Bob Andinata

Bladder is well protected by the bony pelvis

and thus injury is rare

Dome has no bony support

- weakest point is adjacent to the peritoneum

>300cm H20 to rupture the normal bladder

>85% bladder rupture have serious associated

injuries mortality rate of 22-44%

Blunt trauma
- Deceleration injuries.
- 60-85% have bladder injuries
- The most common mechanisms are motor vehicle
accidents , falls and assaults
- 10-12% patients with pelvic fractures bladder injuries

Penetrating trauma
- 15-40% are from a penetrating injury.
- gunshot wounds (85%) and stabbings (15%).
- concomitant abdominal and/or pelvic organ injuries

Obstetric trauma
- prolonged labor or a difficult forceps delivery
- direct laceration is reported in 0.3% cesarean
delivery

Gynecologic trauma
occur during a vaginal or abdominal
hysterectomy

Urologic trauma
- perforation of the bladder during a bladder
biopsy, cystolitholapaxy, TURP and TURBT.

Orthopedic trauma
- orthopedic pins and screws during internal
fixation of pelvic fractures.
- Thermal injuries to the bladder wall may
occur during the setting of cement substances
used to seat arthroplasty prosthetics

Spontaneous or idiopathic bladder trauma

- reported <1%
- intraperitoneal.
- result from a combination of bladder
overdistention and minor external trauma.

50-71 % of all bladder ruptures (80%)

laterally or at the base

Traumatic extraperitoneal ruptures usually are

associated with pelvic fractures (89-100%) or an
avulsion tear at fixation points of puboprostatic
ligaments

associated with fractures of the anterior pubic

arch, and may occur from a direct laceration of
the bladder by the bony fragments. The degree of
bladder injury is directly related to the severity of
the fracture.

complex injury, contrast material thigh, penis,

perineum, or into the anterior abdominal wall.

The classic cystographic finding :

contrast extravasation around the base of the bladder
confined to the perivesical space.

The bladder may assume :

- a teardrop shape from compression by a pelvic
hematoma
- Starburst, flame-shape, and featherlike patterns

10-20% of all major bladder injuries dome primarily

Blunt trauma intraperitoneal rupture

in children > adults

Classic intraperitoneal bladder ruptures large

horizontal tears in the dome of the bladder

The mechanism of injury is a sudden large increase in

intravesical pressure in a full bladder.

Common among patients diagnosed with alcoholism

or those sustaining a seatbelt or steering wheel injury.

Intraperitoneal ruptures demonstrate

contrast extravasation into the peritoneal
cavity, often outlining loops of bowel,
filling paracolic gutters, and pooling
under the diaphragm

more common in children because of the

relative intra-abdominal position of the
bladder. The bladder descends into the
pelvis usually by the age of 20 years

5-12% of bladder ruptures.

combined ruptures resulting from a

combination of penetrating and blunt trauma

Cystogram reveals contrast outlining the

abdominal viscera and perivesical space.

Often, the cystogram is bypassed, and the

diagnosis is made during an exploratory
laparotomy.

Type I: Bladder contusion

Most common form
Incomplete tear of bladder mucosa & cystography is normal

Type II: Intraperitoneal rupture

Type III: Interstitial injury-rare

Caused by a tear of the serosal surface
Mural defect without extravasation

Type IV: Extraperitoneal

Almost always associated with pelvic fractures
Subdivided into
Simple : extravasation limited to perivesical space
Complex : extending to thigh, scrotum or perineum

Type V: Combined extra- and intraperitoneal rupture

A triad of symptoms is often present

gross hematuria
suprapubic pain or tenderness
difficulty or inability to void

98% of bladder ruptures gross hematuria,

and 10% microscopic hematuria

conversely, 10% have normal urinalyses.

presentation

An abdominal examination may reveal

distention, guarding, or rebound tenderness
urinary ascites, electrolyte disturbances and
absent bowel sounds
Intraperitoneal bladder rupture

bilateral palpation of the bony pelvis

abnormal motion indicating an open-book
fracture or a disruption of the pelvic girdle.

Cystogram
- 100% accuracy w/ significant bladder injury
- 15% only visible on post-evacuation films

A properly performed cystogram consists of

- an initial kidney-ureter-bladder (KUB)
- AP and oblique views filled with contrast
- AP film obtained after drainage

Using a diluted contrast medium, slowly fill the bladder by

to a volume of 300-400 cc.
In children : Bladder capacity = 60 cc + (30 cc X age in y)

CT ~60% accuracy

CT cystogram approaches 100% accuracy

Extraperitoneal rupture can be more difficult

to visualize

While extraperitoneal bladder rupture can be treated

conservatively, intraperitoneal bladder rupture
requires surgical repair

Small extraperitoneal
- Catheter drainage for 7-10 days
- Approximately 85% of the time, the laceration is
sealed.

Large extraperitoneal +/- bony fragments

-Exploration
-Cystostomy
-Debridement
-Pelvic reduction and fixation

Bladders with extensive extraperitoneal

extravasation often are repaired surgically.
Early surgical intervention decreases the length
of hospitalization and potential complications,
while promoting early recovery

Intraperitoneal
Laparotomy
Intraperitoneal irrigation and repair of bladder
Cystostomy tube

Abscess (retroperitoneal, intraperitoneal, pelvic)

Fistula (vesicoperitoneal, enteric, retroperitoneal

cutaneous)

Incontinence secondary to bladder neck injury

and/or pelvic fx

Bladder outlet obstruction / neck contracture

Thank You