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Bladder Trauma

Bladder injuries complicate roughly 1.6% of all blunt trauma admissions and up to 29% of pelvic fractures with gross hematuria.[1] The most common mechanism is pelvic ring distortion transmitting force to the perivesical structures, though hydraulic bladder rupture at a distended dome is the hallmark of intraperitoneal injury. Timely diagnosis — relying on dedicated cystography rather than passive filling — and appropriate repair strategy based on injury type are the cornerstones of management.

:::note Cross-Reference — Imaging Detailed cystography technique and CT protocol interpretation is covered in Imaging (Evaluation & Workup). A protocol summary is included below. :::

Classification​

Bladder injuries are classified by the location of urinary extravasation relative to the peritoneum:

TypeFrequency (Blunt)MechanismKey Features
Extraperitoneal (EPB)~63%Pelvic ring distortion, bony fragment, contrecoup60–90% associated with pelvic fracture; urine confined to extraperitoneal space
Intraperitoneal (IPB)~32%Hydraulic rupture of distended domeUrinary ascites; ileus; risk of peritonitis
Combined<5%High-energy polytraumaBoth components; operative repair required

The highest-risk fracture patterns are pubic symphysis diastasis >1 cm and obturator ring disruption with >1 cm displacement.[2]

AAST Bladder Injury Scale​

GradeDescription
IContusion; intramural hematoma; partial-thickness laceration
IIExtraperitoneal laceration <2 cm
IIIExtraperitoneal laceration ≥2 cm, or intraperitoneal laceration <2 cm
IVIntraperitoneal laceration ≥2 cm
VExtension into the bladder neck or ureteral orifice (trigone)

Complex Extraperitoneal Injury​

Despite extraperitoneal location, the following features mandate operative repair:[3]

  • Concomitant urethral or bladder neck injury
  • Concomitant vaginal or rectal injury
  • Intravesical clot burden impairing catheter drainage
  • Intraluminal foreign body (bone fragment, projectile)
  • Need for anterior pelvic internal fixation

Imaging — Cystography Protocol​

Indication: Gross hematuria with pelvic fracture or high-risk mechanism; any penetrating injury near the bladder with hematuria; clinical signs of bladder rupture (low urine output, urinary ascites, rising creatinine, abdominal distension).[3]

Microhematuria alone without high-risk features in stable blunt trauma does not require cystography.

:::warning Do Not Rely on Passive Filling Passive antegrade filling (clamping the Foley during CT) provides inadequate bladder distension and has unacceptably high false-negative rates. It is not an acceptable substitute for retrograde cystography.[3] :::

CT Cystography (Preferred)​

  • Dilute contrast retrograde fill: 50 mL iohexol in 500 mL normal saline (~2–5 g iodine/100 mL)
  • Minimum fill volume: 300 mL (or until patient discomfort or contrast stops flowing)
  • Image after full distension; post-drainage images are not routinely required
  • CT cystography can be performed by the radiology technologist with the Foley in place; no need for patient transport to fluoroscopy

Conventional (Fluoroscopic) Cystography​

  • Higher-density contrast: diatrizoate meglumine (Cystografin) or iothalamate meglumine at ~8–25 g iodine/100 mL
  • Minimum 300 mL retrograde fill
  • Views: AP, bilateral obliques, and post-drainage lateral
  • Sensitivity and specificity equivalent to CT cystography (~90–95% sensitivity, ~100% specificity)[4]

Management​

Nonoperative Management (Uncomplicated EPB)​

Appropriate for uncomplicated extraperitoneal bladder injuries from blunt trauma:[3]

  • Continuous large-bore urethral catheter drainage (≥18 Fr)
  • Minimum 7 days of drainage; some centers extend to 2–3 weeks
  • Confirm healing with repeat cystography before catheter removal
  • No strong evidence for routine antibiotic prophylaxis for the catheterization duration

Operative Management​

Indications for operative repair:

  • All intraperitoneal bladder injuries
  • All complex extraperitoneal injuries (see above)
  • Bladder injuries found incidentally at exploratory laparotomy
  • Penetrating bladder injuries (generally)
  • EPB in patients undergoing laparotomy for other indications

Technique:

  • Lower midline incision
  • IPB: Widen the dome laceration to exclude a concomitant extraperitoneal component; close in two layers
  • EPB (transvesical approach): Wide anterior cystotomy provides full intraluminal exposure including bladder neck and trigone; directly catheterize ureteral orifices to confirm patency
  • Two-layer closure with 2-0 or 3-0 absorbable suture (mucosal layer followed by seromuscular layer)
  • Leave a closed-suction pelvic drain
  • Post-repair cystography at minimum 7 days; extend to 3–4 weeks for complex repairs[3]

:::note Orthopaedic Coordination When bladder repair and anterior pelvic internal fixation are both indicated, performing them in the same surgical setting is preferred. Repair the bladder before pelvic reduction — symphyseal reduction can make bladder repair technically impossible. The evidence on SPT increasing infection risk with anterior hardware is mixed; most orthopaedic trauma surgeons consider a definitive SPT a relative contraindication to anterior internal fixation.[3] :::

Special Populations​

Pediatric: Bladder is more intraabdominal in children; greater IPB risk for a given pelvic fracture. Smaller capacity requires more precise catheter sizing. High index of suspicion warranted even with microhematuria.[3]

Pregnant: Bladder displaced superiorly and anteriorly in late pregnancy, increasing IPB risk. Early urologic consultation recommended.

Neurogenic bladder: Chronically distended bladder is at higher risk for hydraulic rupture from lower-energy mechanisms.

References​

1. Johnsen NV, Dmochowski RR, Young JB, Guillamondegui OD. Epidemiology of blunt lower urinary tract trauma with and without pelvic fracture. Urology. 2017;102:234–239. PMID 28126329

2. Avey G, Blackmore CC, Wessells H, Wright JL, Talner LB. Radiographic and clinical predictors of bladder rupture in blunt trauma patients with pelvic fracture. Acad Radiol. 2006;13(5):573–579. PMID 16627192

3. American College of Surgeons Trauma Quality Programs. ACS TQP Best Practices Guidelines: Management of Genitourinary Injuries. Chicago, IL; August 2025. Available at: facs.org/cot

4. Quagliano PV, Delair SM, Malhotra AK. Diagnosis of blunt bladder injury: A prospective comparative study of CT cystography and conventional retrograde cystography. J Trauma. 2006;61(2):410–421. PMID 16917451