Bladder Trauma Treatment & Management
- Author: Bradley C Gill, MD, MS; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Most extraperitoneal bladder leaks can be effectively managed with maximal bladder drainage per urethral or suprapubic catheter. Depending on the presumed size of the bladder defect, the bladder should be drained for 10 to 14 days and then assessed for healing via cystogram. Approximately 85% of such injuries will heal within 7 to 10 days, at which point the catheter can be removed and trial of voiding completed.[13, 14] Overall, nearly all extraperitoneal bladder injuries heal within 3 weeks. However, if surgery is pursued for other indications, extraperitoneal bladder injuries may be repaired surgically in the same setting if the patient is stable.
Intraperitoneal Bladder Rupture
Essentially every intraperitoneal bladder rupture requires surgical management.[15, 16] Such an injury will not usually heal with prolonged bladder drainage alone, as urine will continue to leak into the abdominal cavity despite the presence of a functional catheter. This results in metabolic derangements and can produce urinary ascites, abdominal distention, and even ileus. All gunshot wounds to the abdominopelvic region should be surgically explored, as the likelihood of injuries to other abdominal organs and vascular structures is high. At that time, any concurrent bladder injury can be directly repaired.
Bladders with extensive extraperitoneal extravasation are often repaired surgically. In cases where surgical exploration for other injuries is pursued, minor extraperitoneal leaks can be repaired, as well. This facilitates more rapid healing and decreases the potential for complications, as well as the necessary duration of indwelling catheter use in many cases.
In the trauma setting, closure of bladder defects is usually performed in a two-layer fashion. With iatrogenic injury, some surgeons routinely close the bladder in one layer with success. In either manner, a running suture is placed to obtain a water-tight closure. Only absorbable suture should be used on the bladder, as permanent sutures serve as a nidus for later stone formation and infection. Similar to nonoperative management of bladder leaks, an indwelling catheter is left for at least 10 to 14 days to facilitate healing of the defect. A cystogram is done prior to catheter removal.
In any trauma setting, the Advanced Trauma Life Support protocol should be followed first and foremost. With the patient stabilized in anticipation of surgical intervention, broad-spectrum antibiotics should be administered. In a non-emergent setting, informed consent should be obtained if possible, from the patient, family member, or person holding medical power of attorney, as appropriate.
A standard repair of bladder injury in the trauma setting is performed as follows:
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 using electrocautery to attain hemostasis
Thoroughly inspect the bladder lumen and remove any foreign bodies encountered
Confirm that both ureteral orifices are intact and productive of urine
Localize the bladder injury and debride all nonviable tissue to healthy bleeding edges
Place a large-bore suprapubic tube via separate cystotomy before closing the bladder
Create a watertight closure using two layers of absorbable suture in a running stitch
Interpose an omental fat flap to protect the closure from sharp or bony protrusions.
Test the integrity of the closure by inflating the bladder with saline or water irrigation
Place a closed suction pelvic drain in the perivesical space and intraperitoneal pelvis
Close the abdominal wall layers and skin, and apply a sterile dressing to the incision
Postoperative management following bladder trauma repair is as follows:
Continue intravenous antibiotics through the hospital stay, based on the surgical findings
Remove the pelvic drain when its output has minimized, generally after 48 to 72 hours
Maintain the indwelling urethral and suprapubic catheters for at least 10 to 14 days
Obtain a cystogram before catheter removal to confirm healing and rule out a leak
See the list below:
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 include, but are not limited to, the following:
Persistent or recurrent urinary extravasation
Urinary tract infection
Low bladder capacity
Despite technically proper reconstruction, urinary extravasation through the bladder closure may occur. Generally, this will resolve with extended catheter drainage. An abdominal fascial dehiscence presents as persistent drainage from the incision site, which should not be confused with a urine leak.
Violation of a pelvic hematoma during surgery may result in severe hemorrhage. A pelvic hematoma may be seeded by bacteria or fungus at the time of injury or surgery, and subsequently become a pelvic abscess.
Lastly, necessary aggressive surgical debridement may result in a small bladder capacity, which can result in urinary urgency and urge incontinence. However, over time these symptoms may resolve, as the bladder will generally enlarge.
Outcome and Prognosis
Traumatic bladder rupture, once uniformly fatal, is now managed successfully with or without surgery, depending upon the type of injury. It is difficult to cite a single specific rate of successful bladder repair due to the wide variety of concurrent trauma these patients often present with. Regardless, critical to the successful management of traumatic bladder rupture are a timely evaluation, accurate diagnosis, and proper management based on the location and severity of the bladder leak.
Future and Controversies
The most recent American Urological Association Guidelines on Urotrauma, published in 2014, state that "surgeons must perform surgical repair of intraperitoneal bladder rupture in the setting of blunt or penetrating external trauma" and that "clinicians should perform catheter drainage as treatment for patients with uncomplicated extraperitoneal bladder injuries."
Nevertheless, the literature contains a handful of case reports describing intraperitoneal bladder rupture managed conservatively. Two such reports describe successful treatment of small ruptures in patients with a benign abdomen, using prolonged large-diameter urethral catheter drainage and antibiotic prophylaxis. The authors warn that communication with the peritoneal cavity may persist, and advise open surgical management if clinical deterioration occurs (eg, uremia, infection) or follow-up cystography demonstrates a persistent leak.
Similarly, two recent studies found that patients who undergo open repair of extraperitoneal injuries have lower rates of persistent urine leak than patients treated with urethral catheter drainage.[19, 20] In the absence of a randomized trial comparing open repair and conservative managemen, the authors advocate performing open bladder repair in patients who will be undergoing surgery for other reasons.
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