Bladder Trauma Treatment & Management

Updated: Mar 26, 2019
  • Author: Bradley C Gill, MD, MS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Treatment

Approach Considerations

Most extraperitoneal bladder leaks can be effectively managed with maximal bladder drainage per urethral or suprapubic catheter.  [22] 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 a trial of voiding completed. [23, 24] 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.

In a trauma situation, blood at the urethral meatus is an absolute indication for retrograde urethrography. Approximately 10-20% of men with posterior urethral injury have an associated bladder injury. Therefore, it is critical that no attempt at blind passage of a urethral catheter is made. Doing such may tear a partially disrupted urethra and convert it into a completely disrupted urethra.

Only after urethral injury is excluded should urethral catheter placement be attempted. In the setting of a posterior urethral injury, placement of a suprapubic (cystotomy) tube, via an open or percutaneous approach, is generally pursued. Otherwise, direct inspection of the bladder during surgical exploration, if indicated, can be carried out.

Posterior urethral injury is a contraindication to urethral catheter insertion. Such an injury should be suspected if blood is present at the urethral meatus, in all pelvic fractures, or if a high-riding prostate is found on digital rectal examination.

When posterior urethral injury is suspected, assess urethral intactness via retrograde urethrogram prior to any attempts at urethral catheter insertion.

A basic retrograde urethrogram is performed as follows:

  • Gently stretch the penis away from the body at an obtuse angle from the pelvis

  • Place a 16 French Foley catheter into the very distal urethra

  • To seal off the urethral meatus, carefully inflate the balloon, using 3 mL of sterile saline, within the fossa navicularis; or use a Brodney clamp, if available, to obtain a better seal at the urethral meatus

  • Alternatively, the tip of a 60-mL piston syringe may be engaged directly into the urethral meatus for contrast injection, but leaded gloves should be worn if doing to provide shielding from radiation exposure

  • Using a diluted medium of 50% contrast and 50% sterile saline or sterile water, which is suitable for intravenous administration, slowly inject solution into the catheter using a 60-mL piston syringe

  • Obtain a plain film or fluoroscopy of the urethra and the bladder before, during, and after injection; oblique views are usually most informative; extravasation indicating urethral injury is generally readily apparent

After posterior urethral injury is excluded and a catheter has been inserted, the radiographic workup to assess for bladder injury may commence. However, in the presence of urethral injury, a suprapubic (cystotomy) tube must be placed, either in an open or percutaneous fashion, and primary urethral realignment attempted once the patient is stable. This can help prevent severe urethral stricture formation.

Alternatively, primary urethral realignment may be attempted at bedside via flexible cystoscopy and guidewire placement. This procedure may eliminate the need for subsequent formal urethroplasty.

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Surgical Therapy

Intraperitoneal Bladder Rupture

Essentially every intraperitoneal bladder rupture requires surgical management. [25, 26] 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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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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Long-Term Monitoring

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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