Bladder injuries

1. BLADDER INJURIES
MOHAMMAD IHMEIDAN PGY2

2. •a relatively rare condition
•<2% of all abdominal and pelvic injuries requiring surgery
•Because the bladder is well protected within the bony
pelvis

3. • Non-iatrogenic
Extraperitoneal (70%)
Intraperitoneal (30%)
• Iatrogenic

4. • In adults, the empty bladder is well
protected within the bony pelvis,
• but a full bladder may be distended to
reach the level of the umbilicus, making
it more vulnerable to injury.
• In very young children, the bladder is an
intraabdominal organ, exposing it to
injury in the setting of trauma.
• The weakest part of the bladder is the
peritoneal dome

5. •Extraperitoneal ruptures are usually
associated with pelvic fractures either due to
compressive forces on the pelvis causing
rupture of the anterior or lateral bladder wall
or from direct penetration of the bladder by
bony fracture fragments

6. •Iatrogenic injury to the bladder may be associated
with gynecological and colorectal surgery, urologic
procedures, and Foley catheter placement.
•Also bladder punctures occur in association with
midline trocar placement below the umbilicus
during laparoscopic procedures. ensuring the
bladder is empty, preferably with a catheter inserted
prior to trocar placement, helps to minimize this
risk.

7. •Spontaneous bladder rupture is quite rare and is
associated with high mortality.
• Cases have been reported in association with
vaginal delivery, hemophilia, malignancy, radiation,
infection, and urinary retention.

8. CLINICAL SIGNS AND SYMPTOMS
• hematuria
• pelvic pain
• difficulty voiding
• Abdominal bruising
• No urine return after urethral catheterization
• Delayed?
• Fever
• No urine output
• Peritoneal signs

9. •extravasation of urine
•visible laceration
•clear fluid in the surgical field
• appearance of the bladder catheter
• gas (in case of laparoscopy) in the urine bag.
INTRA-OPERATIVE
SIGNS AND SYMPTOMS DURING OPEN
OR LAP SURGERY

10. DURING ENDOUOLOGICAL PROCEDURES
•Fatty tissue or bowel between detrusor
muscle fibres
• Inability to distend the bladder
•Low return of irrigation fluid

11. POSTOPERATIVE SIGNS AND SYMPTOMS OF
UNRECOGNIZED BLADDER PERFORATION
Hematuria
Lower abdominal pain
Abdominal distension
Ileus, peritonitis, fever
Urine leakage from the wound
Persistent high output drain
Decreased urinary output.

12. PLAIN CYSTOGRAPHY
• The bladder should be filled with 300 mL of contrast material and a
plain film of the lower abdomen obtained.
• Contrast medium should be allowed to drain out completely, and a
second film of the abdomen should be obtained.
• The drainage film is extremely important, because it demonstrates
areas of extraperitoneal extravasation of blood and urine that may not
appear on the filling film
• With intraperitoneal extravasation, free contrast medium is visualized
in the abdomen, highlighting bowel loops

13. •e

14. •CT cystography is an excellent method for detecting
bladder rupture; however, retrograde filling of the
bladder with 300 mL of contrast medium is
necessary to distend the bladder completely.
• Incomplete distention with consequent missed
diagnosis of bladder rupture often occurs when the
urethral catheter is clamped during standard
abdominal CT scan with intravenous contrast
injection.

16. MANAGEMENT
• American Urological Association (AUA) guidelines recommend that
intraperitoneal bladder ruptures be surgically repaired.
• Since many are associated with major trauma, open repair is most
common, but laparoscopic repair may be appropriate in some
circumstances.
• During operative evaluation of bladder rupture at the dome, it is
recommended to evaluate the entire bladder and not just repair the
obvious injury.

17. • Repair of the bladder injury may be single or double layered
closure.
• It is recommended to avoid permanent suture on the mucosal
repair as this may be a nidus for future stone formation.
• A Foley catheter is routinely left in the bladder after repair.
• Follow-up cystography should be performed to confirm
healing in some complex cases.

18. •AUA guidelines recommend that uncomplicated
extraperitoneal bladder injuries be managed
conservatively with catheter placement.
•Standard therapy involves leaving the catheter in
place for 2 to 3 weeks, but it may be left in longer in
some cases.
• Extraperitoneal ruptures that do not heal after 3-4
weeks of catheter drainage should be considered for
surgical repair.

19. •Complicated extraperitoneal bladder ruptures, such
as those associated with bone fragments within the
bladder and those associated with vaginal or rectal
injuries, often require operative repair.
•Bladder neck injuries often will not heal without
surgical repair.

20. THANK
YOU