damage and bladder trauma.

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