Bladder Injury

How bladder injuries happen

The empty bladder sits low in the pelvis, protected by the pelvic bones. When full, it rises into the lower abdomen, where it is more exposed and its wall is thin and stretched.

Blunt trauma

• Pelvic fracture: the most common cause. Bone fragments or shearing forces tear the bladder. Most patients with bladder rupture from blunt trauma have a broken pelvis.
• A blow to a full bladder: a seatbelt, steering wheel, fall or assault can burst a distended bladder, often at its dome. This is more likely after drinking alcohol.

Penetrating trauma

Gunshot and stab wounds to the lower abdomen, buttocks or perineum can injure the bladder, often with bowel and blood vessel damage.

Surgery (iatrogenic injury)

The bladder can be injured during cesarean delivery, hysterectomy, pelvic floor surgery, hernia repair, bowel surgery, and urological procedures such as bladder tumor resection. Many are recognized and repaired during the operation. Unrecognized injuries show up days later with pain, fever, belly swelling or urine leakage.

Types of bladder injury

For detail on full tears, see bladder rupture.

Symptoms

• Blood in the urine (gross hematuria), present in the large majority of bladder ruptures
• lower belly (suprapubic) pain and tenderness
• difficulty passing urine, a weak stream or passing none despite urge
• swelling and bruising of the lower belly, groin, scrotum or thighs from leaking urine
• with intraperitoneal rupture: belly swelling, pain throughout the abdomen, nausea, rising kidney test results (urine is absorbed back into the blood) and later signs of peritonitis

Blood at the tip of the penis after a pelvic injury suggests a urethral injury, and a catheter should not be inserted blindly until the urethra is checked.

Diagnosis

People with major trauma are assessed by a trauma team. If bladder injury is suspected:

• Urinalysis: blood in the urine
• CT cystography: contrast is instilled into the bladder through a catheter, then a CT scan shows where it leaks. This is the preferred test. A regular CT with contrast given only through a vein is not reliable for excluding bladder rupture
• Retrograde urethrogram: first, if urethral injury is suspected
• Cystoscopy: a camera in the bladder, especially during or after surgery
• Blood tests: kidney function, blood count

Treatment

Contusion

Rest, monitoring and sometimes a catheter for a few days. Blood in the urine clears on its own.

Extraperitoneal rupture

Most heal with a catheter (through the urethra or above the pubic bone) for about 10 to 14 days, followed by a repeat cystogram to confirm healing before removal. Surgery is chosen if bone fragments are in the bladder, the bladder neck is involved, there is a rectal or vaginal injury, or surgery is already being done to fix the pelvis.

Intraperitoneal rupture and penetrating injuries

These need surgery to close the tear in layers, followed by a catheter for 7 to 14 days. Surgeons also check the bowel, rectum and ureters.

Surgical injuries

Injuries recognized during surgery are repaired immediately. Delayed recognition may need surgical repair or catheter drainage depending on the type.

Antibiotics are given to prevent infection while the catheter is in.

Complications

• urinary tract infection
• urine collection (urinoma) or abscess
• peritonitis and sepsis with missed intraperitoneal rupture
• fistula between the bladder and vagina or bowel, causing constant leakage
• bladder dysfunction or urgency after healing
• urethral stricture if the urethra was also injured

Outlook

Isolated bladder injuries that are diagnosed and treated promptly usually heal well, with normal bladder function. Overall outcomes in trauma depend largely on the other injuries, especially pelvic fractures and internal bleeding.

Frequently asked questions

What are the symptoms of a bladder injury?

The main sign is blood in the urine after an injury or surgery. Others include lower belly pain, difficulty or inability to urinate, swelling or bruising of the lower belly or groin, and, with tears into the abdomen, belly swelling, nausea and fever.

How long does it take for a bladder injury to heal?

Bruises heal within days. Most bladder tears treated with a catheter heal in about 10 to 14 days, confirmed by a repeat bladder X-ray. After surgical repair, a catheter usually stays for 1 to 2 weeks, and full recovery takes several weeks.

Can a bladder injury heal on its own?

Bladder bruises and many tears outside the abdominal cavity heal with catheter drainage, which keeps the bladder empty while it heals. Tears into the abdominal cavity do not heal reliably on their own and need surgical repair.

How common is bladder injury during a C-section?

Bladder injury during cesarean delivery is uncommon, occurring in a small fraction of procedures. It is more likely with repeat cesareans, scar tissue, emergency surgery or placenta accreta. Most are recognized and repaired during the operation with good results.

Is blood in the urine after a fall serious?

It can be. Visible blood in the urine after a significant fall, crash or blow to the belly or back may mean injury to the kidneys, bladder or urethra. It needs emergency assessment, often with a CT scan.