Bladder trauma

Background

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.

Anatomy of the male bladder, showing transitional epithelium and part of the wall in a histological cut-out.

Axial image of the pelvis during CT cystogram demonstrates contrast surrounding the bowel (arrowheads) which is diagnostic of intraperitoneal bladder rupture. Bone fragments from GSW are also present in the L5 left lateral recess (arrow).

Clinical Features

• 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

Differential Diagnosis

Genitourinary Trauma

• Urinary system
  • Renal trauma
  • Ureter trauma
  • Bladder trauma
  • Urethral trauma
    • Traumatic foley catheter removal
• Genital
  • Penile trauma
    • Traumatic foley catheter removal
  • Testicular trauma
  • Vaginal trauma
• Other
  • Child abuse
  • Pelvic fracture (often accompanies)
  • Sexual assault

Evaluation

Retrograde cystogram. Bladder filled with contrast (bottom arrow). Extravasation of contrast (top arrow).

Male with scrotal gunshot wound. Axial image of the pelvis during CT cystogram demonstrates contrast extravasating through a perforation in the posterior wall of the bladder (arrow).

Workup

• Retrograde cystogram (CT or plain film) indicated for:
  • Gross hematuria
  • Inability to void
  • Pelvic fracture in associated with microscopic hematuria
  • Clinical suspicion of bladder injury
  • Penetrating injuries of the buttock, pelvis, or lower abdomen with any hematuria

Diagnosis

• Typically made on retrograde cystogram
  • CT A/P with IV contrast NOT sensitive enough for bladder rupture: bladder must be distended with 350 mL contrast

Management

• Extraperitoneal Rupture
  • Nonoperative management with bladder cathether drainage (Foley vs suprapubic catheter)
• Intraperitoneal Rupture
  • Operative management

See Also

• GU Trauma