Bladder Rupture Management (AUA Urotrauma 2020)

Algorithm Steps

1. ▶

   Start

   Suspected Bladder Trauma

   Gross hematuria + pelvic trauma or penetrating injury

   1. ●

      Action

      Clinical Indicators

      High suspicion scenarios

      • Gross hematuria + pelvic fracture
      • Inability to void with suprapubic pain
      • Penetrating lower abdominal injury
      • Blood at urethral meatus (check urethra first)
      • 85% of blunt bladder injuries have pelvic fracture
      • 10% of pelvic fractures have bladder injury
      1. ◆

         Decision

         Urethral Injury Suspected?

         Blood at meatus, high-riding prostate, perineal ecchymosis

         1. ●

            Action

            Retrograde Urethrogram First

            Must rule out urethral injury before catheter

            • NEVER catheterize if urethral injury suspected
            • RUG to evaluate urethral integrity
            • If intact: proceed with catheter + cystogram
            • If disrupted: suprapubic tube
            1. ●

               Action

               CT Cystography

               Gold standard for bladder injury (AUA Strong Rec)

               • Fill bladder with 350mL dilute contrast
               • Adequate distension critical (false negatives if underfilled)
               • Post-drainage images essential
               • Look for: intra vs extraperitoneal leak
               • Combined injury in 5-10%
               1. ◆

                  Decision

                  Type of Bladder Rupture?

                  Determines management pathway

                  1. ⚠

                     Warning

                     Intraperitoneal Rupture

                     REQUIRES SURGICAL REPAIR (AUA Strong Rec)

                     • Contrast in peritoneal cavity
                     • Usually dome rupture (weakest point)
                     • More common with full bladder + blunt trauma
                     • Risk of peritonitis, urinary ascites
                     • Cannot manage with catheter alone
                     1. ●

                        Action

                        Surgical Repair

                        Open or laparoscopic cystorrhaphy

                        • Two-layer closure with absorbable suture
                        • Debride devitalized tissue
                        • Water-tight closure
                        • Leave suprapubic or urethral catheter
                        • Drain pelvic space
                        • Concurrent procedures if laparotomy
                        1. ●

                           Action

                           Follow-Up Cystogram

                           Before catheter removal

                           • Typically 10-14 days post-injury/repair
                           • Earlier if clinical concern (sepsis, leak)
                           • If healed: remove catheter
                           • If leak persists: continue drainage
                           • Re-image in 1-2 weeks if persistent
                           1. ⚠

                              Warning

                              Potential Complications

                              Monitor and manage

                              • Persistent leak: extend catheter drainage
                              • Infection/sepsis: IV antibiotics
                              • Fistula formation (rare with prompt treatment)
                              • Incontinence (rare, usually resolves)
                              • Small bladder capacity (if delayed diagnosis)
                              1. ✓

                                 Outcome

                                 Expected Outcomes

                                 Excellent with appropriate management

                                 • Healing rate >95% with proper treatment
                                 • Extraperitoneal: >85% heal with catheter alone
                                 • Surgery success rate >98%
                                 • Long-term bladder function usually normal
                  2. ●

                     Action

                     Extraperitoneal Rupture

                     Catheter drainage usually sufficient (AUA Strong Rec)

                     • Contrast confined to pelvis
                     • Associated with pelvic fracture
                     • Lateral/anterolateral bladder wall
                     • Most heal with catheter drainage alone
                     • Exception: bladder neck injury, bone in bladder
                     1. ●

                        Action

                        Catheter Management

                        Large bore Foley drainage

                        • 18-22 Fr Foley catheter
                        • Keep bladder decompressed
                        • Monitor urine output
                        • Antibiotics controversial (AUA: selective use)
                        • Duration: 10-14 days typically
                  3. ●

                     Action

                     Combined Rupture

                     Both intra and extraperitoneal

                     • Occurs in 5-10% of bladder injuries
                     • Treat as intraperitoneal (surgery)
                     • Repair both components
                     • More complex injury pattern