Vesical Trauma and Hemorrhage

CHAD M. GRIDLEY

CHRISTOPHER D. MCCLUNG

BLADDER TRAUMA

Trauma is the most common cause of bladder injury; however, only 1.6% of trauma victims will have a bladder laceration (1). Blunt trauma, such as high-impact motor vehicle collisions or falls, is the cause of 80% to 85% of bladder injuries (2,3,4). The mechanisms through which these injuries typically occur are either by a direct blow to the abdomen with a full bladder (classically causing rupture at the dome) or by an injury associated with a pelvic fracture. Pelvic fracture is associated with 80% of bladder injuries and accounts for almost all extraperitoneal injuries (3). These fracture-related injuries occur due to shearing from disruption of fascial attachments to the bladder or due to direct lacerations by bone fragments. The latter is more rare. Penetrating injuries to the bladder are less common in the civilian literature. Bladder injury has been cited to be present in 3.6% of abdominal gunshot wounds, 13% of penetrating injuries to the rectum, and 20% of penetrating injuries to the buttocks (5,6,7,8). The bladder can also be injured iatrogenically. Common iatrogenic causes include gynecologic surgery (52% to 61%), urologic surgery (12% to 39%), and general surgical procedures (9% to 26%) (9,10).

Presentation and Diagnosis

In the classical clinical presentation of a bladder injury, patients complain of suprapubic fullness and an inability to void. Hematuria is the hallmark of a bladder laceration. Swelling of the perineum and scrotum is also common when significant urinary extravasation or pelvic bleeding has occurred. Gross hematuria is present in 95% of patients.

According to the 2004 consensus statement on bladder injuries, the absolute indication for bladder imaging is a pelvic fracture associated with gross hematuria (11). Relative indications for imaging include clinical situations where there is a high index of suspicion of bladder injury. These include microscopic hematuria associated with a pelvic fracture and gross hematuria without a pelvic fracture. Specific pelvic fracture patterns have been shown to be predictive of injury. In a review of 37 patients, Avey et al. (12) showed that pubic symphysis diastasis and obturator ring fractures with displacement greater than 1 cm were predictors of bladder laceration. Acetabular fractures were not predictive of injury.

Static and computerized tomography (CT) cystography are the current studies recommended to diagnose bladder injuries. A recent study showed that noncontrast CT scan failed to detect or misdiagnosed the location of bladder injuries in 13% of patients (13). Although both static and CT cystography have equal sensitivities and specificities, a CT cystogram is the most common test performed in modern trauma centers. Patients with bladder trauma generally have coexisting injuries requiring a CT scan for other reasons. A CT cystogram can be performed quickly in this clinical situation where many centers have CT scanners in close proximity to the trauma bay. The sensitivity and specificity of CT cystography to detect bladder injury are 95% and 100%, respectively. Furthermore, CT cystography has the ability to determine the location of the bladder laceration with 82% accuracy (14). If static cystography is performed, it is important to obtain drainage phase images because up to 10% of lacerations can be missed if these images are not taken (15). Drainage phase images are not required for CT cystography.

Static and CT cystography require a Foley catheter for imaging. It is important to remember that 10% to 29% of bladder injuries will have a coexisting urethral injury (16). If blood at the meatus is present on initial exam, the urethra should be assessed with a retrograde urethrogram prior to inserting the catheter. Once the urethra is cleared, a Foley catheter may be placed. The bladder is then filled under gravity in a retrograde fashion through the Foley catheter with 350 mL of contrast in an intubated patient or until tolerated in an awake patient. Capping the Foley catheter and allowing renal secretion of intravenous (IV) contrast to fill the bladder is not an appropriate way to perform bladder imaging (17).

The initial diagnostic element is to define the location of injury: extraperitoneal (EP), intraperitoneal (IP), or both. These occur with frequencies of 60%, 30%, and 10%, respectively (2,4,15). The hallmark of an IP injury is the presence of contrast that outlines loop of bowel (Fig. 26.1). Isolated EP injuries have no communication with the peritoneum and will classically have a “flame” or “molar tooth” appearance on imaging (Fig. 26.2). A fine diagnostic detail is to assess the status of the bladder neck. Bladder neck lacerations can be seen as areas of extravasation low on the bladder near the Foley balloon (Fig. 26.3).

The American Association for the Surgery of Trauma (AAST) has established a grading system for organ injuries due to trauma. Most urologists are familiar with this grading system for renal trauma, but they are less familiar with the system for bladder trauma. In brief, the AAST grades injuries on a scale from 1 to 5, with grade I being a low-grade injury and V being a severe injury. This scale is shown in Table 26.1. The classification becomes easy to remember if one thinks of contusions or small EP lacerations as low-grade injuries and combined EP/IP injuries or bladder neck lacerations as high grade.

FIGURE 26.1 A CT cystogram demonstrating an IP injury with contrast outlining loops of bowel.

Management

The management of bladder lacerations depends on injury location. The two options are conservative management with Foley catheter alone or primary surgical repair (cystorrhaphy). In general, EP injuries without bladder neck involvement may be managed with a Foley catheter alone. Healing occurs within 10 to 14 days in 74% of cases, and almost all heal within 3 weeks (18,19). However, complications have been cited to occur such as delayed healing, vesicocutaneous fistula formation, septic events, and bladder calculi (18). Prior research does suggest that complications are lower for EP lacerations repaired primarily relative to conservative management with a Foley catheter alone (19).

IP injuries and bladder neck injuries require formal surgical repair. Although bladder neck injuries are by definition EP, resolution with Foley catheter alone is marginal at best. Persistent leaks are common in this situation.

Penetrating injuries should be managed with exploration. These patients are commonly explored for nonurologic indications to manage other injuries because up to 80% of penetrating bladder injuries also have gastrointestinal injuries. Concomitant rectal and bladder injuries can result in fistula formation if not surgically repaired. Repair is encouraged in this setting along with the use of an omental flap as tissue interposition to avoid overlapping suture lines between bladder and rectal repairs. In the largest penetrating lower urinary tract study to date, 90% of patients had dual entrance and exit wounds (20). All lacerations should be repaired, and gastrointestinal injuries should be addressed.

FIGURE 26.2 A CT cystogram revealing an EP injury. This image depicts the “molar tooth” sign common in many EP injuries.

FIGURE 26.3 A CT cystogram image imaging revealing a bladder neck injury, with contrast extravasation at the bladder neck.

A unique consideration is the coexisting vaginal laceration and bladder laceration. All female patients presenting with a pelvic fracture require a manual vaginal exam to rule out vaginal laceration and open pelvic fracture. If not surgically addressed, hematoma infection and fistula formation may occur (21). The bladder and vagina require suture repair. As with rectal injuries, the use of an omental flap for tissue interposition between the bladder laceration and vaginal laceration repair sites is suggested.

Surgical repair of bladder lacerations should be done during the index admission. If the patient is having exploratory laparotomy shortly after admission for other intra-abdominal injuries and is hemodynamically stable, the repair should be done at this time. A trauma patient will not infrequently require resuscitation and pelvic angioembolization for pelvic bleeding immediately after presentation. In this setting, resuscitation takes precedent, and surgical repair should be done as soon as the patient is hemodynamically stable.

TABLE 26.1 AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA BLADDER INJURY CLASSIFICATION

Grade	Injury type	Description
I	Hematoma	Contusion, intramural hematoma
	Laceration	Partial thickness
II	Laceration	EP laceration <2 cm
III	Laceration	EP (≥2 cm) or IP (<2 cm) laceration
IV	Laceration	≥2 cm IP laceration
V	Laceration	IP or EP laceration extending into the bladder neck or ureteral orifices
EP, extraperitoneal; IP, intraperitoneal.

FIGURE 26.4 A: The filling phase of a static cystogram in a patient with bladder entrapment from a pelvic fracture. The arrow demonstrates the site of bladder entrapment. B: The drainage phase of a static cystogram in a patient with bladder entrapment from a pelvic fracture. The arrow demonstrates the site of persistent extravasation.

Cystorrhaphy can be accomplished by two separate approaches: transabdominally or retropubically. In an acute setting, the benefit of a transabdominal approach is to avoid a pelvic hematoma associated with a pelvic fracture. The space of Retzius should not be opened in this situation because significant bleeding can ensue. EP and bladder neck lacerations can be repaired from within the bladder through an abdominal incision.

Primary surgical closure of EP repairs is most commonly done at the time of open reduction and internal fixation of a pelvic fracture. This commonly occurs several days after admission when the patient has been resuscitated and bleeding has resolved. It is the authors’ practice to repair all EP injuries primarily at the time of open reduction and internal fixation for the pelvic fracture. Although more studies are needed to document superiority of primary suture repair over conservative management with a Foley for EP injuries, older data does suggest that complication rates are higher with Foley treatment alone (19).

In summary, EP lacerations may be managed solely with Foley catheter decompression. Indications for open surgical repair are the following:

IP bladder rupture
Bladder neck laceration
Penetrating bladder injury
Inadequate drainage with a Foley catheter
Concomitant rectal or vaginal injury
Hemodynamic stability and undergoing laparotomy for other indications
EP repair at time of open fixation for a pelvic fracture

Rarer indications for surgical intervention include the presence of bone fragments protruding into the bladder and bladder entrapment into a pelvic fracture site. Bladder entrapment into a pelvic fracture site can occur during the injury itself, or at the time of internal or external fixation of the pelvis (22,23). Failure to treat these early after injury can result in persistent urinary leaks, lower urinary tract symptoms, and dyspareunia (24). Examples of radiographic and intraoperative findings of bladder entrapment after pelvic fracture are shown in Figures 26.4 and 26.5.

Description of Repair

Transabdominal (Fig. 26.6A and B): A vertical, midline incision is made. The skin and rectus fascia are opened. The
peritoneum is entered. Urine and abdominal fluid are evacuated. The abdominal is serially examined to rule out other organ injuries. The location of the IP laceration is identified, and the bladder is evacuated of any residual hematoma. Bony spicules, if present, are removed at this time. The bladder is thoroughly investigated transvesically through the laceration. If the laceration is small, the cystotomy is extended to improve visualization. The presence of concomitant EP lacerations and bladder neck injuries are ruled out. If nonviable tissue is present, laceration edges are gently debrided. Exposure of the bladder neck can be facilitated with the use of a long nose nasal speculum. If a bladder neck laceration is present, it is repaired with interrupted 2-0 polyglycolic acid sutures from within the bladder. If a separate EP injury is identified, it is repaired in two layers with a running 3-0 polyglycolic acid suture from within the bladder. During the acute setting of a pelvic fracture, it is important to do repairs within the bladder and to avoid the space of Retzius. Opening up the space of Retzius will disturb the pelvic hematoma and significant bleeding may follow.

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