1. MANAGEMENT OF
BLADDER INJURIES
PRESENTER : AROJU S.A
MODERATOR : PROF. MBIBU
UROLOGY UNIT,
SURGERY DEPARTMENT,
ABUTH, ZARIA

2. OUTLINE
Introduction
Surgical Anatomy
Aetiology
Pathophysiology
Clinical Features
Investigations
complications
Treatment
prognosis
Conclusion
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3. INTRODUCTION
• Relatively uncommon
• 2% of abdominal injuries
• Rarity ► protection in bony pelvis
• 83 – 100% are due to blunt injury
• 90% are associated with pelvic #
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4. INTRODUCTION…
Pelvic # associated with bladder
rupture :
• Pubic symphysis diastasis
• Sacroiliac diastasis,
• Sacral, iliac,
• Pubic rami #s
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5. INTRODUCTION…
• Up to 30% of patients with pelvic
fractures will have some degree of
bladder injury.
• 5 – 10% : major bladder injury
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6. INTRODUCTION…
• Previously fatal
• prompt diagnosis & intervention
► excellent outcome
• The probability of bladder injury α
the degree of bladder distention
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7. SURGICAL ANATOMY
• Bladder: hollow muscular organ that
serves as reservoir for urine.
• Empty bladder : protected behind
the pubic symphysis
• Largely a pelvic organ in adults,
abdominal organ in children.
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8. SURGICAL ANATOMY
• The bladder enters the greater
pelvis by 6yrs & it is not entirely
within the lesser pelvis until after
puberty.
• When empty : tetrahedral in shape
& has apex, body, fundus, neck &
uvula.
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9. SURGICAL ANATOMY…
• Separated from the pubic
symphysis by space of retzius.
• The posterior surface & Dome of
bladder is covered with
peritoneum thus related to
bowels.
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10. SURGICAL ANATOMY…
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11. SURGICAL ANATOMY…
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12. SURGICAL ANATOMY…
• Bladder neck in males is contiguous
with the prostate, & attached to the
pubis by puboprostatic ligaments.
• Body of the bladder receives support
from the urogenital diaphragm
inferiorly, & the obturator internus
Laterally.
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13. SURGICAL ANATOMY…
• The superior fascia of the urogenital
diaphragm is continuous and
includes the obturator, and
endopelvic fasciae.
• The inferior fascia of the urogenital
diaphragm fuses with the Colles
fascia.
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14. SURGICAL ANATOMY…
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15. SURGICAL ANATOMY…
• Injury above the peritoneal
reflection ► intraperitoneal
extravasation
• Injury below the peritoneal
reflection ► extraperitoneal
extravasation
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16. SURGICAL ANATOMY…
• Arterial : superior, middle &
inferior vesical arteries, uterine
and vaginal arteries.
• Venous: internal iliac veins.
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17. SURGICAL ANATOMY…
• Lymphatics: vesical, internal iliac,
& common iliac nodes.
• Sympathetic : Thoraco-lumbar;
Parasympathetic : pelvic plexus.
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18. AETIOLOGY
• Penetrating trauma(15 – 40%)
• Blunt trauma(60 – 85%)
• Iatrogenic: from gynecologic, urologic,
and orthopedic operations near the
urinary bladder.
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19. AETIOLOGY…
Gynaecologic Trauma Urological Trauma
• Myomectomy • Cystoscopy +
• TAH biopsy(36%),
• Vag. Hysterectomy • TURP
• Litholapaxy
• Idiopathic:
chronic alcoholics
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20. AETIOLOGY…
Orthopaedic Trauma
• Orthopaedic pins : pelvic & hip #
• Thermal injury : bone cement used
in hip arthroplasty.
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21. PATHOPHYSIOLOGY
EXTRAPERITONEAL
• Blunt or penetrating trauma.
• Associated pelvic # (90-100%)
• commonly anterolateral
• Due to direct burst injury
• Shearing force of the deforming pelvic
ring.
• Direct perforation by a bony fragment.
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22. PATHOPHYSIOLOGY...
EXTRAPERITONEAL
• When the sup. fascia of UD is ruptured,
urine can infiltrate the abdominal wall,
scrotum & perineum.
• When the Inf. fascia of UD is ruptured,
urine can infiltrate the thigh or penis.
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23. PATHOPHYSIOLOGY...
INTRAPERITONEAL
• Sudden large increase in intravesical
pressure in a full bladder.
• Full bladder ► widely separated
muscle fibres ► thin bladder wall
►no resistance to perforation
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24. PATHOPHYSIOLOGY...
INTRAPERITONEAL
• Usually involves the dome &
posterior part of the bladder.
• common in seat-belt & steering
wheel injury and in chronic
alcoholics, following trivial fall.
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25. Intraperitoneal bladder
rupture
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26. PATHOPHYSIOLOGY...
• Continuous urine drainage into
the abdomen ► hyperkalemia,
hypernatremia, uremia & acidosis.
• Such patients may appear anuric,
and have urinary ascites.
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27. CLINICAL FEATURES
relatively
nonspecific
• Triad of symptoms is often present
(1) gross haematuria (90%),
(2) suprapubic pain or tenderness,
(3) difficulty or inability to void.
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28. CLINICAL FEATURES…
• Swelling in perineum, scrotum or
Anterior abdominal wall.
• Evidence of pelvic # (>90%),
symphysial / sacro- iliac diasthesis,
pubic rami #.
• Posterior urethral injuries (10%)
& renal injuries in (~2%)
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29. CLINICAL FEATURES…
• Mortality (~50%) ► severe pelvic #s,
haemorrhage, & MODS
• Late presentations are due mild
intraperitoneal rupture ►
azotemia, hyperchloremia,
hypernatremia hyperkalemia &
metabolic acidosis.
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30. INVESTIGATIONS
Cystography
• Very accurate (>90%)
• By gravity filling of contrast into
bladder.
• At least 3 films must be taken ►
Plain, Filled,& post drainage.
• Severity of injury can be graded
• Distinguishes intraperitoneal from
extraperitoneal rupture.
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31. Cystogram
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32. INVESTIGATIONS…
CT Cystography
• Has approx. 100% sensitivity.
• Has advantage of being able to
correctly assess other visceral
injuries in a polytraumatized pt.
• Expensive
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33. CT cystogram
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34. INVESTIGATIONS…
USS
• Not routinely used
• Show injury to other structures
• Peritoneal fluid + normal viscera
OR failure to visualize bladder
after the transurethral intro of
saline ► highly suggestive of
bladder rupture
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35. INVESTIGATIONS…
• Haematocrit
• E/U/Cr
• RBS
• CXR
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36. STAGING…
• Cystoscopy & cystogram findings
• Adapted by AAST & used by EUA
Stage I :
Hematoma Contusion, intramural
hematoma, Laceration Partial
thickness.
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37. STAGING…
Stage II :
Laceration Extraperitoneal
bladder wall laceration < 2 cm
Stage III :
Laceration Extraperitoneal (2cm)
or intraperitoneal (< 2cm) bladder
wall laceration
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38. STAGING…
Stage IV :
• Laceration Intraperitoneal
bladder wall laceration 2cm
• Stage V :
Laceration Intraperitoneal or
extraperitoneal bladder wall
laceration extending into the
bladder neck or ureteral orifice
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39. COMPLICATIONS
• Urinary extravasation
• Sepsis & MODS
• Haemorrhage
• Pelvic infection
• Small-capacity bladder
• Urinary incontinence
• Obstructive uropathy
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40. MANAGEMENT
• Multidisciplinary approach
Trauma surgeon, Urologist,
anaesthesiologist, Orthopaedic
surgeon
• The first priority: stabilization of
the patient and treatment of
associated life-threatening injuries.
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41. MANAGEMENT…
• High velocity : urgent exploration
• Isolated bladder injury: definitive
treatment depends on grade of
injury.
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42. MANAGEMENT…
Grades 1&2
Nonsurgical management
• Adequate analgesics
• Indwelling catheter is passed
• Observe pt. for Increasing pains or
changes in vital signs.
• Repeat Cystogram at 10-14 days.
• If normal, discharge pt home.
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43. MANAGEMENT…
Grades 1&2
Nonsurgical management
• Obstruction of the catheter by clots or
tissue debris must be prevented.
• 87% of cases heal in 10days and
virtually all heal in 3weeks.
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44. MANAGEMENT…
Grades 3, 4 & 5
Surgical management
• Pre-op analgesic, antibiotics
• Midline approach, bladder & any
bowel injury inspected & severity
assessed.
• Bladder bivalved at dome, & UO
inspected.
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45. MANAGEMENT…
Grades 3, 4 & 5
Surgical management
• Repair in at least two layers,
• Leave SPT in situ via a diff. Stoma
• Leave drain in situ.
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46. MANAGEMENT…
Post-Op
• IV antibiotics & analgesics
• Drain out when it not functioning
• Do x-ray cystogram at 14th day.
• If normal, remove SPC, the
urethral catheter & discharge.
• For those with pelvic #s, invite
orthopaedics
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47. PROGNOSIS
 Appropriate Rx
Excellent outcome
 Bladder neck involvement
Temporary incontinence
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48. CONCLUSION
• Traumatic bladder injuries was
previously fatal, BUT currently
managed quite successfully.
• Adequate evaluation, application
of modern imaging techniques, &
prompt surgical intervention are
conditions for optimal outcome.
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49. Thank you for your patience
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