The bladder is an intraabdominal organ in children but is situated deep in the bony pelvis in adults. It is protected from all but the most severe injuries to the abdomen and pelvis. Bladder injuries are the second most common injury to the genitourinary tract after renal injuries and are usually associated with blunt trauma and pelvic fracture. Penetrating bladder injuries are often associated with injuries to other abdominal and pelvic organs.
BLADDER CONTUSION Bladder contusion is bruising of the bladder wall and resultant hematuria. A cystogram demonstrates an intact bladder outline. With a fractured pelvis, a large hematoma often results inside the bony pelvis, causing displacement of the bladder superiorly and laterally ( Fig 2.54-2). This finding can serve as an indicator of pelvic hemorrhage. Large bladder hematomas also alter the architecture of the bladder, which takes on the shape of an inverted pear, hence the term "pear-shaped" bladder. Hematomas are best detected by CT.
BLADDER RUPTURE There are two types of bladder injuries.19 Intraperitoneal bladder rupture is usually a burst injury of a full bladder resulting in a 1-in laceration in the dome posteriorly, the only portion of the dome covered by the peritoneum. In this type of injury, urine is spilled into the peritoneal cavity. Extraperitoneal bladder rupture is more common. The rupture is usually located at the bladder neck. Associated pelvic ring fractures predominate. The classic triad includes abdominal pain and tenderness, hematuria (usually gross), and inability to void. If the rupture is intraperitoneal, there may be peritonitis. Kehr sign (pain referred to the shoulder), suggesting blood or urine irritating the diaphragm, may be a clue. Patients in whom bladder injury is suspected but who are unable to void spontaneously should have a retrograde or suprapubic catheter placed. Retrograde catheter placement should be avoided until urtheral disruption has been ruled out.
Bladder injuries are best diagnosed by cystogram or CT cystogram (see above). Gross extravasation indicates rupture. Intraperitoneal rupture is demonstrated by extravasation of contrast material in the cul-de-sac posterior to the bladder, along the paracolic gutters, and between the loops of intestine above the bladder. In extraperitoneal bladder rupture, the cystogram shows flamelike extravasation of contrast material streaking into the perivesical tissues. The washout film (not necessary with CT cystogram) is helpful when the extravasation is predominantly behind the bladder and obscured by contrast material in the full-bladder film of the cystogram. An irregular outline of an intact bladder may indicate contusion, hematoma, or an incomplete tear. Cystoscopy is not considered useful in this setting due to the gross hematuria and clot formation.3
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