Fortunately traumatic injury to the bladder is uncommon. The bladder is located within the bony structures of the pelvis and is protected from most external forces. But injuries can occur as a result of blunt or penetrating trauma. The following information should help explain why timely evaluation and proper management are critical for the best outcomes.
What happens under normal conditions?
The bladder is a hollow, balloon-shaped organ that is located within the pelvis. The bladder stores urine - the liquid waste made by the kidneys when they clean the blood. Muscular tissue within the bladder wall allows it to enlarge or shrink as urine is held or emptied.
How does bladder trauma happen?
When the bladder is empty, it is protected from injury from a blow to the lower abdomen by the bones of the pelvis. As it fills, the top of the bladder rises into the abdomen and makes it more vulnerable to be ruptured. In the child, the pelvic bones are not fully developed and so it is more easily injured than in the adult. If the force of the impact is great enough to fracture the bones of the pelvis, the bladder may be injured even if it is empty. Bullets or knives can also injure the bladder despite its level of fullness.
What are causes of injury to the bladder?
The most common way the bladder is injured is in motor vehicle accidents, falls from a high place or having a heavy object fall on the lower abdomen of a person. Automobile passengers that have a full bladder and are wearing a seat belt around the lower abdomen may have the force of the collision focus on the lower abdomen and thus the full bladder. To prevent this, wear your seat belt properly as a lap belt and always empty your bladder when planning a long car ride.
What are the symptoms of bladder trauma?
Virtually everyone who has a blunt injury to the bladder will see blood in the urine. Those with penetrating injury many not actually see bleeding. There may be pain below the bellybutton but many times the pain from other injuries makes the discomfort from the bladder hardly noticeable. If there is a large hole in the bladder and all of the urine leaks into the abdomen, it is impossible to pass urine. In women, if the injury is severe enough, the vagina may be torn open as well as the bladder. If this happens, urine may leak from the bladder through the vagina. Blood may also come out of the vagina in this instance. Other symptoms may include: difficulty beginning to urinate, weak urinary stream, painful urination, fever and severe back pain.
How is bladder trauma diagnosed?
The diagnosis of injury to the bladder is done by placing a catheter into the bladder and performing a series of X-rays. If the doctor is worried that the urethra is injured an X-ray of this organ may be done before a catheter is inserted. Before the X-rays are taken, the bladder is filled with a liquid that will make it visible on the X-rays.
What are the different types of bladder injuries and how are they treated?
Contusion: Most of the time the bladder wall does not rupture but is only bruised. If this happens, merely leaving a large diameter catheter in the bladder so clots may pass is all that is necessary. Once the urine has become clear and the doctor does not need the catheter in the bladder for other reasons (accurate measurement of urine made during the day or in patients too sick to urinate on their own), it can be removed.
Intraperitoneal Rupture: If the tear is on the top of the bladder, the hole will usually communicate with the abdominal cavity that holds all of the vital organs (liver, spleen and bowel). This injury should be surgically repaired. Urine that leaks into the abdomen is a serious problem. The repair is performed by making an abdominal incision and sewing the tear closed. A catheter is left in the bladder for up to 2 weeks to rest the bladder after the surgery, either through the urethra or coming directly out the abdominal wall, below the bellybutton.
Extraperitoneal Rupture: If the tear is at the bottom or sides of the bladder, the urine will not leak into the abdominal cavity but into the tissues around the bladder. Patients who have complex injuries of this type should have surgical repair of the injury but in some circumstances small injuries can be treated by simply placing a large diameter catheter into the bladder to keep it empty and allow the urine and blood to drain out into a collection bag. If the catheter does not drain properly, surgical repair is required. Allowing the bladder to repair itself in this fashion usually takes at least 10 days and the catheter is not removed until an X-ray is done as described above to prove the leak has sealed.
Penetrating Injuries: Patients who have injury to the bladder from a penetrating object are usually operated upon and the hole(s) is surgically repaired. Most of the time other organs in the area will be injured and need repair as well. A catheter is left in the bladder to drain the urine and blood as described above.
What can be expected after treatment for injuries to the bladder?
After the catheter is removed, urination should return to normal in a few weeks. Antibiotics are commonly given to the patient for a few days to eliminate any infection in the bladder from the injury or the catheter. In some patients, the bladder remains overactive for many weeks or months due to the irritation of the injury. Medication to calm this bladder over activity may be given to help the symptoms of having to pass urine frequently or the feeling that when you get the first sensation to pass urine, you think you have to get to the bathroom immediately or you might wet yourself (urgency).