Bladder Rupture (Ruptured Bladder)

What to do right now

If someone has had a major injury to the lower belly or pelvis:

1. Call 911 or your local emergency number.
2. Keep the person still and lying down, especially if a pelvic fracture is possible.
3. Do not give food or drink, as surgery may be needed.
4. Do not try to pass a catheter or encourage straining to pass urine.
5. Note any blood in the urine, and the time of the injury, and tell the emergency team.

How bladder rupture happens

The bladder sits low in the pelvis behind the pubic bone. When empty, it is well protected. When full, it rises into the lower abdomen and becomes thin-walled and vulnerable. There are two main types:

Causes

• Blunt trauma: car crashes, falls from height, crush injuries and sports injuries. Most bladder ruptures occur with a pelvic fracture.
• A blow to a full bladder: for example a seatbelt injury, an assault, or a fall while intoxicated, when the bladder is distended.
• Penetrating injuries: gunshot and stab wounds.
• Medical procedures (iatrogenic): cesarean section, hysterectomy, hernia repair, bladder or prostate surgery (such as transurethral resection), and catheter insertion.
• Spontaneous rupture: rare, in bladders weakened by radiation, cancer, infection, previous surgery or long-term retention, often after heavy alcohol use.

Bladder rupture signs and symptoms

• Blood in the urine (hematuria): seen in nearly all cases, usually visible. See blood in urine.
• Lower belly pain and tenderness above the pubic bone.
• Difficulty or inability to pass urine, or passing only small amounts.
• Swelling or bruising of the lower belly, perineum, scrotum or thighs from urine and blood leaking into tissues.
• Belly swelling, pain and stiffness with intraperitoneal rupture, as urine irritates the abdominal lining.
• Signs of shock: fast pulse, low blood pressure, pale clammy skin, usually from associated bleeding.

Late signs, if missed, include fever, belly distension, rising creatinine (urine reabsorbed from the abdomen raises kidney blood tests), and peritonitis.

Diagnosis

Bladder injury is suspected in anyone with pelvic trauma and blood in the urine.

• CT cystography: the standard test. Contrast is instilled into the bladder through a catheter, then a CT scan shows where it leaks. A normal CT scan without filling the bladder can miss a rupture.
• Retrograde urethrogram: if there is blood at the tip of the penis or a suspected urethral injury, the urethra is checked with contrast before a catheter is passed, to avoid worsening a urethral injury.
• Blood tests: blood count, kidney function and electrolytes.
• During surgery: some injuries are found during an operation for other trauma.

Treatment

Extraperitoneal rupture

Most are treated with a urinary catheter that drains the bladder continuously for around 10 to 14 days, allowing the tear to heal. A cystogram is done before the catheter is removed to confirm healing. Surgery is needed if the tear involves the bladder neck, there are bone fragments in the bladder, the rectum or vagina is also injured, or the person is having pelvic surgery anyway.

Intraperitoneal rupture

These need surgical repair, usually through an open operation or sometimes keyhole surgery. The tear is closed in layers, the abdomen is washed out, and a catheter drains the bladder while it heals.

Penetrating and iatrogenic injuries

Penetrating injuries are usually explored surgically. Injuries recognized during surgery are repaired immediately.

Supporting care

Treatment of associated injuries and bleeding, antibiotics to prevent infection, pain control and stabilization of pelvic fractures.

Complications

• Urinary infection and abscess
• Peritonitis if urine leaks into the abdomen undetected
• Urinary leakage or fistula
• Bladder dysfunction, including urgency or incomplete emptying, especially with nerve injury from pelvic fractures
• Death, mostly from the severe associated injuries rather than the bladder injury itself

Outlook

Bladder injuries that are recognized and treated promptly usually heal well, and most people regain normal bladder function. Outcomes depend largely on the severity of other injuries. Delayed diagnosis increases the risk of infection and kidney problems.

Frequently asked questions

What are the signs and symptoms of a ruptured bladder?

The main signs are blood in the urine, pain and tenderness in the lower belly, and difficulty or inability to pass urine, usually after an injury. There may be bruising or swelling of the lower belly, groin or genitals. Intraperitoneal tears cause belly swelling and pain from urine in the abdomen.

What causes a bladder to rupture?

Most bladder ruptures are caused by blunt trauma, especially car crashes or falls with a pelvic fracture, or a blow to the lower belly when the bladder is full. Penetrating wounds and surgical procedures in the pelvis are other causes. Spontaneous rupture is rare.

Can a ruptured bladder heal on its own?

Small tears outside the abdominal cavity (extraperitoneal) usually heal with a catheter draining the bladder for about 2 weeks. Tears into the abdominal cavity (intraperitoneal) do not heal reliably on their own and need surgery. Any suspected bladder injury needs emergency care.

Can a full bladder burst from holding urine?

In a healthy bladder, simply holding urine does not make it burst. You would leak or be forced to urinate first. Rupture of a full bladder happens with a blow to the belly, or rarely in bladders weakened by radiation, surgery or disease, often when intoxication dulls sensation.