Bladder Trauma

Risk estimates depend on the population: a single-center series of 5,518 pelvic fractures found bladder injury in 3.2% of men and 3.3% of women; the AUA guideline reports bladder injury in approximately 29% of patients with both pelvic fracture and gross hematuria.^[1][5] 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]

Bladder rupture compartmentsOriginal schematic · v2026-09-11 · Clinical review pending

Extraperitoneal leakage stays around the bladder; intraperitoneal leakage communicates with the peritoneal cavity. Uncomplicated extraperitoneal injury usually permits catheter drainage; traumatic intraperitoneal rupture usually requires repair. Complex extraperitoneal and selected iatrogenic injuries need separate management. (Original WARWIKI schematic; see the figure source record and review limits.)

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

Features favoring repair include the following; the pelvic-fixation indication requires coordination with the trauma and orthopaedic teams.^[3][5][6]

• Concomitant urethral or bladder neck injury
• Concomitant vaginal or rectal injury
• Intravesical clot burden impairing catheter drainage
• Intraluminal foreign body (bone fragment, projectile)
• Planned anterior pelvic internal fixation: ACS favors repair; EAU notes conflicting evidence on hardware infection

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)
• Drainage duration differs by guideline: ACS specifies at least 7 days; AUA describes 2–3 weeks as standard, adjusted for healing and associated injuries^[5]
• 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:

• Intraperitoneal rupture from blunt or penetrating trauma; selected small uncomplicated iatrogenic perforations are a separate conservative-management exception^[6]
• 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:

• Open exposure, usually through a lower midline incision; laparoscopic repair is possible in selected isolated injuries
• IPB: Inspect for additional injury, particularly with pelvic fracture; enlarge the defect only as needed for exposure
• EPB (transvesical approach): Wide anterior cystotomy provides full intraluminal exposure including bladder neck and trigone; identify the ureteral orifices and confirm drainage, with catheterization when needed
• Use absorbable suture and a watertight closure. ACS favors two layers; EAU finds no evidence that two layers outperform a watertight single layer^[3][6]
• Leave a closed-suction pelvic drain
• Confirm healing after complex repair and catheter-only treatment. ACS recommends cystography for most repairs at ≥7 days, later for complex injuries; AUA/EAU allow omission after selected simple repairs. See cystography follow-up for the guideline differences^[3][5][6]

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. Discuss catheter positioning with orthopaedics, but do not treat SPT as an established hardware-infection contraindication: AUA and EAU find no evidence that appropriate suprapubic drainage increases this risk.^[5][6][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 28043650

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 16627198

3. American College of Surgeons Trauma Quality Programs. ACS TQP Best Practices Guidelines: Management of Genitourinary Injuries. Chicago, IL; August 2025. ACS guideline PDF

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 16917459

5. American Urological Association. Urotrauma Guideline, amended 2020. Full guideline.

6. European Association of Urology. EAU Guidelines on Urological Trauma, 2026. Bladder and urethral trauma sections. Full guideline.