The document provides a comprehensive overview of bladder trauma, detailing its anatomy, mechanisms of injury, clinical presentation, diagnosis, and management strategies. It emphasizes the importance of timely identification and intervention, distinguishing between conservative and surgical approaches based on the nature and severity of the injury. Key diagnostic tools include cystography and CT scans, which help guide treatment decisions to prevent complications such as infection and peritonitis.

1. Bladder Trauma
Dr Abdul Qayyum Khan PGR

2. LEARNING OBJECTIVES
• Introduction
• Anatomy of bladder
• Mechanism of injury
• Types of trauma
• Evaluation
• Management
• Complication
• Follow up

3. INTRODUCTION
•Bladder injuries may result from
blunt,Penetrating and Iatrogenic trauma.
•Full bladder is more susceptible to injury
than empty bladder.
•Management varies from conservative to
surgical aiming to directly repair the injury.

4. Anatomy
• In adults,bladder is located in the anterior pelvis and
envelop by the connective tissue and extra peritoneal
fat.
• It is separated from pubic symphysis by anterior
prevesical space called space of retzius.
• The dome is covered by peritonium.
• The neck of bladder is held in position by
puboprostatic and pubovesical ligament.

8. Trauma
• Trauma is defined as physical injury or a wound to living tissue cause
by an extrinsic agent.
• 6th leading cause of death worldwide.
• 5 million deaths worldwide and diasability to millions more.
• Mangement of trauma based on ATLS guidlines.

9. Mechanism of injury
The bony pelvis protects the urinary bladder very
well. When the pelvis is fractured by blunt
trauma, fragments from the fracture site may
perforate the bladder. These perforations usually
result in extraperitoneal rupture. If the urine is
infected, extraperitoneal bladder perforations
may result in deep pelvic abscess and severe
pelvic inflammation.

10. When the bladder is filled to near capacity, a direct blow to
the lower abdomen may result in bladder disruption. This
type of disruption is ordinarily intraperitoneal. Since the
reflection of the pelvic peritoneum covers the dome of the
bladder, a linear laceration will allow urine to flow into the
abdominal cavity. If the diagnosis is not established
immediately and if the urine is sterile, no symptoms may
be noted for several days. If the urine is infected,
immediate peritonitis and acute abdomen will develop.

11. Risk factors
• Pre existing Neuropathic Diasease
• Prior urological procedure
• Malignancy

12. Clinical Presentation
• Associated with other non urological life threatening injuries.
• Patients may present with
1. Haematuria ..... Most common
2. Suprapubic pain or abdominal distension due to urinary ascites.
3. Inability to void or reduced urine output
4. Uremia and raised creatinine due to intraperitoneal absorption.
5. Entry or exit wound at lower abdomen, perineum or buttocks
in penetrating injuries.

13. Diagnosis
• History
• Examination
• Investigation

14. Diagnosis
Clinical indicators of Bladder trauma
1. Suprapubic pain or tenderness.
2. Abdominal distention or ileus.
3. Inability to void or low urine output.
4. Haematuria associated with pelvic fracture.
5. Enlarged scrotum with ecchymosis.
6. Free intraperitoneal fluid on USG or CT scan.

15. AAST CLASSIFICATION

17. Investigation
• Cystogram
• CT Cystogram
• Cystoscopy
• Ultrasound

18. Investigation
Cystography:
•Preferred modality for non iatrogenic and suspected IBT in post op
setting.
• Both plain and CT urography have comparable sensitivity ( 90-95%)
and specificity (100%).
• Absolute indication : gross haematuria associated with pelvic
fracture (29% of patients have bladder trauma)

19. Investigation
• Relative indications after blunt trauma are
gross haematuria without pelvic fracture and
microhaematuria with pelvic fracture.
• Penetrating injuries of the buttock, pelvis
or lower abdomen with any degree of
haematuria warrant cystography.

20. Investigations
• Retrograde cystography is nearly 100% accurate if performed
precisely.
• In cooperative and conscious patient bladder should be filled upto
sense of discomfort and otherwise upto 350 ml.

21. Investigations
• Plain film technique :
• Three images must be obtained
i. Control.
ii. Full bladder AP film.
iii. Drainage film. ( Posterior extravasation of
•contrast can be missed without this film)

23. CT Urogram :
• Superior in identification of bony fragments in
the bladder and bladder neck injuries as well as
concomitant abdomen injuries.
• Bladder must be filled in retrograde manner
with contrast material diluted upto 2-4% to avoid
scatter artifact.

24. •Cystoscopy :
• Preferred method for detection of
intraoperative injuries.
• Localize the lesion in relation to the position of
trigone and ureteral orifices.
• Lack of bladder distension suggest a large
perforation.

25. Ultrasonography:
• Alone is insufficient.
• Can be used to visualise intraperitoneal
fluid or extraperitoneal collection of fluid.

26. Conservative Managment:
• Clinical observation.
• Continuous bladder drainage.
• Antibiotic prophylaxis.

27. Conservative Managment
• Standard treatment of uncomplicated extraperitoneal and
intraperitoneal injury i-e in the absence of peritonitis and ileus.
• If lesion is larger intraperitoneal drain may be placed.
• In these situations ,when conditions are ideal, urethral catheter
management alone suffices.

28. • Large bore 22 Fr catheter should be used to promote
adequate drainage.
• Cystography is necessary to verify complete healing before
catheter removal 14 days after injury.
• In case of extravasation continue with bladder drainage until
radiograhic confirmation of healing.
• Antibiotics should be continued for 7 days to avoid infection.

29. Surgical Managment
INDICATIONS FOR IMMEDIATE REPAIR OF BLADDER INJURY
• Intraperitoneal injury from external trauma
• Penetrating or iatrogenic nonurologic injury
• Inadequate bladder drainage or clots in urine
• Bladder neck injury
• Rectal or vaginal injury
• Open pelvic fracture
• Pelvic fracture requiring open reduction and intemal! ixation ;
• Selected stable patients undergoing laparotomy tor reasons
• Bone fragments projecting into the bladder

30. Surgical Managment
• PENETRATING OR INTRAPERITONEAL INJURIES should
be managed by immediate operative repair.
• These injuries are often larger than suggested on
cystography and are unlikely to heal spotaneously.
• Prolonged leak of urine may cause chemical
peritonitis or abscess.

31. WHEN OPERATING WITHOUT PRIOR IMAGING :
•The ureteric orifices should be inspected for
clear efflux of urine.
• Ureteral integrity may be confirmed by
retrograde passage of ureteric catheter or IV
administration of methylene blue or indigo
carmine.

32. INJURIES INVOLVING URETERIC ORIFICES OR
INTRAMURAL URETERS:
•Warrants primary closure with stented
reimplantation of the ureter and a perivesical
drain.
• In repaired bladder cystogram can be obtained
after 7-10 days.

33. • Technique of bladder repair :
• Removal of devitalized tissue.
• Removal of intravesical clots.
• Repair of bladder in two layers:
• Running 3-0 vicryl suture for mucosa.
• Running 2-0 vicryl sutures for muscularis.

34. Unrecognized bladder injuries may manifest as
• Azotemia
•Acidosis
• Fever and sepsis
• Low urine output
• Peritonitis
• Ileus
• Urinary ascites
Complications

35. Follow up
• Conservatively treated bladder injuries are followed
up by cystograhy to rule out extravasation and ensure
bladder healing.
• 1st cystography is planned ten days after surgery.
• If ongoing leak, cystoscopy done to rule out bony
fragments in the bladder and then cystography 7 days
later