What is Bladder Trauma (Bladder Injury)?
Bladder trauma is a rare injury that can happen due to a strong blow to a filled bladder, a severe injury that disrupts the pelvis, injuries that penetrate the body, or injuries caused by medical treatment. These kinds of bladder injuries are divided into three main types: ones that occur outside the peritoneum (EP), ones that occur inside the peritoneum (IP), or a combination of both. These types help guide the treatment plan. There isn’t much data on the severity and potential fatalities from bladder injuries alone, as patients typically have other injuries at the same time. However, up to 10% of injuries to the abdomen are bladder injuries, and they can have serious consequences, with a risk of severe illness or death ranging from 10% to 22%.
What Causes Bladder Trauma (Bladder Injury)?
Bladder trauma, or injury to the bladder, can happen in a variety of settings, including car accidents, at work, due to violent crimes, and even during medical procedures. It usually results from two main types of incidents: a hard hit to the lower stomach when the bladder is full, often leading to internal injury, or trauma that results in pelvic fractures and external injury.
It’s fairly common for bladder trauma to occur alongside injuries to bones or other organs in the abdominal or pelvic region. Traumatic bladder rupture, or a tear in the bladder wall, makes up 1.6% of all cases of blunt abdominal and pelvic trauma. However, consistently studying and reporting bladder trauma can be challenging. For instance, existing data suggests that around 85% of bladder injuries result from blunt, or non-penetrating, trauma, yet penetrating trauma, such as a stab or gunshot wound, can account for up to 51% of injuries.
While the overall incidence of penetrating injuries in 2015 was less than 10%, the proportion of bladder injuries caused by such injuries could be much higher. Furthermore, bladder trauma can also be caused by medical procedures, primarily those related to childbirth, women’s health, or urinary system procedures.
Risk Factors and Frequency for Bladder Trauma (Bladder Injury)
Bladder injuries can be caused by both blunt and penetrating traumas and can be classified as extraperitoneal (EP) or intraperitoneal (IP). It is also not uncommon for these injuries to occur as a result of medical procedures. Statistically, 60% of bladder traumas are extraperitoneal, 30% are intraperitoneal, and 10% are a combination of both.
- Bladder injuries can happen from blunt and penetrating traumas.
- 60% of these injuries are extraperitoneal (outside the bladder).
- 30% of these injuries are intraperitoneal (inside the bladder).
- 10% are combined, meaning they include both types.
- Bladder injuries can also come from medical procedures, like cesarean sections and hysterectomies.
- About 13.8 in every 1000 of these procedures result in a bladder injury.
Signs and Symptoms of Bladder Trauma (Bladder Injury)
When a patient comes in with trauma, doctors start by checking a few crucial things. This check is known as the primary survey and includes the patient’s airway, breathing, circulation, disability, and exposure. After this, they perform a more detailed head-to-toe examination, known as the secondary survey. This could reveal signs that suggest bladder trauma such as instability in the pelvic area, blood at the urinary opening, severe pain in the abdomen and pelvic area, sensitivity above the pubic bone, an unusually positioned prostate, and visible blood in the urine.
If the pelvis is unstable and there are signs of heavy internal bleeding, a pelvic binder can help stabilize the patient before surgery. Similarly, if the patient’s stomach is rigid, they are guarding their stomach, or there is rebound tenderness, it might not only point towards a perforated internal organ in the abdomen but also a bladder injury inside the lining of the abdominal cavity. A quick ultrasound assessment, known as a FAST exam, helps to identify any fluid in the pericardial, intra-abdominal, and pelvic areas. However, it’s important to note that a FAST exam can’t tell the difference between blood and urine.
When examining the genitals, if the doctors find blood at the urinary opening, they need to make sure that there’s no injury to the urethra before inserting an in-dwelling catheter, a tube used to drain urine from the bladder. If during a rectal examination, the prostate is unusually positioned, it could also mean that the urethra is injured. It’s important to note that visible blood in the urine is the most common symptom associated with bladder trauma and is seen in 67% to 95% of cases.
Testing for Bladder Trauma (Bladder Injury)
As part of the process to check for bodily injuries, doctors often conduct basic lab tests. These could include checking your blood count, metabolism rate, blood clotting ability, and urine analysis. If the patient is stable but presents symptoms such as visible bleeding in urine, blood at the urine exit point, inability to urinate, pelvic fracture with microscopic blood in urine, or has experienced a penetrating injury to the pelvis, buttock, or lower abdomen, a type of medical imaging called “retrograde cystography” is required.
Retrograde cystography is a technique that uses either a computed tomography (CT) or traditional X-ray to scan your bladder. These two types of imaging have comparable effectiveness. However, the CT scan is usually favored because it works faster and is more convenient to run the test. Moreover, CT scanning is better at spotting other processes that might be going on inside your abdomen or any bone fragments within the bladder.
How do doctors spot bladder trauma in these scans? If the bladder injury is extraperitoneal (outside the membrane lining the abdominal cavity), the scan will show a leakage of contrast material around the base of the bladder and leaking into areas like the thighs, penis, perineum, or the front of the abdominal wall in case of a complex injury. If the bladder injury is intraperitoneal (inside the membrane lining), the contrast material will be seen leaking into the cavity, circling the loops of intestines, and filling the gutters alongside the colon.
Finally, to check for suspected bladder damage or to evaluate the success of a bladder repair surgery, medical dyes like methylene blue or indigo carmine can be used.
Treatment Options for Bladder Trauma (Bladder Injury)
According to the American Urological Association, internal bladder ruptures require surgery, while external bladder ruptures can usually be treated with a catheter. If the urethra is injured, a catheter is inserted through a small incision. Surgery is chosen for internal bladder injuries to prevent infection. Laparoscopy is a minimally invasive option for stable patients. The bladder is examined, foreign bodies are removed, and nonviable tissue is cut away. The bladder is stitched in two layers and filled with fluid to ensure it is sealed tightly. Antibiotics are given after surgery. For uncomplicated external bladder injuries, a catheter is used for about two weeks and antibiotics are given. Surgery may be needed for certain conditions or if leakage continues after three months.
What else can Bladder Trauma (Bladder Injury) be?
While analyzing a patient who has faced bladder damage, healthcare providers should also bear in mind the possibility of other injuries such as:
- Injury to the penis
- Injury to the testicles
- Injury to the vagina
- Injury to the urethra
- Fractures in the pelvis – including fractures in the hip socket, “open book” fractures, straddle fractures, and avulsion fractures of the pelvis
- Bleeding in the area behind the abdominal cavity
- Injury to the kidneys
- Injury to the tubes that pass urine from the kidneys to the bladder (ureteral trauma)
Each of these possibilities should be duly considered by physicians to make an accurate diagnosis about the extent and nature of the patient’s trauma.
What to expect with Bladder Trauma (Bladder Injury)
People with bladder injuries often also have a range of other traumatic injuries. A study done at a leading trauma center found that the deaths occurred in 10.8% of the patients who had bladder ruptures and needed surgery for trauma. If a bladder rupture is not treated, it could lead to serious complications such as severe infection, inflammation of the abdomen lining, and unusual connections between organs.
To manage bladder ruptures successfully, quick assessment, accurate diagnosis, and the right treatment are needed based on the location and severity of the rupture. Most patients regain their regular bladder function after treatment. However, severe injuries involving the bladder neck, the tube that carries urine out of the body, or the muscles at the bottom of the pelvis can lead to an uncontrolled urination problem that may or may not be fixed with surgery.
Possible Complications When Diagnosed with Bladder Trauma (Bladder Injury)
Complications can happen because of the bladder injury itself or from surgery to fix the bladder. Below are the potential complications:
- Urinary incontinence (unable to control urine flow)
- Wound dehiscence (the wound splits open), and sometimes it can be mistaken as a urine leak because of drainage from the wound site
- Reduced bladder capacity due to excessive removal of damaged tissue
- Persistent urine leakage outside the bladder
- Bleeding can happen if there’s damage to the blood vessels in the pelvic area
- A pelvic abscess (a collection of pus) can form from a blood clot that gets infected
- Infection inside the abdomen
- Fistula (an abnormal connection between two body parts)
- Urinary tract infection
- Urinary urgency (feeling a sudden, strong urge to urinate)
Recovery from Bladder Trauma (Bladder Injury)
Patients are typically advised to visit their surgeon for a wound assessment and staple removal between seven to ten days after surgery. Catheters, which are tubes that help with urine flow, are usually taken out between 10 to 14 days post-surgery, provided there’s no leak found in successive cytogram tests and the patient passes a urine test. The Eastern Association of Surgery for Trauma (EAST) guidelines for managing blunt force bladder injuries recommend that patients who had simple bladder injury surgeries do not need routine follow-up cystography (a type of X-ray for the bladder) unless they show signs suggesting a urine leak. However, cystography is suggested for high-risk patients, such as those who had a non-surgical treatment for a bladder rupture, those who are malnourished, or those using steroids. Any persistent urine leak usually heals with extended catheter drainage.
Preventing Bladder Trauma (Bladder Injury)
Bladder injuries can occur from different types of trauma, like car accidents or violent incidents such as gunshot or stab wounds. There are programs in place that aim to prevent these types of injuries. The research supporting them is limited, but it does exist. These programs focus on issues like crime-related injuries, driving safety, and curbing alcohol or substance misuse.
In 2015, studies showed that injuries caused by penetration, like gunshots, made up approximately 8% of cases at trauma centers. Interestingly, around 30% of patients with these types of injuries went to different hospitals when they got hurt again. Those who did this saw a higher risk of dying from their injuries. Additionally, individuals causing self-harm were the group at the highest risk of getting hurt again. In terms of prevention, areas that implemented gun-related injury prevention initiatives saw around a 50% drop in such injuries among children.
Car accidents are a big cause of physical injuries to the lower torso. Teenagers, in particular, are at a high risk for distracted driving. Most teens who took part in a distracted driving program found it helpful, with over 80% identifying texting while driving as the biggest risk.
Since 2006, trauma centers have been required to test all admitted patients for alcohol. This is because drinking can lead to a number of risky behaviors. Studies found that many patients engaged in risky driving and violent behaviors, and some reported having suicidal thoughts in the past year. Even though many patients were under the influence when they arrived at a trauma center, this moment often served as a starting point for conversations about changing their habits. In some cases, however, patients didn’t take advantage of offered resources or follow-up appointments. Despite this, providing brief motivational interviews or advice to patients with a history of substance misuse seemed to help reduce their substance use in the long term.
By educating the community and providing appropriate outreach to at-risk individuals, we can potentially reduce both car-related and violent crime-related injuries.
