Introduction
Bladder trauma is caused by penetrating, pelvic, and iatrogenic injuries. Bladder trauma is divided into two categories: intraperitoneal and extraperitoneal injuries. There are instances where the injury is a combination of the two types. Abdominal trauma accounts for 10 % of bladder injuries.
What Is the Etiology of Bladder Trauma?
Bladder trauma mainly occurs due to work-related instances, violent crimes, motor vehicle collisions, and iatrogenic. A high-energy blow to the lower abdomen causes blunt bladder injury when the bladder is distended, leading to intraperitoneal injuries. Trauma caused by pelvic fractures results in extraperitoneal injuries and bladder injuries. In many instances, bladder trauma is associated with abdominopelvic visceral and concomitant orthopedic injuries. Abdominopelvic trauma cases cause 1.6 % of traumatic bladder rupture cases. Blunt trauma, 85 % of the time, is the cause of bladder injuries. 51 % of the injuries are caused by penetrating trauma.
What Is the Epidemiology of Bladder Trauma?
Blunt and penetrating trauma causes intraperitoneal and extraperitoneal injuries. 60 % of bladder traumas are extraperitoneal bladder injuries, 30 % are intraperitoneal bladder injuries, and the remaining 10 % are combined injuries. Iatrogenic bladder injuries are mainly caused by obstetric/gynecologic procedures involving cesarean sections and hysterectomies.
What Is the Pathophysiology of Bladder Trauma?
In an adult, the bladder is located at the anterior pelvis. The bladder neck is attached to the pelvis with the help of ligaments and fascia. The peritoneum covers the dome. The dome of the bladder and the site above the peritoneal reflection are sites of intraperitoneal bladder rupture. For extraperitoneal bladder rupture, the site is usually below the peritoneal reflection and on the lateral or anterior aspects of the bladder. Blunt trauma leads to bladder contusion, which causes a partial thickness tear of the bladder and hematoma formation.
The presentation for individuals with bladder contusion is usually gross hematuria (blood in urine). Rapid deceleration causes extraperitoneal bladder rupture. The mechanism of extraperitoneal bladder rupture is a combination of shearing force and direct penetration resulting from the spicules of a fractured pelvis. Leakage of urine into the penis, perineum, thighs, or anterior abdominal wall.
According to research, bladder injuries are associated with concomitant pelvic fractures 85 % to 100 % of the time. The dome of the bladder is the least protected site and hence the common site for intraperitoneal bladder fracture as the peritoneum does not cover it. A direct blow to a distended bladder causes intraperitoneal bladder rupture and is also associated with deceleration injuries. The urine that drains into the abdomen gets absorbed in the peritoneal cavity leading to increased levels of blood urea nitrogen, creatinine, electrolyte, metabolic derangements, and decreased urine output. Combined extraperitoneal and intraperitoneal bladder is seen in association with pelvic fractures accounting for up to 5 % to 8 % of bladder injuries.
Physical Examination of Bladder Trauma:
The individual is first examined for airway, breathing, circulation, disability, and exposure. The second examination involves a head-to-toe exam. The second test may involve findings for bladder trauma inclusive of blood at the meatus, pelvic instability, significant abdominal pain, pelvic pain, high riding prostate, gross hematuria, and suprapubic tenderness. An unstable pelvic fracture leads to extensive internal bleeding into the pelvis. This can be managed surgically or can be stabilized using a pelvic binder.
A perforated viscus in the abdomen shows peritoneal signs of guarding, rigidity, and rebound tenderness. These signs are also suggestive of intraperitoneal bladder injury. Intra-abdominal, pericardial, and pelvic free fluid can be examined by focused assessment with sonography trauma (FAST). The demerit of focused assessment with sonography in trauma is that it does not distinguish between blood and urine. Before inserting a catheter, the urethral injury should be ruled out by evaluating the genitals for blood in the urethral meatus. High-riding prostate found during a rectal exam is also a cause of urethral injury.
Evaluation of Bladder Trauma:
Basic lab tests include a metabolic panel, blood tests, coagulation panel, and urine analysis. Individuals with gross hematuria, inability to void, pelvic fracture with microscopic hematuria, blood at the meatus, penetrating injury to the pelvis, lower abdomen, or buttock, and hemodynamically stable individuals are examined by retrograde cystography, conventional x-ray, or computed tomography.
Computed tomography (CT) and x-ray have similar specificity and sensitivity rates. Retrograde cystography is more specific and sensitive than intravenous contrast CT scans. According to the guidelines from the European association of urology, CT cystography has a rapid turnover time and convenience and can detect intra-abdominal processes and bony fragments in the bladder. Hence preferred over traditional x-ray. In extraperitoneal bladder injury, the imaging finds the contrasts extravasate into the thighs, abdominal wall, penis, and perineum.
What Is the Treatment for Bladder Trauma?
Treatment depends on the following cause:
- Contusion: In cases of contusion, the bladder wall is only bruised and does not tear. The only sign of contusion is hematuria. A wide catheter is placed so that large blood clots can pass through easily. Once the urine clears, the catheter is removed.
- Intraperitoneal Rupture: The hole opens at the part of the abdomen which holds the bowel, spleen, and liver. This causes urine to leak into the abdomen, which may lead to serious complications. However, the tear can be managed through surgery. A catheter is placed for two weeks after surgery to allow the bladder to heal.
- Extraperitoneal Rupture: The urine leaks into the tissues of the bladder when the tear is at the side or bottom of the bladder. Surgery is the treatment of choice if the catheter fails to drain the urine for extraperitoneal rupture. Extraperitoneal rupture is a complex injury. The catheter can also be used as a mode of treatment. A wide catheter is placed for ten days, and the bladder is allowed to heal. For follow-up, x-ray tests may be performed to check if the rupture is healed.
- Penetrating Injuries: These injuries are mostly managed by surgery. Penetrating injuries are often seen in association with injuries to the surrounding organs. After the surgery, a catheter is placed for the bladder to heal.
Conclusion
Bladder trauma is caused by penetrating, pelvic, and iatrogenic injuries. It mainly occurs due to work-related instances, violent crimes, motor vehicle collisions, and iatrogenic. Treatment mainly involves surgery. Individuals should promptly follow follow-up procedures.
