Bladder injury: Clinical sciences

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Introduction0:00–0:36

Traumatic bladder injuries are rare injuries most often caused by blunt trauma to the genitourinary tract, but it can also be caused by penetrating or iatrogenic trauma.
According to the anatomic location involved, these injuries are classified as intraperitoneal, extraperitoneal, or urethral injury.
As with any trauma patient, the first step in assessing a patient with signs and symptoms suggestive of bladder injury is to perform the primary survey, including the ABCDE assessment.
Acute management should be started immediately to stabilize the patient's airway, breathing, and circulation. First, intubate or insert a surgical airway if needed.

Primary survey0:36–2:30

Next, ensure adequate ventilation. Then, obtain a large-bore IV or IO access, and monitor vitals continuously.
Additionally, you’ll need to calculate the Glasgow Coma Scale. As well, position the patient supine in a flat position, and stabilize the cervical spine with a C-collar.
It is essential to ensure that the patient's entire skin is exposed, meaning back and front, to ensure there’s no other obvious injuries.
Finally, you need to assess for pelvic injury, which can lead to severe bleeding. Keep in mind that a bladder injury, per se, wouldn’t typically cause your patient to be hemodynamically unstable; so, if your patient who has a bladder injury is unstable, you should suspect that they have an associated pelvic fracture, and manage accordingly.
If the pelvis is unstable, stabilize it with a mechanical pelvic binder. This will hold the pelvis in place, and maintain internal pressure, which helps control the bleeding.
Finally, place an indwelling urinary catheter, also known as Foley, to maintain a patent urinary outflow tract.Here's a clinical pearl!
If you saw blood at the meatus, and therefore suspect urethral injury, avoid urethral catheterization, because it can cause further damage to the urethra and create a false passage with the catheter.
Instead, consider placing a suprapubic catheter for urinary diversion, which involves making a surgical cut in the abdomen above the pubis and placing a catheter directly into the bladder.Alright, following the primary survey, perform a secondary survey by obtaining a detailed history and physical examination; as well as some adjunctive tests like labs and imaging.

Secondary survey2:30–6:42

Labs should include urinalysis, as well as blood tests for CBC and blood type and cross; while imaging typically includes Focused Assessment With Sonography in Trauma, or FAST, for short.
Let’s start with the secondary survey. Usually, history reveals blunt trauma, such as high speed or deceleration injuries; but sometimes it may reveal penetrating trauma; or iatrogenic injury, most often from urologic, gynecologic, or even colorectal procedures.
The patient can report abdominal or suprapubic pain accompanied by hematuria, dysuria, and urinary retention.On a physical exam, you could find an abdominal or suprapubic mass and tenderness due to bladder fullness, but keep in mind that in cases of a bladder rupture, the bladder would actually be empty.
You might also notice pelvic instability, gross hematuria, blood at the urethral meatus, perineal ecchymosis or swelling indicating urethral injury.Make sure to look for vaginal lacerations; or signs of an associated scrotal injury, such as scrotal edema and testicular disruption.
Don’t forget to perform a rectal examination to assess for a high-riding prostate.Here's a clinical pearl! The male urethra is divided into anterior and posterior divisions by the urogenital diaphragm.
The anterior urethra includes the penile and bulbar urethra, while the posterior urethra includes the membranous and prostatic urethra.
The anterior urethral injury is usually associated with perineal ecchymosis, while the posterior is associated with high-riding prostates.
In biological males with urethral injuries, direct trauma and penile fractures are common. On the other hand, in biological females, urethral trauma most commonly occurs during obstetric procedures.Now let’s go over your adjunctive tests.
Labs might often show microscopic or gross hematuria on urinalysis. In addition, if the patient suffered other concomitant injuries like a pelvic fracture, labs may reveal low hemoglobin and hematocrit, which would indicate that there’s a more serious hemorrhage.On the other hand, FAST can help you look for intraperitoneal free fluid.
This would indicate that the injury involves the bladder dome, which is intraperitoneal, so the urine would be able to leak into the peritoneum.
On the other hand, if FAST is negative for intraperitoneal free fluid, the injury likely involves any other wall of the bladder below the peritoneal reflection, which is extraperitoneal, so the leaked urine would stay contained in the perivesical space.
Here's a high-yield fact! Extraperitoneal bladder ruptures are commonly caused by bone fragments from a pelvic fracture perforating the bladder base.
Intraperitoneal bladder rupture, on the other hand, is generally accompanied by elevated intravesical pressure, and can result from a direct blow or steering wheel trauma.
As a result of intraperitoneal rupture, urine drains into the abdominal cavity and can be systemically absorbed, resulting in electrolyte and metabolic imbalance, as well as elevated creatinine.
Additionally, even though the patient is still making urine, it’s leaking out of the bladder, so they won’t be able to urinate, which may falsely appear as anuria.
Okay, if you see these findings, you should suspect a bladder or urethral injury, and you can obtain some additional imaging tests.

Imaging6:42–8:15

The typical choice is a CT scan of the abdomen and pelvis with IV contrast, or either a cystogram or retrograde urethrogram.
These tests can be used to locate the anatomic site of injury along the genitourinary tract.Here’s a clinical pearl! Typically, CT scans are done with contrast in the portal venous phase, however if suspecting a bladder injury, be sure to order CT in a delayed phase, also called a CT cystogram.
This type of CT will allow enough time for the contrast to pool in the kidneys, be excreted in urine, and then be seen in the ureters and bladder, which allows better visualization of these structures.
Usually, you’ll just have to wait for a few minutes on the table, and this will allow you to see if there’s any contrast leakage.Now, if the CT scan in the portal venous phase doesn’t show any evidence of bladder or urethral injuries, don’t rule them out just yet, because a normal CT might sometimes miss these injuries.
If there’s still a high index of suspicion, order a CT cystogram or take a good look at the retrograde urethrogram. If there’s no contrast leakage on these studies, consider an alternative diagnosis.
Let's move on to extraperitoneal bladder injury. CT scans may reveal an extraperitoneal bladder rupture with contrast extravasation into the perivesical space.

Extraperitoneal bladder injury8:15–9:13

Additionally, cystogram may reveal contrast extravasation outside the urinary bladder and no contrast in the peritoneal space.
If you see either of those findings, you can diagnose extraperitoneal bladder rupture. As for the treatment, you should start the patient on antibiotics to prevent infection.
Before placing a catheter, check for blood at the urethral meatus. If there is none, you can go ahead and place a transurethral catheter.
However, if you saw blood at the meatus, that means that there could be an associated urethral injury. In that case, don’t place a catheter, as it can cause more harm.
Another option for treatment is a suprapubic catheter for urinary diversion.Let’s go back to imaging and talk about intraperitoneal bladder injury.

Intraperitoneal bladder injury9:13–9:58

On CT, you might see intraperitoneal bladder rupture with free contrast extravasation within the peritoneal cavity. Now, contrast leak might be caused by something else, like a bleeding vessel, so be sure to confirm with RUG.
On cystogram, you can expect to see contrast extravasation outside of the urinary bladder and in the peritoneal space, which confirms intraperitoneal bladder rupture as your diagnosis.
As for the treatment, start with antibiotics to prevent infection. In addition, intraperitoneal bladder rupture typically requires surgical repair.Finally, let's discuss urethral injury findings.

Urethral Injury9:58–10:47

CT might show urethral contrast extravasation. However, this would be best seen on a retrograde urethrogram, which would reveal contrast extravasation outside of the urethral tract.
If you see these findings, your diagnosis is a urethral rupture. Now, the treatment of minor injuries usually involves placing a transurethral catheter and waiting for the urethra to heal on its own.
However, if you noted a urethral tear on RUG, you shouldn’t place the transurethral catheter, but instead insert a suprapubic catheter for urinary diversion.
This will decompress the bladder and prevent the urine from further extravasating into the pelvis. Alright, as a quick recap… Bladder injuries are rare and most often caused by blunt trauma.

Review10:47–11:55

First, perform the primary survey, including ABCDE assessment and acute management. A bladder injury per se wouldn’t typically cause hemodynamic instability; so, if your patient is unstable, they may have a concomitant pelvic fracture, so manage accordingly.
After the primary survey, perform a secondary, as well as adjunctive tests. Labs might often show microscopic or gross hematuria on urinalysis; while FAST can help you look for intraperitoneal free fluid.
Then, obtain a CT with IV contrast or RUG to determine the anatomic location of the injury. Extraperitoneal bladder injuries require transurethral catheter or or suprapubic catheter for urinary diversion; while intraperitoneal bladder injuries need surgical repair; and finally, minor urethral injuries can be treated by placing a transurethral catheter, but urethral tears typically require suprapubic catheter