Bladder injury

Alternative names
Injury - bladder and urethra; Bruised bladder; Urethral injury; Straddle injury; Pelvic fracture; Urethral disruption

Definition
Traumatic injury of the bladder and urethra involves damage caused by external force.

Causes, incidence, and risk factors
Injuries to the bladder can be divided into blunt trauma (such as a blow to the body) or penetrating wounds (such as bullet or stab wounds). The nature of the injury to the bladder depends on the fullness of the bladder at the time of injury as well as the mechanism of the injury.

Traumatic injury to the bladder is uncommon. Only about 8-10% of pelvic fractures are associated with bladder injury. Because the bladder is located within the bony structures of the pelvis, it is protected from most external forces. Injury may occur if there is a blow to the pelvis that is severe enough to break the bones and cause bone fragments to penetrate the bladder wall.

Other causes of bladder injury include surgeries of the pelvis or groin, including hernia repair and abdominal hysterectomy. Injury to the urethra (the tube that carries urine out of the body) is slightly more common, especially in men. It is rare in women. Injury to the urethra includes cuts, tears, bruises, and similar injuries.

Injury to the bladder or urethra may cause urine to leak into the abdomen, leading to infection (peritonitis). This type of injury is more common if the bladder is full.

There may be severe bleeding and loss of fluids. Scarring (stricture) or obstruction of the bladder or urethra from swelling may develop, leading to urinary stricture, obstruction, and retention.

This may eventually cause vesicoureteric reflux or bilateral obstructive nephropathy (a type of kidney damage). There is an increased chance of developing urinary tract infections (UTI) after injury to the tissues of the urethra or bladder because of retained urine.

Symptoms

     
  • Difficulty beginning to urinate or inability to empty the bladder  
  • Small, weak urine stream  
  • Blood in the urine or at the urethral meatus  
  • Abdominal pain, lower  
  • Pelvic pain  
  • Painful urination

Emergency symptoms indicating shock or hemorrhage:

     
  • Decreased alertness       o Drowsiness, lethargy       o Coma  
  • Increased heart rate  
  • Pale skin  
  • Sweating  
  • Skin cool to touch

Note: Symptoms follow a history of injury.

Signs and tests

Examination of the genitals may indicate injury to the urethra. Blood at the urethral meatus and high-riding prostate on rectal exam may suggest an urethral injury. If injury is suspected, a retrograde urethrogram should be performed to adequately show the anatomy of the lower urinary tract.

Palpation (examination by touch) over the bladder may show tenderness. Palpation may indicate bladder fullness, caused by retention of urine. Examination of the abdomen or rectum may indicate bladder injury or may show distended bladder. Or, if the bladder lining has been disturbed, urine may escape from the bladder into abdominal cavity, and the patient may only complain of vague abdominal pain or discomfort associated with inability to void.

There may be signs of hemorrhage or shock, including decreased blood pressure - especially in cases of pelvic fracture. MAST trousers may be applied to reduce pelvic bleeding.

A Foley catheter (a tube that drains urine from the body) is usually inserted as a part of trauma protocol. If bladder or urethral injuries are suspected, an urological consultation should be obtained prior to attempting to use any urinary catheter.

Treatment

The goals of treatment are control of symptoms, repair of the injury, and prevention of complications. Emergency treatment of bleeding, shock, or hemorrhage may include intravenous fluids, blood or monitoring in the hospital.

Treatment of peritonitis may include emergency surgery to repair the injury and to drain the urine from the abdominal cavity. Antibiotics may be given to treat peritonitis and to prevent the development of urinary tract infections.

Surgical repair of the injury is usually successful. The bladder may be drained by a catheter through the urethra or the abdominal wall over a period of time (days to weeks). This will prevent urine from accumulating in the bladder, which allows the injured bladder or urethra to heal. This also prevents obstruction of urine flow caused by urethral swelling.

Expectations (prognosis)

Traumatic injury of the bladder and the urethra may range from minor and self-limiting to major and life-threatening. There may be severe, immediate, or long-term complications.

Complications

     
  • Bleeding, hemorrhage, shock  
  • Peritonitis  
  • Scar formation, obstruction of the urethra  
  • Urinary retention  
  • Vesicoureteric reflux  
  • Acute bilateral obstructive uropathy  
  • Chronic bilateral obstructive uropathy

Calling your health care provider

Go to the emergency room or call the local emergency number (such as 911), if symptoms of traumatic injury of the bladder or urethra occur - particularly if there is a history of injury to the area.

Call your health care provider if symptoms worsen or new symptoms develop, including symptoms of shock or hemorrhage (see symptoms), fever, severe abdominal pain, severe flank or back pain, or decrease in urine production.

Prevention

External damage to the bladder and urethra may be prevented by using general safety precautions. Use appropriate safety equipment during work and play. Do not insert objects into the urethra. If self-catheterization is required, follow the instructions of the health care provider.

Johns Hopkins patient information

Last revised: December 6, 2012
by Dave R. Roger, M.D.

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All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.