Blunt Trauma Abdomen – Bladder Injury 

 Types of Bladder Injury 

 1. EPIDEMIOLOGY & MECHANISM 

 Incidence

• Occurs in ~1.6–2% of blunt abdominal trauma
• Strong association with pelvic fractures (85–100%)

 Mechanism of Injury

A. Intraperitoneal rupture (IPR)

• Mechanism: Sudden ↑ intravesical pressure
• Example: blow to distended bladder
• Weak point: bladder dome (peritoneal-covered)

B. Extraperitoneal rupture (EPR)

• Mechanism: Pelvic fracture fragments → direct laceration
• Most common type (~60–70%)

C. Combined injury

• Both intra + extraperitoneal (rare but severe)

 2. ANATOMY (WHY INJURY PATTERN MATTERS)

• Dome → covered by peritoneum → rupture → urine leaks into peritoneal cavity
• Base/neck/anterior wall → extraperitoneal → urine leaks into pelvis

 3. CLASSIFICATION 

 Bladder neck injury = surgical emergency (continence risk)

 4. CLINICAL FEATURES (CLASSIC TRIAD)

 Classic triad:

• Gross hematuria (MOST IMPORTANT)
• Suprapubic pain
• Inability to void

Other features

Intraperitoneal rupture

• Generalized abdominal pain
• Peritonitis (chemical → urine irritation)
• ↑ serum creatinine (pseudo-renal failure due to reabsorption)

Extraperitoneal rupture

• Localized suprapubic pain
• Perineal/scrotal swelling
• Urinary retention

 Important associations

• Pelvic fracture → ALWAYS suspect bladder injury
• Urethral injury (coexistence common)

 5. DIAGNOSTIC APPROACH 

When to suspect bladder injury?

According to trauma guidelines:

• Gross hematuria + pelvic fracture → MUST evaluate
• Microscopic hematuria alone → not sufficient unless unstable

 Imaging Modality of Choice—-CT cystography

 CT Cystography Findings

Intraperitoneal rupture

• Contrast outlines bowel loops
• Free intraperitoneal fluid

Extraperitoneal rupture

• “Flame-shaped” contrast extravasation
• Confined to pelvis

• FAST → NOT reliable for bladder injury
• Routine CT abdomen → may MISS injury → needs retrograde filling

 Retrograde cystography (technique)

• Fill bladder with 300–400 mL contrast
• Imaging during filling + post-void

 6. MANAGEMENT 

 A. Intraperitoneal rupture 

 GOLD STANDARD:Surgical repair (mandatory)

Why?

• Urine → peritonitis → sepsis

Surgical steps

• Laparotomy/laparoscopy
• Debridement + 2-layer closure
• Peritoneal lavage
• Foley catheter drainage

 B. Extraperitoneal rupture (EPR)

 Standard treatment:Conservative management

Components:

• Foley catheter drainage (10–14 days)
• Antibiotics
• Repeat cystography before removal

 Indications for surgery in EPR

 C. Combined injury

 Treat as intraperitoneal → surgery

 7. ICU & CRITICAL CARE CONSIDERATIONS

 Initial trauma management

• Follow ATLS Protocol
• ABC stabilization

Key ICU issues

1. Electrolyte abnormalities

• Urinary ascites → reabsorption →
• ↑ urea, creatinine
• Hyperkalemia

2. Sepsis risk

• Especially intraperitoneal rupture

3. Associated injuries

• Pelvic fractures
• Urethral injury
• Abdominal organ injury

4. Urinary diversion

• Foley vs suprapubic catheter (if urethral injury suspected)

 8. COMPLICATIONS

Early

• Urinary peritonitis
• Sepsis
• Abscess

Late

• Fistula formation
• Bladder dysfunction
• Incontinence (neck injury)
• Stricture

 9. SPECIAL SCENARIOS 

 Bladder + Urethral Injury

Suspect if:

• Blood at meatus
• High-riding prostate

DO NOT insert Foley → do RUG first

 Pediatric bladder injury

• More intraperitoneal (thin bladder wall)

 Alcohol intoxication

• Distended bladder → ↑ risk of dome rupture

 REVISION TABLE