BLADDER INJURIES

Bladder injuries
Situations in which the bladder may be injured
TURBT , cystoscopic bladder biopsy, TURP, cystolitholapaxy, penetrating trauma to the lower abdomen or back, caesarian section (especially as an emergency), blunt pelvic trauma in association with pelvic fracture or  minor  trauma in the inebriated patient, rapid deceleration injury (e.g. seat belt injury with full bladder in the absence of a pelvic fracture), spontaneous rupture after bladder augmentation, total hip replacement (very rare).

Types of perforation
- Intraperitoneal perforation the peritoneum overlying the bladder is breached allowing urine to escape into the peritoneal cavity.
- Extraperitoneal perforation the peritoneum is intact and urine escapes into the space around the bladder, but not into the peritoneal cavity.

Making the diagnosis
During endoscopic urological operations (e.g. TURBT, cystolitholapaxy), the diagnosis is usually obvious on visual inspection alone a dark hole is seen in the bladder and loops of bowel may be seen on the other side. No further diagnostic tests are required.

In cases of trauma, the classic triad of symptoms and signs suggesting a bladder rupture is:
- suprapubic pain and tenderness
- difficulty or inability in passing urine
- haematuria

Additional signs:
- abdominal distension
- absent bowel sounds (indicating an ileus from urine in the peritoneal cavity)

These symptoms and signs are an indication for a retrograde cystogram.
The diagnosis may be made only at operation for fixation of a pelvic fracture.

Imaging studies
Retrograde cystography or CT cystography.
- Ensure the bladder is adequately distended with contrast. With inadequate distension a clot, omentum, or small bowel may  plug  the perforation, which may not therefore be diagnosed. Use at least 400ml of contrast in an adult and 60ml plus 30ml per year of age in children up to a maximum of 400ml in children.
- Obtain images after the contrast agent has been completely drained from the bladder (a post-drainage film). A whisper of contrast from a posterior perforation may be obscured by a bladder distended with contrast.
In extraperitoneal perforations, extravasation of contrast is limited to the immediate area surrounding the bladder. In intraperitoneal perforations, loops of bowel may be outlined by the contrast.

Treatment of bladder rupture
Extraperitoneal
Bladder drainage with a urethral catheter for ~2 weeks followed by a cystogram to confirm the perforation has healed.
Indications for surgical repair of extraperitoneal bladder perforation:
- If you have opened the bladder to place a suprapubic catheter for a urethral injury
- A bone spike protruding into the bladder on CT
- Associated rectal or vaginal perforation
- Where the patient is undergoing open fixation of a pelvic fracture, the bladder can be simultaneously repaired

Intraperitoneal
Usually repaired surgically to prevent complications from leakage of urine into the peritoneal cavity.

Spontaneous rupture after bladder augmentation
Spontaneous bladder rupture occasionally occurs months or years after bladder augmentation and usually with no history of trauma. If the patient has spina bifida or a spinal cord injury, they usually have limited awareness of bladder fullness and pelvic pain. Their abdominal pain may therefore be mild and vague in onset and nature. Fever or other signs of sepsis may be present. Have a high index of suspicion in patients with augmentation who present with non-specific signs of illness. A cystogram usually, though not always, confirms the diagnosis. If doubt exists, consider exploratory laparotomy.