Bladder, Trauma

Author: Daniel L Platter, MD, Consulting Staff, Department of Emergency Medicine, Kaiser Permanente
Medical Center
Coauthor(s): Jonathan P Vaccaro, MD, Assistant Clinical Professor of Radiology, Department of Diagnostic
Imaging, Rhode Island Hospital; Lawrence E Nelson, DO, Consulting Staff, Department of Surgery, Eastern
Maine Medical Center, Marshfield Clinic
Contributor Information and Disclosures
Updated: Aug 12, 2008

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Introduction

Background

Bladder trauma is a semi-emergent condition, especially trauma that results in uroperitoneum. In such
injuries, sepsis can develop within 24 hours if surgery with repair is not performed.
Radiologic examination is of paramount importance and should be performed to identify and classify the
injury and to plan surgical repair, but it should not hinder patient treatment and stabilization. Several
radiologic evaluations are appropriate, ranging from computed tomography (CT) cystography to basic
retrograde cystography. All have been moderately well studied and require different equipment, locations,
protocols, and operator expertise. It is always necessary to consider the stability of the patient's condition
with regard to airway patency and circulation during the transfer and radiologic evaluation of the patient.
Trauma continues to be a major cause of morbidity and mortality in all areas of the world. Many
immediately life-threatening insults are to the vital organs or to their blood supplies, and many diagnostic
skills and studies are meant to rapidly reveal these complications. However, other life-threatening conditions
must be addressed in a timely manner to avoid morbidity and, occasionally, mortality.
Ideally, these conditions are diagnosed simultaneously, rather than individually, and the search for a
universally applicable study is under way. Immediate surgery or another approach is commonly the
diagnostic and therapeutic procedure of choice if the patient is exsanguinating or if his or her condition is
deemed otherwise unstable.
For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see
eMedicine's patient education article Blood in the Urine.

Related eMedicine topics:

Related Medscape topics:

Mechanism of injury
Bladder trauma can occur in a number of settings. They are usually considered in the context of whether
blunt or penetrating trauma is the inciting event. Blunt trauma is responsible for a large number of severe
associated injuries, such as pelvic, splenic, renal, aortic, bowel, and hepatic insults. Injury is not necessarily
localized to obviously traumatized areas.
Penetrating injury is often secondary to missiles, impaling objects, or knives. These injuries are of varying
severity and often, but not always, result in damage to more focal areas. Some missile injuries have a vaguely
estimable trajectory when one considers the entrance and exit wounds, and in the case of knife wounds, the
impaling blade is often still in place at the time of presentation.
Classification of injury
Any discussion of bladder trauma must include the classification of injuries and associated injury patterns. In
bladder trauma, the following 5 grades of insults are recognized:

 Type I injuries - These are partial tears of the mucosa. The most common injury pattern of
multisystem trauma patients, it is associated with blunt trauma for obvious reasons. Patients with
type I injuries present with hematuria and suprapubic pain.1 However, no rupture is present, and
findings on cystograms, conventional CT scans, and CT cystograms are normal, unless an
intraluminal hematoma is present. This pattern is mentioned here only to point out that it is not a
major bladder injury.

 Type II injuries - These are intraperitoneal bladder ruptures, and they account for approximately
10-20% of all major bladder injuries. Most commonly, they result from a direct blow to the
distended organ. The bladder is weakest at its dome, where reinforcing tissue is absent; thus,
intraperitoneal rupture usually occurs as a result of a rift in the bladder dome. Intraperitoneal
fluid is observed bathing loops of bowel and presents in the paracolic gutters and mesenteric folds.

 Type III injuries - These are interstitial pattern injuries; they are described as intramural or partial-
thickness lacerations of the intact serosa. Only CT cystography is commonly diagnostic and
demonstrates intramural contrast within the bladder wall.2 This condition is most often secondary
to blunt trauma. However, laceration by pelvic fragments or by a penetrating object, with minimal
serosal damage, can present with a primarily interstitial pattern, with minimal extracystic urine
demonstrated.

 Type IV injuries - These are extraperitoneal bladder injuries, and they are the most common bladder
ruptures. In blunt trauma, a theoretical cause for laceration of the lower bladder is from secondary
injury from pelvic fragments. Simple extraperitoneal ruptures involve urine buildup in the
perivesicular space. More complex patterns of urine tracking involve different fascial planes. Urine
or contrast material can be seen in the thigh or scrotum, with disruption of the inferior fascia of the
urogenital diaphragm (perineal membrane). Urine may also breach the Scarpa or Camper fascia,
and it may be observed in the rectus sheath or even under the skin.

 Type V injuries - These are combined ruptures resulting from a combination of penetrating and
blunt trauma; they result in the presence of intraperitoneal and extraperitoneal urine. Type V
injuries constitute 5-12% of bladder ruptures.

Frequency

United States

Trauma to the genitourinary system occurs in approximately 5-10% of all patients with trauma. Most of
these injuries are secondary to blunt trauma, and approximately 10% of genitourinary calamities result in
bladder trauma. Although limited accurate data are available, similar numbers apply to adults and in
children. Bladder trauma is considered to be the second most common genitourinary injury after renal
trauma.

International

Accurate data are limited.

Mortality/Morbidity

Morbidity and mortality are most commonly infectious in nature. Therefore, complications are usually
associated with bladder rupture. Bladder disruption occurs in 5-10% of patients with pelvic fractures, and
the type of perforation, with respect to classification, is important to prognosis. Broadly classified,
approximately 50-85% of ruptures (many of which have associated pelvic fractures) are extraperitoneal, 15-
45% of them are intraperitoneal, and only 1-10% of disruptions consist of both types.
In the event of an intraperitoneal rupture, a preexisting urinary tract infection, if present, will greatly
influence morbidity and mortality. Thus, under certain circumstances, sepsis can ensue within 24 hours.
Treated properly with operative repair and urologic consultation, nearly all patients with an intraperitoneal
bladder rupture have few or no long-term complications.

Race

To the author's knowledge, no studies have been performed to determine whether racial differences exist in
the frequency of bladder trauma.

Sex

No significant difference has been appreciated between the sexes with regard to the percentage of patients
with concomitant bladder injury in the event of abdominopelvic trauma.

Age

Bladder trauma does not appear to be age specific.

 Limited data suggest that children have injury to their bladder in approximately 10% of the
instances where genitourinary injury occurs.
 However, research suggests that preadolescent bladders are more intra-abdominal and that they
consequently have a higher incidence of intraperitoneal rupture when this complication is present.
 Children are at risk of injury to the bowel, bladder, and lumbar spine, with rates of 20%, 4%, and
21%, respectively. Lap-belt ecchymosis is an indication for careful evaluation.

Anatomy

The bladder is located within the bony pelvis. (In adults it is considered to be a mostly extraperitoneal organ).
There, the bladder, prostate, and proximal urethra are protected by 1 of the most secure bony enclosures in
the body.
The bladder has a tetrahedral form when empty and has 4 primary surfaces. A superior, a posterior, and 2
inferolateral surfaces define the shape. The superior portion is triangular and is lined completely by the
visceral peritoneum. This portion extends into the abdomen when distended and has little support from other
structures. It is considered to be a dome when distended; in the female, it contacts the uterus, and in the male,
it contacts the sigmoid colon in addition to loops of bowel.
The posterior surface, or fundus, of the bladder is anterior to the rectum, but it remains mostly
retroperitoneal. A male bladder has the seminal vesicles coursing between the posterior bladder wall and the
rectum. The posterior base of the bladder is supported by the rectum and is secured by the rectovesicular
ligaments. In females, the posterior surface and the superior surface are loosely fixed to the upper vaginal
wall and the uterus.
The pelvic floor musculature and overlying, loose areolar tissue support the inferolateral margins of the
bladder. The pubovesical, medial, and paired lateral umbilical ligaments strengthen the bladder's association
with the anterior body wall. The space of Retzius exists anterior to the bladder. This area consists of loose
connective tissue that allows easy mobilization of the bladder from other surrounding structures. There is
little preventing motion of the bladder, in that the only rigidly fixed point is the bladder neck. This is the
primary adaptation to allow distention during filling.

Presentation

Trauma to the bladder is associated with significant trauma to the pelvis and intra-abdominal organs. Thus,
patients present in a wide variety of ways, with large differences in the stability of their condition.
Commonly, patients have few symptoms secondary to their bladder injury or even to rupture. The literature
suggests that these patients have no strong propensity to develop peritonitis initially, even with a large
amount of uroperitoneum.
Physical examination findings that are suggestive of bladder trauma include vague peritoneal signs or
abdominal tenderness. However, more suggestive findings include isolated suprapubic tenderness, pelvic
instability, or lap-belt ecchymosis. One study revealed that approximately 4% of children with lap-belt
ecchymosis had suffered bladder rupture.3
Unlike upper renal trauma, bladder injury is essentially ruled out when no red blood cells (RBCs) are
observed in the urine. Urogenital injury is suggested when microscopic hematuria is present (defined as
>25,000-35,000 RBCs per high-power field). Gross hematuria is highly suggestive and certainly warrants full
investigation. Gross hematuria is present in 95% of patients, and the remaining patients have microscopic
hematuria.1
A problem can arise when bladder trauma is presumed to be the cause of hematuria, because this finding is
not specific and can stem from more ominous sources, such as renal fracture. Urine should be collected from
the first few hundred milliliters of the initial sample to prevent errors in interpretation. Furthermore,
urethral trauma should always be ruled out before a Foley catheter is placed, especially when gross
hematuria is present. Suggestive findings include blood at the meatus, a high-riding prostate, the patient's
inability to void, perineal hematoma or scrotal swelling, and pelvic fracture.
Bladder injury is strongly associated with pelvic fracture. Eighty percent of bladder ruptures that are
associated with pelvic fracture are extraperitoneal. Pelvic fracture is associated with bladder injury in 80% of
patients, but the reverse is not true. Indeed, only 10% of pelvic fractures are associated with a major bladder
trauma. When a pubic rami fracture exists or pubic symphysis diastasis is present, a higher index of
suspicion should be maintained. A great deal of effort has been made to determine which pelvic fractures are
associated with bladder injury. Patients with disruption of the pubic symphysis or pubic rami or with a
vertically unstable pelvic fracture have a high incidence of concomitant bladder trauma, whereas those with
an isolated acetabulum, femur, or iliac crest fracture have a low incidence of bladder injury or rupture.

Preferred Examination

The extent and type of radiologic evaluation required depends on the patient's condition and on the size of the
area that may be affected. Many patients in stable condition require extensive screening, which means
that diagnostic procedures should ideally provide views of large areas following quick and common
preparation. For many patients in unstable condition or in patients with penetrating abdominal injuries who
are immediately treated in the operating room (at the discretion of the surgeon), intraoperative radiologic
evaluation is needed.2,4,5,6
Retrograde cystography, performed after urethrography, was considered the criterion standard for
evaluation of bladder trauma. However, support has grown for using computed tomography (CT)
cystography in proper diagnosis. Initial studies were not indicative of the reliability of CT scanning when
retrograde contrast enhancement was not used. However, contemporary studies have overwhelmingly
demonstrated that the technique is sensitive and accurate, provided that adequate bladder distention (with at
least 350-400 mL of contrast material) is achieved before the study is performed. In diagnosing bladder
rupture, CT cystography, performed with 400 mL of contrast material that is administered in a retrograde
fashion, is as accurate as plain radiography with retrograde cystography. 2
Ultrasonography is not sensitive or specific enough to be useful for evaluation of bladder rupture.
Retrograde cystograms have long been used for detecting bladder rupture. They are nearly 100% sensitive
for detecting rupture, provided that adequate distention is accomplished and that postvoiding images are
obtained. However, they are time consuming, the examinations are costly when one considers their value
relative to their benefit, and they require extra radiography that does not occur in addition to necessary
trauma evaluation. Furthermore, they are not useful in thoroughly evaluating other structures present in the
abdomen and pelvis.
CT retrograde cystograms are completed in the radiology suite when routine spiral scans of the head, neck,
chest, and abdomen and pelvis are performed. CT retrograde cystography generally requires the same
retrograde introduction of contrast agent as does retrograde cystography. However, unlike plain
radiography, the technique does not require multiple images, including postvoiding and oblique views. Thus,
this procedure is less time consuming and, some would argue, less costly. At 1 hospital cited in the literature,
the cost of CT cystography was $500 or more, a marginal increase over a plain radiographic examination.
Costs should be specifically evaluated at each institution.
A final step is the washout study. After the full-bladder findings are recorded (on radiographs or CT scans),
the bladder is drained. If no residual contrast enhancement is present, the examination is completed, and the
results are negative. If residual contrast enhancement is present in the bladder area, fluid (eg, sterile water) is
used to lavage the bladder. If no residual contrast enhancement is noted after drainage, the examination is
completed, and the results are negative. If contrast enhancement remains, a bladder wall injury is present.
CT cystography may be used somewhat less often in patients who are not undergoing CT scanning for
another reason. In a study of 157 patients with hematuria, an absence of free fluid on abdominopelvic CT
scans was a strong negative predictor of bladder rupture.7 In such patients, not performing cystography may
be reasonable.
Further study into this matter is warranted. Perhaps 1 of the greatest advantages of retrograde CT
cystography with prior abdominopelvic CT scanning is the ability to detect renal parenchymal injury. In
these patients, intravenous urography is not necessary, as it commonly is with traditional retrograde
cystography.
A few studies have focused on delayed evaluation of the bladder. For example, the use of contrast material for
chest and abdominal CT scanning (for which a large amount of contrast material is routinely required) has
been studied. In these examinations, the contrast agent was allowed to distend the bladder in an anterograde
fashion. However, in such cases this distention occurs at the expense of valuable time, because the Foley
catheter should be clamped for at least 20-30 minutes to have any opportunity to achieve accurate results.
Furthermore, if preexisting renal insufficiency or renal pedicle injury is present, this method may be
inadequate.
The author does not recommend this diagnostic strategy for the reasons mentioned. Because study results
have also cast doubt on the consistent accuracy of this method in the evaluation of blunt trauma, its use is
discouraged.

Limitations of Techniques

Cystography generally has served to greatly decrease trauma morbidity and mortality by helping to
successfully screen for bladder rupture. Little doubt exists concerning the accuracy of plain film cystography,
as long as a bladder hematoma does not occlude a rift in the bladder wall and prevent dye from flowing out
into the surrounding spaces. The primary concern is that the examination often does not occur in parallel
with other radiologic examinations of patients with trauma who require CT scanning.
A caveat should be noted: a normal cystogram finding does not exclude a bladder rupture. At surgery,
intraperitoneal or extraperitoneal extravasation may be found. The consideration in this scenario is the
spasm of the detrusor muscle, which is possibly secondary to the irritation effect of the contrast
medium, which causes a leak to become sealed. With general anesthesia, the detrusor relaxes; this is
associated with the eventual intraoperative leak.
CT cystography is faster than are plain radiographic studies; moreover, it has no labor-intensive
requirements for completion, and it can be used to diagnose large hematomas of the bladder, which
potentially could overlie an occult breech in the bladder wall. Furthermore, classification of bladder injury
patterns requires CT scanning because cystography addresses perforations but not more subtle findings.
The cost in each prospective hospital should be considered, because the monetary costs, which favor classic
cystography, may not reflect actual benefits. For instance, because radiographic technologists currently are in
short supply, increasing their use adds to the expense. Furthermore, time is valuable in the trauma setting,
especially because patients in seemingly stable conditions can deteriorate quickly, and a more rapid
evaluation can facilitate their transfer to the trauma intensive care unit or operating room. In general, the
author believes that evaluation with CT cystography is the study of choice when patients already require
transfer to the radiology suite for CT scanning evaluation. This is true especially when microscopic
hematuria is present and a possibility of renal trauma exists.

Differential Diagnoses

Lumbar Spine, Trauma

Other Problems to Be Considered

Renal trauma, especially if hematuria is present