Definition

Bladder trauma is a urinary tract emergency condition that rarely occurs. It can be classified into several categories:

• Extraperitoneal injury, involving tears in the lower or side part of the bladder, causing urine leakage into the tissues around the bladder.
• Intraperitoneal injury, involving tears above the bladder and causing urine leakage into the abdomen.
• Combination of both types of injury.

Each type of injury requires different therapies. 

Leaking urine from the bladder can trigger infections in the abdominal area. Although rare, bladder trauma has an incidence rate of up to 10% and can lead to significant disability and death for those affected. Because these cases are considered emergencies, prompt and appropriate action is needed to ensure proper management.

Causes

Bladder trauma can be caused by several factors, including:

• Direct trauma to the bladder disrupting pelvic organ continuity
• Sharp injuries and stab wounds
• Iatrogenic injuries (caused by medical devices and procedures)
• Surgical procedures in the pelvic and groin areas
• Careless gynecological surgeries in women
• Improper catheter placement

In most cases, bladder trauma is accompanied by pelvic bone fractures (pelvic fractures) that protect the urinary and genital organs.

Motor vehicle accidents are the most common cause of bladder trauma. Injuries often occur when the bladder is full, and the victim is wearing a tight seat belt. The force generated from the accident can compress the bladder, leading to injury.

Risk factor

Several factors can increase the risk of bladder trauma, including:

• Engaging in risky driving behaviors such as speeding
• Falling from a height
• History of pelvic surgery (hernia repair, hysterectomy, cesarean section)
• History of inserting objects into the urethra
• History of improper urinary catheterization

Symptoms

Bladder trauma can present with symptoms such as:

• Lower abdominal pain
• Bruising and wounds at the site of injury
• Presence of blood in the urine (hematuria)
• Difficulty initiating urination or inability to empty the bladder
• Leakage of urine into the abdominal cavity or near the bladder
• Pain during urination
• Pelvic pain
• Weak and small urine stream
• Changes in the shape of the abdomen such as swelling (abdominal distension)

In some cases, patients may also experience fever and severe back pain. However, since bladder trauma is a urological emergency, the following signs indicate a need for immediate medical attention:

• Decreased consciousness
• Increased heart rate or weakly palpable pulse
• Decreased blood pressure
• Pale, sweaty, and cold skin

Diagnosis

In diagnosing bladder trauma, the doctor will first evaluate the general condition of the patient to determine if they are stable or not. If the patient is unstable, the doctor will prioritize checking the patient's vital signs and stopping any ongoing bleeding. Once the patient is stable, the doctor will proceed with an interview, physical examination, and diagnostic tests.

The examination will initially be performed by a general practitioner and may then be referred to a urology surgeon for further management. During the interview, the doctor will gather information about the patient's:

• History of injury and mechanism of injury
• Urination history
• Level of pain experienced
• History of previous medical device placement

During the physical examination, the doctor will conduct a comprehensive assessment from head to toe, checking vital signs such as respiratory rate, pulse, and blood pressure. The doctor will also perform an inspection, with a focus on the abdomen and pelvis, to check for the following signs:

• Presence of bleeding
• Wounds or lacerations
• Swelling
• Changes in the shape of the abdomen and pelvis

For diagnostic tests, the doctor will conduct laboratory tests and imaging examinations. Laboratory tests may include:

• Routine blood tests
• Blood clotting factors
• Electrolyte levels
• Urinalysis to detect the presence of blood and other substances in the urine

Imaging examinations are the primary choice for diagnosing cases of bladder trauma, as they can provide accurate diagnostic information. Examples of imaging examinations that may be performed include cystography, a specialized imaging modality for the bladder, which can be conducted using either an X-ray or computed tomography (CT) scan.

These imaging examinations are typically performed when the patient's condition is stable. However, other examinations such as ultrasound (USG) are not recommended as they are considered less specific for diagnosing bladder trauma.

Management

The initial treatment of bladder trauma focuses on stabilizing the patient's condition, as it is considered an emergency situation with the potential for intra-abdominal bleeding and life-threatening blood loss.

Once the patient's condition is stabilized, the doctor will assess the severity of the trauma. Management is generally divided into two categories: non-surgical and surgical.

Non-surgical treatment methods are typically chosen for cases of bladder trauma that are less severe and where the bleeding does not extend into the abdominal cavity. The doctor may insert a urethral catheter and monitor the patient for 2-3 weeks. A cystogram examination may assess bladder development around the 10th day. Antibiotics may also be prescribed to prevent bacterial infection and complications resulting from bladder trauma.

For more severe cases, especially those accompanied by pelvic fractures or extensive bladder trauma extending into the abdominal cavity, surgical intervention may be recommended. Surgery helps mitigate the risk of infection, which may be higher in such cases.

Complications

Complications can occur as a result of the trauma itself or as a consequence of the surgical management, including:

• Urinary incontinence (inability to control urination)
• Surgical wound leakage
• Decreased bladder capacity
• Bleeding
• Abscess or pus formation in the pelvic area due to infected bleeding
• Infection in the abdominal cavity (intra-abdominal infection)
• Urinary tract infection

Prevention

Bladder trauma typically results from injury or trauma, making it challenging to prevent through specific measures. However, individuals can take the following precautions:

• Exercise caution during activities, especially when driving or engaging in physical tasks.
• Avoid applying heavy pressure to the pelvic area
• Refrain from inserting any objects into the urethral opening
• Educate yourself further about bladder trauma and its risk factors to better understand how to prevent it

When to see a doctor?

After sustaining an injury around the pelvic area, accompanied by the symptoms listed above, it's crucial to seek medical attention in the Emergency Department promptly. Delaying treatment can lead to severe consequences, including death and permanent injury.

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