Bladder injury: Clinical sciences

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. 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. 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.