Injuries to the bladder, also known as bladder trauma, though not very common, can occur due to blunt or penetrating trauma to the lower abdomen. The bladder is a muscular sac that stores urine until you urinate.
Injuries to the Bladder
Symptoms of a bladder injury can include:
- Blood in the urine (hematuria).
- Pain in the lower abdomen or pelvis.
- Difficulty urinating (urinary retention).
- Inability to urinate (complete urinary retention).
- Bruising in the lower abdomen.
Treatment for a bladder injury
- Catheterization: A thin tube is inserted into the urethra to drain urine from the bladder, This may be necessary for a few days or weeks to allow the bladder to heal.
- Antibiotics: These medications may be prescribed to help prevent infection.
- Surgery: In some cases, surgery may be necessary to repair the bladder.
In most cases, a bladder injury heals completely with prompt medical attention. However, there can be complications from bladder injuries, such as Infection, Scarring, and Urinary incontinence (leakage of urine).
Cause of bladder injuries
- Blunt trauma. Road traffic accident or falling from height with fracture of the pelvic bones, bone fragments are the direct cause of injury.
- Penetrating trauma. Stab wound or gunshot especially with a full bladder.
- latrogenic. Perforation of the bladder during cystoscopy (for bladder tumor resection or stone crushing) or abdominoperineal surgery.
Types
1. Extraperitoneal rupture of the bladder.
a. Site: Areas not covered by peritoneum: lateral walls, posterior wall, and bladder base (all walls close to the bladder neck).
b. Presentation:
- Hematuria.
- Severe pelvic pain from the pelvic collection of a hematoma) (from bleeding fractured pelvic bones) + urinoma (extravasated urine)
c. Diagnosis:
i. Ascending cystogram (investigation of choice) will show:
- The contrast in the bladder escapes to the perivesical space or deeper in the pelvic cavity, depending on the extent of perforation.
- Compression and elongation of the bladder (inverted tear drop appearance) by a perivesical collection of urinoma and hematoma.
Contrast escapes to the pelvis. Bladder compression causes the “inverted tear drop appearance”
ii. CT cystography is also a valuable alternative to detect associated injuries
d. Management:
- A small perforation with minimal extravasation is managed conservatively by insertion of an indwelling wide-bore urethral Foley catheter for at least 1 week. This allows bladder healing while absorption of the urinoma occurs.
- A big perforation with excess urine extravasation is managed surgically by suturing the perforated bladder wall, insertion of cystostomy tube, draining the urinoma, and controlling pelvic bleeding.
2 Intraperitoneal rupture of the bladder:
a. Site: the bladder dome (covered by peritoneum).
b. Presentation:
- Hematuria and severe pelvic pain.
- Manifestations of the acute abdomen from intraperitoneal collection of urine that cause chemical peritonitis.
- The bladder is usually empty and the patient does not pass urine.
c. Diagnosis: Ascending (retrograde) cystogram: Contrast escapes from the bladder to the peritoneal cavity around the intestinal loops, CT cystogram is also more reliable.
d. Management: Immediate surgical drainage of urine from the peritoneal cavity, with suturing of the perforations (water-tight in a (double layer and placing a cystostomy tube and a drain in the peritoneum.
Urethral injuries
Anterior urethra: involves (penile and bulbar) urethra and it is covered by corpus spongiosum. Posterior urethra: involves membranous and prostatic urethra, it is not covered by corpus spongiosum and it is surrounded by the external and internal sphincter.
Etiology:
A. Anterior urethra: (usually iatrogenic causes).
- External trauma: fracture penis, bullet, falling astride.
- Internal trauma: during endoscopy or catheter insertion.
B. Posterior urethra:
- Mainly associated with pelvic fracture.
- Other causes include endoscopy, catheter insertion or during prostatectomy.