What is Bladder Rupture?
Bladder rupture is a quite uncommon condition, typically caused by injury to the abdomen or pelvic region. It can also happen spontaneously or due to surgical procedures. The bladder is usually well-shielded by the pelvic bones in adults. As a result, bladder injuries often happen along with pelvic bone breaks, especially those affecting the pubic bones.
Most people with a bladder rupture will experience pelvic pain and blood in their urine. To confirm this condition, doctors may use a procedure called retrograde cystography, which uses computed tomography (a type of advanced X-ray) or standard X-ray imaging. This helps the doctors to identify where the rupture has occurred.
Bladder ruptures can happen within the peritoneal space (the area that contains the abdominal organs) but usually occur outside this area and are known as extraperitoneal ruptures. If it’s an uncomplicated extraperitoneal rupture, doctors often manage it non-surgically using a Foley catheter, a tube inserted into the bladder to drain urine. However, ruptures inside the peritoneal space typically need to be fixed through surgery.
What Causes Bladder Rupture?
Bladder ruptures are often caused by damage due to strong impact, as is common in car or motorcycle accidents. These crashes usually lead to pelvic injuries that may also cause the bladder to rupture. A bladder rupture can happen inside your body, usually when your bladder is full and extreme force is applied to the lower stomach. It can also happen outside the body, typically related to pelvic fractures where the bladder wall is damaged by the intensity of the force on the pelvis or a bone fragment penetrates the bladder. Less commonly, falls or objects piercing the body can cause bladder ruptures.
Damage to the bladder can also accidentally happen during medical procedures related to the female reproductive system, colon, urinary system, and during the placement of a Foley catheter (a tube to drain urine). It’s most common during processes involving the placement of a device called a ‘trocar’ below the belly button during keyhole surgery. To minimize this risk, ideally, a catheter is inserted before placing the trocar, ensuring the bladder is empty.
The spontaneous rupture of the bladder, meaning it happens without a clear cause, is very rare and can be fatal. Some reported cases have been associated with childbirth, conditions that affect blood clotting like hemophilia, cancer, exposure to radiation, infections, and the inability to empty the bladder.
Risk Factors and Frequency for Bladder Rupture
Bladder injuries are a potential risk in about 1.6% of patients who experience blunt abdominal trauma. These injuries can occur in three different areas of the bladder:
- About 60% of these injuries are extraperitoneal, meaning they occur outside the membrane that lines the abdominal cavity.
- Another 30% are intraperitoneal, meaning they happen within the membrane lining the abdominal cavity.
- The remaining 10% of bladder injuries occur both inside and outside of this lining.
It’s also important to note that children are more likely to experience intraperitoneal ruptures due to the position of the bladder within the abdomen at a younger age.
Signs and Symptoms of Bladder Rupture
Bladder rupture is a serious condition, with the main symptom being blood in the urine. Usually, about 77% to 100% of patients with this condition experience this symptom. Other signs and symptoms of bladder rupture can include pain in the pelvic area, lower abdominal pain, and problems with urination. It’s important to remember that a bladder rupture is often mixed up with other injuries that happen from high force impact or sudden blow.
For instance, if someone has a broken pelvis, it could imply that the bladder, urethra, rectum, or vagina might be injured as well. A careful physical check-up is crucial for a timely diagnosis of these injuries. Certain types of pelvic fractures can increase the risk of a bladder rupture significantly, particularly those involving the anterior arch (the front half of the “ring” created by the pelvis) or all four inconspicuous bone extensions in the pelvis, known as pubic rami. If the pelvic ring is disrupted or if there’s an injury to the rear part of the pelvic bone, the chances of a bladder rupture are also high.
- Pelvic pain
- Renal failure
- Urinary ascites (abnormal buildup of fluid in the abdomen)
- Sepsis (a severe infection that can spread in the body)
It is also important to note that bladder rupture is often associated with injuries to the colon.
Testing for Bladder Rupture
If you’ve had an injury and your doctor suspects you might have a bladder rupture, they’ll perform several tests. For instance, an analysis of your urine can help identify bladder damage. With bladder rupture, blood usually appears in the urine. However, fewer than 1% of patients may have fewer than 25 red blood cells per high power field in their urine test.
Most of the time, urine samples given by freely peeing are preferred. However, in cases of severe injury, it might not be practical. Moreover, higher than normal levels of blood urea nitrogen and creatinine, waste products usually filtered by the kidneys, could be present in your blood due to the urine being absorbed into your bloodstream. This is especially true if you’re tested a while after your injury occurred.
Another test that may be conducted is the “Focused Assessment with Sonography for Trauma”, also known as the FAST exam. With this exam, if your bladder has ruptured inside what is known as the peritoneal cavity (the large space in your abdomen that holds your organs), there may be free fluid in your pelvic area, visible on the ultrasound. However, note that ultrasound can’t distinguish between blood and urine. Therefore, if you also have a pelvic injury, the ultrasound could be showing blood rather than urine, which makes it a bit less specific.
If you have injuries in your pelvic area and there’s blood at the opening of your urethra (the tube through which you urinate), there could also be a concern about damage to the urethra. In this case, doctors do a ‘retrograde urethrogram’ or RUG, which is an imaging test that assesses flow and images in ‘reverse’, before placing a urinary catheter.
If you have blood in your urine and a pelvic fracture, you may need a test called a ‘retrograde cystogram’, which involves filling your bladder with a contrast dye, then taking x-rays to get detailed images of your bladder. Even if you don’t have a pelvic fracture, if there’s blood in your urine or symptoms that suggest a bladder rupture, you may still require this test. However, if you have a pelvic fracture, but no blood in your urine or high-risk fracture patterns, you may not need this test.
X-ray film and CT scans taken after filling your bladder with contrast dye have similar abilities to spot problems. The method of imaging often relies on the nature of your injuries and how they happened. Simply limiting urine drainage from the bladder isn’t sufficient, so to avoid missing more minor injuries, your bladder needs to be filled in reverse.
In very severe cases where there is uncontrollable bleeding in the pelvis, some tests may interfere with the interpretation of pelvic angiography, a test used to visualize blood vessels in the pelvis. In such situations, certain tests will be postponed.
Earlier, a technique called fluoroscopic cystography was commonly used to check for bladder rupture. Though effective, this method could be time-consuming. Now, a CT-retrograde cystogram is often the preferred method because it also allows a look at other structures in the pelvic area.
If you have injuries from sharp objects to your pelvis and there’s blood in your urine, your bladder will need to be checked out. Depending on your condition, this can be done surgically, through endoscopy (a procedure that lets your doctor examine your organs through a thin tube inserted into your body), or radiologically with imaging tests.
Treatment Options for Bladder Rupture
The American Urological Association (AUA) recommends that bladder ruptures within the abdominal cavity, also known as intraperitoneal bladder ruptures, be treated with surgery. This is because these ruptures, often resulting from blunt trauma, are typically large injuries that won’t heal on their own – even with the use of urinary drainage via a catheter. If left unnoticed and unrepaired, these ruptures can lead to serious complications, including inflammation of the peritoneum (the membrane lining the abdomen), sepsis (a life-threatening response to infection), and kidney failure.
Due to the severe nature of these injuries, the traditional open surgical method is most commonly used. Nonetheless, performing the surgery through a laparoscope, a small tube with a camera that allows surgeons to operate without making large incisions, could be a suitable option in certain circumstances. During the operation, the entire bladder should be examined, and not just the obvious injury. To achieve this, it might be necessary to enlarge an existing injury for easy access to the trigone area – the lower part of the bladder. Afterwards, the bladder injury is repaired through single or double-layered closure. Permanent stitches are usually avoided on the inner layer of the bladder, as they can lead to the formation of bladder stones in the future. A Foley catheter, a tube inserted into the bladder to drain urine, is typically left in place post-repair. Lastly, a follow-up test (cystography) is performed after surgery to confirm proper healing, especially in complex cases.
AUA guidelines also state that simple injuries to the bladder that occur outside the abdominal cavity, known as uncomplicated extraperitoneal bladder injuries, can be managed without surgery, using a catheter instead. Usually, the catheter is left in place for about two to three weeks, although a longer period may be needed in some cases. If after four weeks of catheter drainage the rupture hasn’t yet healed, surgical repair should be considered. Extraperitoneal bladder ruptures that are complicated – such as those involving bone fragments within the bladder, or those associated with injuries to the vagina or rectum – often require surgical repair. Likewise, injuries to the bladder neck, the area where the bladder connects to the urethra (tube that carries urine out of the body), may not heal without surgery. Just like with intraperitoneal bladder ruptures, a follow-up cystography is used to confirm healing in these cases as well.
Most of the time, drainage can be achieved with a catheter inserted through the urethra. In rare cases, after surgery, a catheter is inserted directly into the bladder through the abdominal wall – a process known as suprapubic cystostomy – usually if a urethral injury is also present, and a catheter can’t be inserted due to urethral disruption. Generally speaking, using urinary catheters has shown positive results, leading to a shorter hospital stay and lower morbidity, or rate of disease.
What else can Bladder Rupture be?
Bladder injuries can happen due to an accident or as a side-effect of a surgical procedure. When examining a patient with such an injury, doctors must remember other related issues might be the cause, such as:
- Child abuse
- Injury to the penis
- Sexual assault
- Damage to the urethra (the tube which carries urine out from the bladder)
- Vaginal trauma
What to expect with Bladder Rupture
Bladder perforation, or a hole in the bladder, is not as deadly as it once was. Thanks to greater awareness and improved imaging techniques, most cases are detected quickly these days. For some patients, surgery can speed up the healing process and reduce the time they spend in the hospital. However, the overall recovery depends on whether there are other injuries involved.
If the bladder neck, urethra (the tube that carries urine out of the body), and muscles in the pelvic floor are injured, some patients may develop urinary incontinence. This condition can make it hard for them to control their urination.
Possible Complications When Diagnosed with Bladder Rupture
Complications may arise either directly from a ruptured bladder, which causes urine to leak into the abdomen, or from the surgery needed to fix the rupture. Here are some potential complications:
- Pelvic abscess: a collection of pus in the pelvic area
- Intraabdominal infection: an infection inside the abdomen
- Hemorrhage: severe, uncontrolled bleeding
- Renal failure: a condition where the kidneys stop working properly
- Electrolyte imbalance: a disruption in the balance of minerals in the body, which can affect bodily functions
- Urinary tract infection: an infection in any part of the urinary system, which includes the kidneys, bladder, ureters, and urethra
- Urinary urgency: a sudden, compelling urge to urinate
- Wound dehiscence: a surgical complication where a wound ruptures along a surgical incision
Preventing Bladder Rupture
When there’s an injury to the bladder, a urinary catheter is usually required. This medical device temporarily helps in draining urine from your bladder until the injury heals. It’s important that you understand how to take care of your catheter and maintain proper hygiene to avoid complications. In the case of surgical procedures, patients are usually asked to return to the medical facility in 10 days to have their staples removed.
A follow-up check, known as an X-ray cystogram, is performed 14 days after the surgery. This test helps the doctor to assess the healing process and look for any possible leaks. If the cystogram shows that everything is normal, the catheter is then removed.
However, do keep in mind that in case of severe bladder injuries, some patients may experience urine leakage or incontinence. It’s important to be aware of this possibility and to discuss this with your medical professional, who can offer further advice and possible solutions.
