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Bladder Trauma Treatment & Management

  • Author: Bradley C Gill, MD, MS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Jul 29, 2014
 

Medical Therapy

Most extraperitoneal bladder leaks can be effectively managed with maximal bladder drainage per urethral or suprapubic catheter.[12] 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.

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Surgical Therapy

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.

Extraperitoneal Extravasation

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.

Surgical Principles

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.

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Preoperative Details

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.

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Intraoperative Details

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
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Postoperative Details

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
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Follow-up

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.
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Complications

Potential complications of bladder surgery include, but are not limited to, the following:

  • Persistent or recurrent urinary extravasation
  • Wound dehiscence
  • Hemorrhage
  • Pelvic abscess
  • Intraabdominal infection
  • Urinary tract infection
  • Low bladder capacity
  • Urinary urgency

Considerations

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.

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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.

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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."[17]

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.[18]

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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Contributor Information and Disclosures
Author

Bradley C Gill, MD, MS Resident Physician, Department of Urology, Glickman Urological and Kidney Institute; Clinical Instructor of Surgery, Cleveland Clinic Lerner College of Medicine, Education Institute; Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic

Bradley C Gill, MD, MS is a member of the following medical societies: American College of Surgeons, American Urological Association, Societe Internationale d'Urologie (International Society of Urology)

Disclosure: Nothing to disclose.

Coauthor(s)

Raymond R Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine; Staff Physician, Center for Neurourology, Female Pelvic Health and Female Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic, Beachwood Family Health Center, and Willoughby Hills Family Health Center; Director, The Urothelial Biology Laboratory, Lerner Research Institute, Cleveland Clinic

Raymond R Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Sandip P Vasavada, MD Physician, Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine, Center for Female Urology and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic

Sandip P Vasavada, MD is a member of the following medical societies: American Urological Association, Engineering and Urology Society, American Urogynecologic Society, International Continence Society, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Allergan and Axonics<br/>Received ownership interest from NDI Medical, LLC for review panel membership; Received consulting fee from allergan for speaking and teaching; Received consulting fee from medtronic for speaking and teaching; Received consulting fee from boston scientific for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Shlomo Raz, MD Professor, Department of Surgery, Division of Urology, University of California, Los Angeles, David Geffen School of Medicine

Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, California Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Acknowledgements

None.

References
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  2. Srinivasa RN, Akbar SA, Jafri SZ, Howells GA. Genitourinary trauma: a pictorial essay. Emerg Radiol. 2009 Jan. 16(1):21-33. [Medline].

  3. Husmann DA. Diagnostic techniques in suspected bladder injury. McAninch JW, ed. Traumatic and Reconstructive Urology. 1996. 261-7.

  4. Melo EL, de Menezes MR, Cerri GG. Abdominal gunshot wounds: multi-detector-row CT findings compared with laparotomy-a prospective study. Emerg Radiol. 2011 Dec 2. [Medline].

  5. Cass AS, Luxenberg M. Features of 164 bladder ruptures [see comments]. J Urol. 1987 Oct. 138(4):743-5. [Medline].

  6. Corriere JN. Extraperitoneal bladder rupture. McAninch JW, ed. Traumatic and Reconstructive Urology. 1996. 269-73.

  7. Brown SL, Persky L, Resnick MI. Intraperitoneal and Extraperitoneal. Atlas of Urol Clin of N Amer. 1998. 6:59-70.

  8. Carroll PR, McAninch JW. Major bladder trauma: mechanisms of injury and a unified method of diagnosis and repair. J Urol. 1984 Aug. 132(2):254-7. [Medline].

  9. Corriere JN Jr, Sandler CM. Bladder rupture from external trauma: diagnosis and management. World J Urol. 1999 Apr. 17(2):84-9. [Medline].

  10. Sandler CM, Hall JT, Rodriguez MB. Bladder injury in blunt pelvic trauma. Radiology. 1986 Mar. 158(3):633-8. [Medline].

  11. Volpe MA, Pachter EM, Scalea TM. Is there a difference in outcome when treating traumatic intraperitoneal bladder rupture with or without a suprapubic tube?. J Urol. 1999 Apr. 161(4):1103-5. [Medline].

  12. Kotkin L, Koch MO. Morbidity associated with nonoperative management of extraperitoneal bladder injuries. J Trauma. 1995 Jun. 38(6):895-8. [Medline].

  13. Corriere JN Jr, Sandler CM. Management of the ruptured bladder: seven years of experience with 111 cases. J Trauma. 1986 Sep. 26(9):830-3. [Medline].

  14. Cass AS, Luxenberg M. Management of extraperitoneal ruptures of bladder caused by external trauma. Urology. 1989 Mar. 33(3):179-83. [Medline].

  15. Kim FJ. Laparoscopic management of intraperitoneal bladder rupture secondary to blunt abdominal trauma using intracorporeal single layer suturing technique. Int Braz J Urol. 2008 September-October. 34(5):650. [Medline].

  16. Al-Aghbari S, Al-Harthy A, Ahmed M, Al-Reesi A, Al-Wahaibi K, Al-Qadhi H. Laparoscopic repair of traumatic intraperitoneal bladder rupture. Sultan Qaboos Univ Med J. 2011 Nov. 11(4):515-8. [Medline]. [Full Text].

  17. [Guideline] Morey A, Brandes S, Dugi D, et al. Urotrauma: American Urological Association Guideline. American Urological Association. Available at https://www.auanet.org/education/guidelines/urotrauma.cfm. Accessed: 07/24/2014.

  18. Geng J, Chang H, Chung S, et al. Nonoperative Treatment for Intraperitoneal Bladder Rupture. Urological Science. 2014. 25:70-72.

  19. Taylor M, Brant W, Wallis C, et al. Extraperitoneal Bladder Ruptures: Complications Associated with Operative Versus Non-Operative Management at the Time of Anterior Pelvic Fixation or Abdominal Exploration for Other Injuries. Journal of Urology. April / 2011. 185(4) Supplement:e41.

  20. Erickson B, Berneking A, Myers J, et al. Ideal Bladder Injury Treatment Modality Unclear. Urology Times. Available at http://urologytimes.modernmedicine.com/urology-times/news/ideal-bladder-injury-treatment-modality-unclear. Accessed: 07/24/2014.

  21. Craggs B, Michielsen D. Conservative treatment of an intraperitoneal bladder perforation. Cent European J Urol. 2011. 64(1):47-9. [Medline]. [Full Text].

  22. Horstman WG, McClennan BL, Heiken JP. Comparison of computed tomography and conventional cystography for detection of traumatic bladder rupture. Urol Radiol. 1991. 12(4):188-93. [Medline].

 
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CT scan of extraperitoneal bladder rupture. The contrast extravasates from the bladder into the prevesical space.
Cystogram of extraperitoneal bladder rupture. Note the fractured pelvis and contrast extravasation into the space of Retzius.
Cystogram of intraperitoneal bladder rupture. The contrast enters the intraperitoneal cavity and outlines loops of bowel.
 
 
 
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