Bladder Injury

Description

• The bladder is well protected deep within the bony pelvis.
• Bladder injury is caused by trauma, iatrogenic surgical complication, or spontaneous rupture.
  • The mechanism of traumatic injury is characterized as blunt or penetrating.
• Bladder injury can be classified as a contusion or rupture.
  • Rupture is classified as intraperitoneal or extraperitoneal.
• Bladder injury is often associated with other traumatic injuries, most commonly pelvic fracture.

Epidemiology

Incidence

• 1.6% of blunt abdominal trauma cases have an associated bladder injury (1)[C].
  • 80% of bladder injuries are associated with pelvic fracture.
  • 10% of pelvic fractures are associated with bladder injury.
  • 90% of bladder injuries due to blunt trauma are caused by motor vehicle collision (MVC).
• 15–40% of bladder rupture from penetrating trauma (2)[B]
  • 85% secondary to gunshot wounds (GSW), 15% from stab wounds
• Bladder ruptures: 55% extraperitoneal, 40% intraperitoneal, and 5% combined (1)[C]
• The bladder is the most common organ damaged during pelvic surgery (1)[C].
  • Obstetric injuries and gynecologic surgery are the most common causes of iatrogenic bladder injury.

Etiology and Pathophysiology

• Bladder contusion (1)[C]
  • Damage to bladder mucosa or muscularis without full thickness injury, usually presenting with gross hematuria but no extravasation on cystogram
• Blunt bladder trauma is associated with rapid deceleration (1)[C].
  • The bladder is well protected within the bony pelvis. It takes a significant amount of blunt force to cause a rupture.
  • MVC, fall, or crush mechanism are most common.
  • Fracture of the bony pelvis tears fascial attachments to the bladder, causing rupture.
  • Bone fragments can directly lacerate the bladder, although this is less common.
  • A blow to abdomen with a full bladder can lead to a rise in intravesical pressure and rupture at the dome with or without associated pelvic fracture.
• Penetrating bladder injuries (1)[C]
  • GSW or stab injury to bladder
  • Iatrogenic surgical injury
    • Complication of open, laparoscopic, or robotic surgeries as well as cystoscopic procedure
• Spontaneous rupture (1)[C]
  • Patients may have neurologic disease, bladder outlet obstruction, or prior urologic surgery.

Pediatric Considerations
Lower rates of bladder injury in children with blunt trauma and pelvic fracture (1)[C]

Risk Factors

• Rapid deceleration injury
• Pelvic fracture
• Penetrating trauma to the pelvis
• Prior pelvic surgery
• Prior pelvic radiation

General Prevention

• Seat belts
• Void prior to driving

Commonly Associated Conditions

80–94% blunt bladder trauma associated with injuries to other structures

• Pelvic fracture is the most common associated injury.
• Urethral injury occurs in 15% of cases of bladder rupture (1)[C].