Bladder rupture is classified as extraperitoneal (~60%), intraperitoneal (~30%), or both (~10%). The distinction drives management: extraperitoneal ruptures usually accompany a pelvic fracture and are managed by catheter drainage, whereas intraperitoneal ruptures need surgical repair.
Background and Pathogenesis
- Extraperitoneal injury is usually associated with a pelvic fracture.
- Intraperitoneal injury can occur with a pelvic fracture but more often follows penetrating trauma or a burst at the dome from a blow to a full bladder.
- The bladder is protected within the bony pelvis, so blunt injury (deceleration MVC, falls, crush) is rarely isolated — 83–95% of bladder injuries have a pelvic fracture, but only 5–10% of pelvic fractures involve the bladder. Obstetric/gynaecologic procedures are the most common cause of iatrogenic open-surgical injury.
AAST Grading
- I — contusion/intramural hematoma or partial-thickness laceration.
- II — extraperitoneal laceration <2 cm.
- III — extraperitoneal >2 cm or intraperitoneal <2 cm laceration.
- IV — intraperitoneal laceration >2 cm.
- V — laceration extending into the bladder neck or ureteral orifice (trigone).
Diagnosis and Evaluation
- Indicators of rupture — gross hematuria is the most common (a few present with microscopic hematuria), plus lower-abdominal bruising, distention, suprapubic pain, guarding, inability to void, low urine output, diminished bowel sounds, pubic-symphysis diastasis, obturator-ring displacement >1 cm, raised creatinine/BUN (peritoneal urine absorption), and urinary ascites.
- Cystography indications (AUA 2020) — absolute: gross hematuria with a pelvic fracture; relative: gross hematuria with a concerning mechanism, or pelvic ring fracture with clinical indicators. Pelvic fracture alone does not warrant cystography. (Campbell's adds penetrating injury with any hematuria as absolute.)
- Modality: retrograde cystography (CT or plain film) — both are highly accurate and distinguish intra- from extraperitoneal rupture. Fill to 300–350 mL (false negatives occur at 250 mL); in CT cystography dilute the contrast 1:6. Plain film needs a fill view and a drainage view (not required for CT). Extraperitoneal rupture shows a flame-shaped pelvic collection; intraperitoneal rupture outlines bowel loops. The amount of extravasation does not reflect injury size.
Management
If blood is at the meatus or the catheter will not pass, perform a retrograde urethrogram first — urethral injury coexists in 10–30% of bladder ruptures.
- Extraperitoneal (uncomplicated) — a large-bore (22-Fr) Foley for 2–3 weeks, with follow-up cystography to confirm healing; consider open repair if it fails to heal after >4 weeks of drainage (start antibiotics if a pelvic hematoma is present).
- Intraperitoneal — prompt surgical repair (failure risks peritonitis and sepsis). Repair the tear intravesically with absorbable suture after confirming the bladder neck and ureteral orifices, and do not disturb the perivesical hematoma. Follow-up cystography at 7–10 days for complex repairs.
- Indications for immediate repair (AUA 2020): intraperitoneal rupture, exposed bone spicules in the lumen, concurrent rectal injury, bladder-neck injury, open reduction–internal fixation of the pelvis, concurrent vaginal injury, and when repairing other abdominal injuries.
- After repair, urethral catheter drainage alone is sufficient (no advantage to adding a suprapubic tube), except with long-term catheterisation needs, a tenuous closure, or significant hematuria.
Self-Test
1. What percentage of bladder injuries are extraperitoneal vs intraperitoneal, and which is associated with pelvic fracture? About 60% extraperitoneal, 30% intraperitoneal, 10% both — the extraperitoneal type is associated with pelvic fracture.
2. What are the indications for cystography in a stable patient? Must: gross hematuria with a pelvic fracture. Should: gross hematuria with a concerning mechanism, or a pelvic fracture with clinical indicators of rupture.
3. What are the clinical indicators of bladder rupture? Gross hematuria, abdominal distention, lower-abdominal bruising, suprapubic pain, guarding, inability to void, low urine output, diminished bowel sounds, raised BUN/creatinine, and urinary ascites.
4. What is the minimum bladder fill volume for CT cystography to exclude injury? 300 mL.
5. What proportion of bladder injuries have a concurrent urethral injury? 10–30%.
6. What is the management of bladder injury? Intraperitoneal rupture — surgical repair; extraperitoneal rupture — Foley catheter drainage for 2–3 weeks.
7. What are the indications for immediate surgical repair of an extraperitoneal bladder injury? Exposed bone spicules in the lumen, concurrent rectal or vaginal laceration, bladder-neck injury, ORIF of the pelvis, or concurrent repair of abdominal injuries.