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.

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:

Type	Frequency (Blunt)	Mechanism	Key Features
Extraperitoneal (EPB)	~63%	Pelvic ring distortion, bony fragment, contrecoup	60–90% associated with pelvic fracture; urine confined to extraperitoneal space
Intraperitoneal (IPB)	~32%	Hydraulic rupture of distended dome	Urinary ascites; ileus; risk of peritonitis
Combined	<5%	High-energy polytrauma	Both components; operative repair required

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

The distinction that drives management. An extraperitoneal rupture tears the bladder base below the peritoneal reflection, so urine is confined to the perivesical space — uncomplicated injuries are usually managed with catheter drainage alone. An intraperitoneal rupture is a hydraulic blow-out of the distended dome above the reflection: urine spills freely into the peritoneal cavity (urinary ascites) and always requires operative repair. (Original WARWIKI schematic)

AAST Bladder Injury Scale

Grade	Description
I	Contusion; intramural hematoma; partial-thickness laceration
II	Extraperitoneal laceration <2 cm
III	Extraperitoneal laceration ≥2 cm, or intraperitoneal laceration <2 cm
IV	Intraperitoneal laceration ≥2 cm
V	Extension 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.

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]

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.

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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