Bladder Trauma Treatment & Management

Most extraperitoneal ruptures can be managed safely with simple catheter drainage (ie, urethral or suprapubic).^[13] Leave the catheter in for 7-10 days and then obtain a cystogram. Approximately 85% of the time, the laceration is sealed and the catheter is removed for a voiding trial.^{[14, 15]}

Virtually all extraperitoneal bladder injuries heal within 3 weeks. If the patient is taken to the operating room for associated injuries, extraperitoneal ruptures may be repaired concomitantly if the patient is stable.

Intraperitoneal bladder rupture

Most, if not all, intraperitoneal bladder ruptures require surgical exploration.^{[16, 17]} These injuries do not heal with prolonged catheterization alone. Urine takes the path of least resistance and continues to leak into the abdominal cavity. This results in urinary ascites, abdominal distention, and electrolyte disturbances.

Surgically explore all gunshot wounds to the lower abdomen. Because of the nature of associated visceral injuries, immediately take patients with high-velocity missile trauma to the operating room, where the bladder injuries can be repaired concomitantly with other visceral injuries.

Stab wounds to the suprapubic area involving the urinary bladder are managed selectively. Surgically repair obvious intraperitoneal injuries, and manage small extraperitoneal injuries expectantly with catheter drainage.

Extraperitoneal extravasation

Bladders with extensive extraperitoneal extravasation are often repaired surgically. Early surgical intervention decreases the length of hospitalization and potential complications, while promoting early recovery.

Follow the basic trauma protocol (advanced trauma life support [ATLS]), and stabilize the patient. Administer broad-spectrum antibiotics, and obtain a surgical informed consent, if possible. In the setting of emergency trauma, however, there is often no time for a formal surgical consent from the patient.

• Position the patient in a supine fashion.
• Create a vertical midline abdominal incision.
• Conduct a thorough inspection of the pelvic viscera, ureters, bowel, and blood vessels.
• Note the presence of pelvic hematoma and, if present, leave undisturbed.
• Bivalve the dome of the bladder.
• Inspect the interior of the bladder. Foreign bodies such as bone or orthopedic hardware are often encountered and should be removed.
• Identify both ureteral orifices and ensure that they are intact.
• Once the bladder injury is localized, débride all nonviable tissue.
• High-velocity missile injuries may cause extensive damage to the bladder tissues.
• Close the bladder in a watertight fashion using 3 layers with an absorbable suture. Every effort should be made to protect the closure from any sharp edges or bony protusions from associated pelvic fractures. Omental fat is often interposed on the closure as an additional layer.
• Test the integrity of the closure by inflating the bladder with saline or water.
• Place a large-bore suprapubic tube through a separate cystotomy site prior to closing the bladder.
• Place a pelvic drain in the perivesical space.
• Close the abdomen in layers, and apply staples to the skin.

• Continue intravenous antibiotics until the patient is discharged.
• Remove the pelvic drain when the drainage output is minimal, usually within 48-72 hours.
• Leave in the SPT and indwelling urethral catheters until x-ray cystography is performed.
• Discharge the patient when he or she shows diet toleration and is ambulatory, afebrile, and relatively pain-free.

• Instruct the patient to return in 7-10 days for staple removal, and check the wound at that time.
• Obtain the x-ray cystogram 10-14 days after surgery.
• If the cystogram finding is normal, remove the urethral catheter.
• Perform a voiding trial via the SPT.
• Remove the SPT when the patient passes the voiding trial.
• Advise the patient to return to normal activity within 4-6 weeks after surgery.

• Potential complications of bladder surgery

  • Urinary extravasation
  • Wound dehiscence
  • Hemorrhage
  • Pelvic infection
  • Small-capacity bladder
  • De novo urge incontinence
• Other complications

  • Despite technically proper reconstruction, urinary extravasation through the bladder closure may occur. This usually responds to extended catheter drainage.
  • Abdominal fascial dehiscence presents as persistent drainage from the incision site.
  • Violation of pelvic hematomas during surgery results in severe hemorrhage.
  • If infected, pelvic hematomas become pelvic abscesses.
  • Aggressive surgical débridement of the bladder may result in a small bladder, giving rise to bladder spasms and urge incontinence. Over time, the bladder may gradually enlarge to more physiologic volumes.

Traumatic bladder ruptures, once uniformly fatal, are currently managed quite successfully. Timely evaluation and proper management are critical for optimal outcomes.

Gross hematuria is the hallmark of bladder injury. Physicians evaluating patients with blunt or penetrating lower abdominal trauma must have a high index of suspicion for urologic injury, especially bladder and urethral injuries.

Almost all extraperitoneal bladder ruptures are associated with pelvic fractures. Most extraperitoneal ruptures can be treated conservatively with catheter drainage alone; however, ensure that all intraperitoneal, combined intraperitoneal and extraperitoneal ruptures, and penetrating injuries are treated with immediate exploration and repair in the operating room.

Proper treatment of tiny intraperitoneal bladder perforations resulting from urologic transurethral instrumentation is controversial. Most authorities recommend an abdominal exploration and closure of the bladder perforation. Others advocate conservative management with an indwelling urethral Foley catheter and prolonged bladder rest. Currently, no published data support conservative management.