BLADDER TRAUMA

MANAGEMENT

Prof Bou Sopheap,

Head of Urology Department,
Preah Kossamak Hospital
 INJURIES TO THE BLADDER
• its extraperitoneal position deep in the pelvis, the
bladder is protected from injury.
• If the bladder injured, other severe injuries are often
associated and the mortality rate is high (22%).
• High velocity impact (road traffic accidents) and
associated with the urethral injury (10-30%).
• More minor degrees of injury ←surgical damage to
the bladder (gynaecological surgery, intravesical
endoscopic surgery…).

2
ANATOMY
Situation de la vessi en rapport avec la
cavité pelvienne.
MALE PELVIS
BASE OF MALE BLADDER
FEMALE PELVIS
FEMALE PELVIS
9
ETIOLOGY
- Vessie vide : organe pelvien

- Vessie pleine, distendue : / fracture du bassin

- Traumatismes fermés et pénétrants 67%-86% , et

14-33% ruptures vésicales

Fréquents chez ceux qui ont une vessie pleine ou

distendue

Traumatisme abdominal fermé  5 % rupture de la vessie

12
25% des fractures du bassin  rupture de la vessie

- 89-100% Rupture extrapéritonéale  fracture du bassin

Traumatismes de l’abdomen qui sont traités chirurgicalement, 

2% touchent la vessie

Rupture extrapéritonéale plus classique

Rupture intrapéritonéale plus sévère

13
• Traumatisme fermé
- Le traumatisme par décélération provoque à la fois de
perforation vésicale et de fracture du basin.

• Traumatisme pénétrant
- par armes à feu, associé d’autres traumatismes
abdominaux et pelviens.

• Traumatisme obstétrical
- durée du travail prolongé, déliverance avec forcep.
L’ancienne césarienne constitue un facteur de risque
d’adhésion.

14
• Traumatisme gynécologique
- Hysterectomie par voie vaginale ou abdominal
- Dissection tissulaire entre la base vésicale et le fascia
du col utérin

• Traumatisme urologique
- Resection endoscopique de la prostate ou de la tumeur
vésicale, biopsie vésicale, cystoscopie

15
• Traumatisme orthopédique
- Fixation interne par vissage dans la
fracture du basin

• Traumatisme idiopathique
- Vessie distendue + traumatisme externe
minime (seat belt injury, remplcament de
la tête fémorale)

16
TOT – (Transobturator Tape)

17
18
19
20
21
 Classification de AAST

American Association of Surgery for Trauma

22
Grade Type Description de la lésion anatomique

Hématome Contusion, hématome intramurale

I Lacération Epaississement partiel
II Lacération Lacération de la paroi extrapéritonéale de
la vessie < 2cm
III Lacération Lacération de la paroi extrapéritonéale (>
2 cm) ou intrapéritonéale (< 2cm) de vessie
IV Lacération Lacération de la paroi intrapéritonéale de
la vessie > 2 cm
V Lacération Lacération de la paroi extrapéritonéale ou
intrapéritonéale de la vessie en extension
au col vésical ou orifice urétéral (trigone)
23
 SING AND SYMPTOM

Absence de miction
Pas de globe
Rarement signe de choc
Contracture abdominale
Empâtement sus-pubien
Epanchement urinaire  péritonite

24
 DIAGNOSTIC

Anamnèse, clinique et examens / imagerie

Echographie  épanchement intra-abdominal
TDM avec injection
 passage intra-péritonéal du produit opaque

Urétro-cystographie rétrograde
 rupture de l'urètre

25
INVESTIGATION
Rupture Intrapéritonéale

27
28
 Intraperitoneal Rupture

• Often no pelvis fractures,

usually blow to full bladder
• Dome is injury site
• Contrast in paracolic gutters
and around bowel
• Management: emergency
laparotomy to repair tear
and prevent peritonitis

29
Intraperitoneal Rupture

• Intraperitoneal rupture in a
53-year-old man who was
involved in a motor vehicle
accident. CT cystogram
demonstrates the classic
appearance of an
intraperitoneal rupture, with
extravasated contrast
material between loops of
small bowel (arrows) and
the anterior pararenal fascia
(arrowheads).

30
Interstitial Bladder Injury
• Interstitial injury in a 41-year-old
man who was involved in a motor
vehicle accident. CT cystogram
demonstrates focal lenticular
thickening of the bladder wall due
to interstitial hematoma and likely
muscular disruption (black
arrow), even though no contrast
material is seen delineating the
injury. Multiple pelvic fractures
are also noted (white arrows).

31
32
33
 Intraperitoneal bladder rupture

pshuor18a1s1m1 34
Based onRésultat tomodensitométriquet CT
Cystography

35
 Type Résultats
1: Contusion Lacération Incomplète ou partielle

2: Rupture Produit de contrast intrapéritonéal

Intrapéritonéale autour des anses intestinales, des
gouttières colo-pariétale

3: Traumatisme Lacération Intramural ou partielle

Interstitiel de la sans contact la séreuse.
vessie
4: Rupture Lacération directe de la vessie par
Extrapéritonéale le fragment du bassin fracturé

36
37
 Assessment
• Most bladder injuries cause only contusion of the
bladder wall and result in minor degrees of
haematuria; more severe bleeding should suggest
bladder rupture.
• Any pt with haematuria following penetrating
trauma to the lower abd should be carefully
assessed for bladder injury.
• After blunt trauma, lower abd pain, tederness,
bruising, hematuria and a pelvic fracture should
suggest possible bladder injuries.
38
 Assessment
• The investigation of choice is direct cystography
using water soluble constrast medium.
• If there is a suspicion of coexisting renal injury or
injury to other intra-abdominal organs, CT with IV
constrast medium is preferred.
• Cystography will demonstrate whether the bladder
is intact ( and simply contused) or ruptured;
ruptured may be intraperitoneal or extraperitoneal.

39
 Management
Bladder contusion:

-67% of bladder injuries consist of contusion

only.
-They are self-limiting and can be managed
conservatively without urethral catherisation.

40
Extraperitoneal rupture of the bladder
• 10-14 days of urethral catherisation alone (no blood
at the urethral meatus).
• Prophylactic antibiotics should be given to all pt
until after the catheter removed.
• The catheter can be removed when repeat
cystography has confirmed healing.
• Bone fragments piercing the bladder, open pelvic
fractures and rectal perforation are indications for
surgical exploration and repair.
International University, S P B 2009 41
Intraperitoneal rupture of the bladder

• ←by penetrating trauma or by “bursting” of the

bladder after blunt trauma.
• When the bladder is filled to near capacity, a
direct blow to the lower abd may result in
bladder disruption.
• In the latter injury, the tear is usually in the vault
of the bladder and communicates directly with
the peritoneal cavity.

42
Intraperitoneal rupture of the bladder

• Intraperitoneal rupture is best managed by

operative repair because the tear is often
larger than suspected from cystography,
because urethral catherisation alone may
result in persistent urinary leakage and
because ongoing extravasation of urine into
the abd can result in peritonitis with a high
mortality.

43
Intraperitoneal rupture of the bladder
• Most intraperitoneal ruptures heal within 10-14
days on repeat cystography.
• Foreign bodies inserted accidentally or
deliberately into the bladder (Fig.1) may
occasionally perforate the vault of the bladder,
resulting in intraperitoneal rupture; removal of
the foreign body and repair of the bladder defect
is necessary.

44
45