Bladder Trauma: Causes, Symptoms, and Effective Management

The Urinary Bladder

The urinary bladder is a hollow organ located near the pelvic floor, posterior to the pubic symphysis and anterior to the vagina in women and rectum in men. The bladder is separated by a prevesical space named the space of Retzius. The peritoneal lining covers the bladder dome, which is the weakest part of the bladder and vulnerable to injury as the bladder distends with urine and rises into the peritoneal cavity. The bladder receives urine from the kidney via the ureters (right and left), which enter the bladder inferiorly and posteriorly. Urine exits the bladder at the bladder neck. The right ureteral orifice, left ureteral orifice, and bladder neck delineate the bladder trigone.

The Urinary Bladder

What is Bladder Trauma

Bladder trauma is a blunt or penetrating injury to the bladder that may cause bladder rupture. Bladder trauma can occur due to blunt trauma, penetrating trauma, or iatrogenic means. The probability of bladder injury varies according to the degree of bladder distension; a full bladder is more susceptible to injury than its an empty one. The majority of traumatic bladder injuries are extra peritoneal, which can often be managed non operatively

Causes & Types of Bladder Trauma

Blunt Trauma:This occurs when a direct blow or impact is applied to the lower abdomen or pelvis. Blunt trauma can cause the bladder to rupture or tear, leading to urine leakage into the abdominal cavity. It can also result in contusions or bruises on the bladder wall

Penetrating Trauma:This occurs when a sharp object, such as a knife or a gunshot, penetrates the bladder. Penetrating trauma can cause perforation or puncture wounds in the bladder, leading to urine leakage into the surrounding tissues.

Iatrogenic trauma occurs as a result of medical intervention, such as improper urethral catheterization and transurethral instrumentation. Other types include; gynaecological, orthopaedic, urologic and idiopathic trauma.

Classifications of Bladder Trauma

TYPE Iinjuries are partial tears of the mucosa. This is the most common form and its associated with blunt trauma

TYPE II or intraperitoneal bladder traumaThis is usually as aa result of direct blow to the distended organs

TYPE III or interstitial patternThis is an intramural or partial thickness laceration of the intact serosa. CT cystography is used to diagnose this form

TYPE IV or extraperitonealThis is the most common bladder rupture

Pathophysiology of Bladder Trauma

Intraperitoneal Bladder Rupture

Classic intraperitoneal rupture is described as large horizontal tears in the bladder dome. This is the least supported area of the bladder and only portion of the organ covered by peritoneum. In such cases, the mechanism of injury is a sudden large increase in intravesical fluid pressure that overcomes the mechanical strength of the bladder wall.
Intraperitoneal bladder rupture generally occurs as the result of a direct blow to a distended urinary bladder. Deceleration injuries can also cause such phenomena. This type of injury is most common in alcoholics and victims of seatbelt or steering wheel trauma. Otherwise, it is more common in children due to the relative intraabdominal bladder position that persists until approximately 20 years of age.

Extraperitoneal Bladder Rupture

Previously, the mechanism of injury was believed to be direct perforation by bony fragment or disruption of the pelvic girdle. It is now thought that pelvic fracture is likely coincidental and that bladder rupture most often is a direct result of deceleration injury and fluid inertia coupled with the shearing force created by pelvic ring deformation.

Extraperitoneal rupture is usually associated with fracture of the anterior pubic arch. When this occurs, the anterolateral aspect of the bladder is typically perforated by bony spicules. Forceful disruption of the bony pelvis or the puboprostatic ligaments also tears the bladder wall. In such instances, the degree of bladder injury is directly related to the severity of the fracture.
A mechanism similar to intraperitoneal bladder rupture is thought to underly some extraperitoneal bladder injuries. Specifically, this is the combination of trauma with bladder over distention, leading to a burst injury.

Signs & Symptoms of Bladder Trauma

• Supra pubic pain or tenderness
• Fever
• Gloss hematuria
• Pain during urination
• Pelvic pain
• Leakage of urine
• Fistula
• Small, weak stream urine
• Shock or internal bleeding may occur after a bladder trauma. This is a medical emergency. Symptoms include;
• Sweating
• Pale skin
• Decreased alertness, drowsiness or coma
• Tachycardia
• Decrease in blood pressure

diagnosis & Test

• History and physical examination
• Cystoscopy
• Cystography
• MRI to assess urethral injury in patient with pelvic fractures
• Ultrasound to assess the extent of the injury and rule out associated bladder injury
• Retrograde urethrography

Management of Bladder Trauma

Treatment of bladder trauma depends on the severity and type of injury. In some cases, minor bladder injuries may heal on their own with conservative management, which includes pain management, antibiotics to prevent infection, and temporary catheterization to drain urine. However, more severe cases may require surgical intervention to repair the bladder or remove any foreign objects.

Nursing Management of Bladder Trauma

Pre operative management

• Strictly monitor intake and output
• Monitor patient for hematuria
• Patient with severe bleeding, grouping and cross matching is done and then transfused
• Maintain patient NPO prior to surgery
• Teach patient deep breathing exercise
• Encourage patient to verbalize fear to allay anxiety
• Explain to the patient some post-opp complications
• Educate the patient about the surgical procedure
• Administer pre-opp medications

Complications of Bladder Trauma

• Pelvic infection
• Urinary extravasation
• Wound dehiscence
• Obstructive uropathy
• Peritonitis
• Urge or urinary incontinence