Overview
Definition:
An extraperitoneal bladder rupture is a tear in the bladder wall that occurs outside the peritoneal cavity
It is the most common type of bladder injury, often resulting from blunt abdominal trauma, pelvic fractures, or penetrating injuries
These injuries typically occur due to direct impact to the lower abdomen or pelvis, leading to increased intravesical pressure or shearing forces.
Epidemiology:
Bladder ruptures account for 1-2% of all traumatic injuries and 20% of genitourinary trauma
Extraperitoneal ruptures are more common than intraperitoneal ruptures, with an incidence of approximately 80% of all bladder ruptures
They are frequently associated with pelvic fractures, occurring in up to 60% of patients with severe pelvic fractures.
Clinical Significance:
Early diagnosis and appropriate management of extraperitoneal bladder rupture are crucial to prevent complications such as infection, sepsis, fistula formation, and long-term urinary dysfunction
Prompt surgical intervention is often required to restore bladder integrity, prevent urine extravasation, and manage associated injuries, significantly impacting patient outcomes and recovery.
Clinical Presentation
Symptoms:
Hematuria, typically gross or microscopic
Inability to void or difficulty voiding
Suprapubic pain or tenderness
Pelvic pain radiating to the groin or perineum
Urethral bleeding or discharge
Abdominal distension in severe cases.
Signs:
Tenderness in the suprapubic region
Palpable bladder mass if distended
Ecchymosis or hematoma in the lower abdomen, perineum, or genitalia
Signs of pelvic instability (e.g., leg length discrepancy, crepitus)
Hypotension or signs of hypovolemic shock in severe trauma with associated injuries.
Diagnostic Criteria:
No specific diagnostic criteria exist solely for extraperitoneal rupture
Diagnosis relies on a combination of clinical suspicion, physical examination findings, and imaging studies
The presence of gross hematuria in the setting of blunt trauma, especially with a pelvic fracture, is highly suggestive of a bladder injury and warrants further investigation.
Diagnostic Approach
History Taking:
Mechanism of injury (e.g., direct blow to the lower abdomen, fall, motor vehicle accident, pelvic crush injury)
Associated symptoms such as pain, difficulty voiding, or blood in urine
Previous urological history or surgeries
Medications and allergies.
Physical Examination:
Thorough abdominal examination, noting distension, tenderness, guarding, and presence of masses or hematomas
Careful assessment of the perineum and genitalia for bruising, lacerations, or bleeding
Pelvic ring stability assessment, looking for crepitus or pain with compression
Rectal examination to assess for posterior urethral injury or rectal trauma.
Investigations:
Urinalysis: To detect hematuria, which is almost universally present
Blood tests: Complete blood count (CBC), electrolytes, renal function tests (RBU), coagulation profile
Imaging: Cystography (retrograde cystogram) is the gold standard for diagnosing bladder rupture, demonstrating extravasation of contrast outside the bladder lumen
CT scan with intravenous contrast and delayed pelvic views can also effectively diagnose bladder injuries and assess associated pelvic fractures
Ultrasonography may be used as a bedside tool but is less sensitive for subtle injuries.
Differential Diagnosis:
Urethral rupture (anterior or posterior)
Pelvic fracture without bladder injury
Contusion of the bladder
Rectal or vaginal injury
Lower urinary tract obstruction
Urinary tract infection.
Management
Initial Management:
Hemodynamic stabilization
Airway, breathing, circulation (ABC) assessment
Control of hemorrhage
Insertion of Foley catheter if no contraindication (e.g., suspected urethral injury), which may also help in drainage of urine and tamponade of small leaks
Analgesia and broad-spectrum antibiotics to prevent infection.
Surgical Management:
Surgical repair is indicated for most extraperitoneal bladder ruptures, especially those larger than 1 cm or associated with pelvic instability
Procedures include: Bladder drainage via cystostomy (suprapubic catheterization) for small, stable extraperitoneal tears where conservative management is considered
Open surgical repair involving cystotomy, direct repair of the bladder tear with absorbable sutures in two layers, and placement of a suprapubic catheter for diversion and drainage
Minimally invasive laparoscopic repair is also an option for select cases.
Postoperative Care:
Continuous bladder drainage via suprapubic catheter or Foley catheter until adequate healing is confirmed (usually 7-14 days)
Pain management
Intravenous antibiotics for prophylaxis
Monitoring for signs of infection, urine leakage, or fistula
Gradual mobilization as tolerated
Fluid management and nutritional support.
Complications
Early Complications:
Infection (urinary tract infection, pelvic cellulitis)
Hemorrhage
Urinary leakage from the repair site
Formation of urinoma
Injury to adjacent organs (bowel, ureters).
Late Complications:
Fistula formation (vesicocutaneous, vesicovaginal, vesicorectal)
Bladder neck contracture
Urethral stricture
Urinary incontinence
Chronic pelvic pain
Erectile dysfunction.
Prevention Strategies:
Prompt diagnosis and surgical intervention
Meticulous surgical technique with secure bladder closure
Adequate bladder drainage postoperatively
Prophylactic antibiotics
Careful assessment for and management of associated injuries.
Prognosis
Factors Affecting Prognosis:
The extent of the bladder rupture
Presence and severity of associated injuries (especially pelvic fractures)
Timeliness of diagnosis and treatment
Patient's overall health status and comorbidities
Presence of infection.
Outcomes:
With prompt and appropriate management, the prognosis for isolated extraperitoneal bladder rupture is generally good, with high rates of successful bladder healing and restoration of function
Most patients can expect a full recovery without long-term sequelae if complications are avoided or managed effectively.
Follow Up:
Postoperative follow-up typically includes removal of the suprapubic catheter after imaging confirms bladder healing
A cystogram may be performed before catheter removal
Long-term follow-up may be required to monitor for late complications like strictures or incontinence
Patients should be advised on signs of infection or voiding difficulties.
Key Points
Exam Focus:
Extraperitoneal rupture is the most common type
Often associated with pelvic fractures
Gross hematuria in trauma is a red flag
Cystography is the gold standard for diagnosis
Surgical repair is the mainstay of treatment for significant tears
Suprapubic catheterization is key for drainage post-repair.
Clinical Pearls:
Always suspect bladder injury with significant pelvic trauma
Perform a sterile Foley insertion only if urethral injury is ruled out, otherwise consider suprapubic catheterization directly
Early antibiotics are crucial
Consider CT cystography for complex cases or when suspicion is high but conventional cystography is equivocal.
Common Mistakes:
Delaying diagnosis due to reliance on less sensitive imaging
Inadequate bladder drainage post-repair
Failure to manage associated injuries
Performing Foley catheterization in the presence of a clear urethral injury (may worsen the injury or create a false passage)
Underestimating the severity of injury in the presence of stable hemodynamics.