BLADDER INJURIES

MOHAMMAD IHMEIDAN PGY2

• <2% of all abdominal and pelvic injuries requiring surgery
• Because the bladder is well protected within the bony
pelvis
• Non-iatrogenic
• Iatrogenic
• Extraperitoneal (70%)
• Intraperitoneal (30%)
• In adults, the empty bladder is
well protected within the bony
pelvis,
• However , 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 secondary to pelvic
fractures are 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, may help to minimize this
risk.
• Spontaneous bladder rupture is quite rare and is
associated with higher mortality.
• Cases have been reported in association with
vaginal delivery, hemophilia, malignancy, radiation,
infection, and urinary retention.
CLINICAL SIGNS AND SYMPTOMS
• Hematuria
• pelvic pain
• difficulty voiding
• Abdominal bruising
• No urine return after urethral catheterization
• Delayed?
• Fever
• No urine output
• Peritoneal signs
INTRA-OPERATIVE
SIGNS AND SYMPTOMS DURING OPEN
OR LAP SURGERY

• extravasation of urine
• visible laceration
• clear fluid in the surgical field
• appearance of the bladder catheter
• gas (in case of laparoscopy) in the urine bag.
DURING ENDOUOLOGICAL PROCEDURES

• Fatty tissue or bowel between detrusor

muscle fibres
• Inability to distend the bladder
• Low return of irrigation fluid
POSTOPERATIVE SIGNS AND SYMPTOMS OF
UNRECOGNIZED BLADDER PERFORATION
Hematuria
Lower abdominal pain
Abdominal distension
Ileus, peritonitis, fever
Urine leakage from the wound
Persistent high output drain
Decreased urinary output.
 INVESTIGATIONS
PLAIN CYSTOGRAPHY

• The bladder should be filled with 300 mL of contrast material and a

plain film of the lower abdomen obtained.
• Contrast medium should be allowed to drain out completely, and a
second film of the abdomen should be obtained.
• The drainage film is extremely important, because it demonstrates
areas of extraperitoneal extravasation of blood and urine that may not
appear on the filling film
• With intraperitoneal extravasation, free contrast medium is visualized
in the abdomen, highlighting bowel loops
e •
• CT cystography is an excellent method for detecting
bladder rupture; however, retrograde filling of the
bladder with 300 mL of contrast medium is also
necessary to distend the bladder completely.

• Incomplete distention with consequent missed

diagnosis of bladder rupture often occurs when the
urethral catheter is clamped during standard
abdominal CT scan with intravenous contrast
injection.
MANAGEMENT

• American Urological Association (AUA) guidelines

recommend that intraperitoneal bladder ruptures be
surgically repaired.
• During operative evaluation of bladder rupture at
the dome, it is recommended to evaluate the entire
bladder and not just repair the obvious injury.
• Repair of the bladder injury may be single or double layered closure.
• It is recommended to avoid permanent suture on the mucosal
repair as this may be a nidus for future stone formation.
• A Foley catheter is routinely left in the bladder after repair.
• Follow-up cystography should be performed to confirm healing in
some complex cases.
• AUA guidelines recommend that uncomplicated
extraperitoneal bladder injuries be managed
conservatively with catheter placement.
• Standard therapy involves leaving the catheter in place
for 2 to 3 weeks, but it may be left in longer in some
cases.
• Extraperitoneal ruptures that do not heal after 3-4
weeks of catheter drainage should be considered for
surgical repair.
• Complicated extraperitoneal bladder ruptures, such
as those associated with bone fragments within the
bladder and those associated with vaginal or rectal
injuries, often require operative repair.
• Bladder neck injuries often will not heal without
surgical repair.
THANK YOU