Injuries to the

bladder
dr.Agung, Sp.U
1
Etiology
Bladder injuries occur
most often from external
force and are often
associated with pelvic
fractures
Iatrogenic injury may
result from gynecologic and
other extensive pelvic
procedures as well as from
hernia repairs and
transurethral operations.
2 Mechanism of vesical injury

A direct blow over the full

bladder causes increased
intravesical pressure.
If the bladder ruptures, it will
usually rupture into the
peritoneal cavity.
3
Pathogenesis and Pathology

Bladder When the pelvis is fractured by

Injuries blunt trauma, fragments from
the fracture site may perforate
the bladder. These perforations
usually result in extraperitoneal
rupture.
If the urine is infected,
Intraperitoneal Extraperitoneal extraperitoneal bladder
perforations may leads to
deep pelvic abscess and severe
pelvic inflammation.
4
Pathogenesis and Pathology

Bladder When the bladder is filled to near

Injuries
capacity, a direct blow to the lower
abdomen may result in bladder
disruption. This type of disruption
is ordinarily intraperitoneal. Since
the reflection of the pelvic
peritoneum covers the dome of the
Intraperitoneal Extraperitoneal
bladder, a linear laceration will
allow urine to flow into the
abdominal cavity.
5
Clinical Findings

90% of cases Pelvic fracture accompanies bladder rupture

The diagnosis of pelvic fracture can be made initially in the emergency
room by lateral compression on the bony pelvis, the fracture site will show
crepitus and be painful to the touch.

SYMPTOMS

Blunt Injury, Pelvic or Spontaneous

Lower lower Unable to voiding
Abdominal abdominal urinate gross
Trauma pain hematuria (+)
6
Clinical Findings
Signs
A large pelvic
Marked
Heavy bleeding Acute abdomen hematoma
tenderness of
+ Pelvic fracture may occur with indistinct
the suprapubic
Hemorrhagic Intraperitoneal landmarks of
area and lower
shock bladder rupture rectal
abdomen.
examination

Laboratory Findings

Catheterization usually is required in patients with pelvic trauma but not if bloody
urethral discharge is noted (urethral injury) urethrogram is needed before
catheterization. When catheterization is done, gross or, less commonly, microscopic
hematuria is usually present. Urine taken from the bladder at the initial catheterization
should be cultured to determine whether infection is present.
7
Clinical Findings
X-ray Findings
Plain abdominal film

Pelvic fracture
Haziness over lower abdomen from blood and urine extravasation

CT Scan

Kidney and ureteral injuries detection

Cystography

Bladder disruption

CT Cystography
8 X-ray findings

Extraperitoneal bladder rupture. Intraperitoneal bladder rupture.

Extravasation (arrow) seen outside the Cystogram shows contrast surrounding
bladder in the pelvis on cystogram. loops of bowel.
9
Complications

A pelvic abscess may develop from extraperitoneal bladder

rupture; if the urine becomes infected, the pelvic hematoma
becomes infected too.
Intraperitoneal bladder rupture with extravasation of urine into the
abdominal cavity causes delayed peritonitis.
Partial incontinence may result from bladder injury when the
laceration extends into the bladder neck.
Meticulous repair may ensure normal urinary control.
10
Treatment

A. Emergency Measures
Shock and hemorrhage should be treated

B. Surgical Measures
A lower midline abdominal incision should be made. As the
bladder is approached in the midline, a pelvic hematoma,
which is usually lateral, should be avoided. Entering the
pelvic hematoma can result in increased bleeding from
release of tamponade and in infection of the hematoma, with
subsequent pelvic abscess. The bladder should be opened in
the midline and carefully inspected. After repair, a suprapubic
cystostomy tube is usually left in place to ensure complete
urinary drainage and control of bleeding
11
Treatment
1. Extraperitoneal bladder rupture
Extraperitoneal bladder rupture can
be managed with urethral catheter
drainage only. (Typically 10 days of
healing time.) Large blood clots in the
bladder or injuries involving the
bladder neck should be managed
surgically. As the bladder is opened
in the midline, it should be carefully
inspected and lacerations closed
from within. Polyglycolic acid or
chromic absorbable sutures should
be used.
Extraperitoneal bladder lacerations
occasionally extend into the bladder
neck and should be repaired
meticulously. Fine absorbable
sutures should be used to ensure
complete reconstruction so that the
patient will have urinary control
after injury. Such injuries are best
managed with indwelling urethral
catheterization and suprapubic
diversion.
12
Treatment

2. Intraperitoneal rupture

Intraperitoneal bladder ruptures should be repaired via a

transperitoneal approach after careful transvesical inspection and
closure of any other perforations. The peritoneum must be closed
carefully over the area of injury. The bladder is then closed in
separate layers by absorbable suture. All extravasated fluid from the
peritoneal cavity should be removed before closure. At the time of
closure, care should be taken that the suprapubic cystostomy is in
the extraperitoneal position.
13
Treatment

3. Pelvic fracture 4. Pelvic hematoma

Stable fracture of the There may be heavy uncontrolled bleeding from

pubic rami is usually rupture of pelvic vessels even if the hematoma
present. In such cases, has not been entered at operation. At
the patient can be exploration and bladder repair, packing the
ambulatory within 45 pelvis with laparotomy tapes often controls the
days without damage or problem. If bleeding persists, it may be
difficulty. Unstable necessary to leave the tapes in place for 24
pelvic fractures hours and operate again to remove them.
requiring external Embolization of pelvic vessels with Gelfoam or
fixation have a more skeletal muscle under angiographic control is
protracted course. useful in controlling persistent pelvic bleeding
14
Prognosis

With appropriate treatment, the prognosis is

excellent. The suprapubic cystostomy tube can be
removed within 10 days, and the patient can usually
void normally. Patients with lacerations extending
into the bladder neck area may be temporarily
incontinent, but full control is usually regained. At
the time of discharge, urine culture should be
performed to determine whether catheter-associated
infection requires further treatment.
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