Overview
Definition:
Intraperitoneal bladder rupture is a severe injury where the bladder wall breaches, leading to leakage of urine into the peritoneal cavity
This can occur due to blunt or penetrating abdominal trauma
Prompt diagnosis and surgical repair are crucial to prevent peritonitis and sepsis.
Epidemiology:
Bladder rupture accounts for approximately 2-4% of all pelvic fractures
Intraperitoneal rupture is less common than extraperitoneal rupture (approximately 10-20% of bladder ruptures)
It is more frequently associated with pelvic ring disruptions, particularly those involving shear forces causing significant anterior-posterior displacement.
Clinical Significance:
Intraperitoneal bladder rupture is a surgical emergency
Untreated, it leads to significant morbidity and mortality due to urinary ascites, electrolyte disturbances, infection, and potential for delayed healing or fistulae
Understanding its management is vital for surgical residents preparing for DNB and NEET SS exams.
Clinical Presentation
Symptoms:
Hematuria, often gross
Severe lower abdominal pain
Inability to void or a sensation of incomplete bladder emptying
Abdominal distension and tenderness
Nausea and vomiting
Signs of hypovolemic shock in severe cases.
Signs:
Abdominal tenderness, guarding, and rigidity suggestive of peritonitis
Palpable suprapubic mass (less common in IP rupture)
Absent or decreased bowel sounds
Signs of hemorrhagic shock (tachycardia, hypotension, pallor)
Possible ecchymosis in the flanks or perineum (grey-turner or cullen's sign).
Diagnostic Criteria:
The diagnosis is primarily based on clinical suspicion in the context of trauma, supported by imaging
There are no formal diagnostic criteria for the rupture itself, but rather for confirming its presence and extent
Hematuria is a key indicator, though absence does not rule out rupture.
Diagnostic Approach
History Taking:
Detailed mechanism of injury (blunt trauma to lower abdomen/pelvis, high-speed motor vehicle accident, fall from height, penetrating injury)
Previous urological or abdominal surgeries
Existing medical conditions.
Physical Examination:
Thorough abdominal examination to assess for distension, tenderness, guarding, rigidity, and masses
Rectal examination for prostatic displacement or hematoma
Pelvic examination for instability or crepitus
Examination for signs of extra-abdominal injuries.
Investigations:
Urinalysis: Gross or microscopic hematuria is typical
Complete Blood Count (CBC): Assess for anemia and signs of infection
Serum Electrolytes: Monitor for electrolyte imbalance due to urine leakage
Imaging: Cystography (retrograde): Considered the gold standard for diagnosing bladder rupture
it involves instilling contrast into the bladder
Intraperitoneal rupture is characterized by contrast spill outside the bladder outline into the peritoneal cavity
CT Urography: Provides excellent visualization of the bladder, urinary tract, and surrounding organs, and is often performed in trauma patients
Ultrasound: Less sensitive but can be used as a screening tool.
Differential Diagnosis:
Other causes of gross hematuria (renal contusion, ureteral injury, urethral injury)
Peritonitis from non-urological intra-abdominal injury
Pelvic fracture with significant soft tissue injury.
Management
Initial Management:
Hemodynamic stabilization: Aggressive fluid resuscitation and blood transfusion if indicated
Pain management
Indwelling Foley catheter insertion: This is contraindicated in suspected bladder rupture as it can worsen the injury or cause extravasation, especially in extraperitoneal ruptures
However, in isolated intraperitoneal rupture with no associated urethral injury, it may be considered after imaging to decompress the bladder, but surgical intervention is usually required
Definitive management is surgical.
Surgical Management:
Indications: All intraperitoneal bladder ruptures require surgical repair
Procedure: Laparotomy (exploratory) followed by bladder repair
The bladder defect is typically closed in two layers with absorbable sutures
The integrity of the repair is then tested by instilling saline or contrast into the bladder via a suprapubic catheter or a catheter through the cystotomy
A suprapubic catheter is usually placed for postoperative bladder drainage and to protect the repair site
Management of associated injuries (e.g., pelvic fractures) is addressed concurrently.
Supportive Care:
Intensive monitoring for fluid balance, vital signs, and signs of infection
Antibiotic prophylaxis to prevent urinary tract infections and peritonitis
Nutritional support
Early mobilization as tolerated.
Complications
Early Complications:
Peritonitis: Due to urine leakage into the peritoneal cavity
Sepsis: From untreated peritonitis or wound infection
Hemorrhage: From the initial injury or operative site
Uretero-enteric fistula formation (rare).
Late Complications:
Urinary fistulae (vesicocutaneous, vesicovaginal)
Bladder neck contracture or stricture
Urinary incontinence
Chronic pelvic pain
Recurrent urinary tract infections
Stone formation within the bladder.
Prevention Strategies:
Prompt surgical intervention
Meticulous surgical technique with secure bladder closure
Adequate postoperative bladder drainage via suprapubic catheter
Prophylactic antibiotics
Early mobilization.
Prognosis
Factors Affecting Prognosis:
Timeliness of diagnosis and treatment
Severity of the initial trauma
Presence of associated injuries, especially severe pelvic fractures
Patient's overall health status
Development of complications like sepsis.
Outcomes:
With prompt diagnosis and surgical repair, the prognosis for isolated intraperitoneal bladder rupture is generally good, with most patients achieving excellent functional recovery
Delayed treatment significantly increases morbidity and mortality.
Follow Up:
Regular follow-up with urologist and/or surgeon
Monitoring for signs of infection, fistula, or voiding dysfunction
Cystography or other imaging may be performed at 2-4 weeks post-operatively to confirm healing and assess for complications before catheter removal.
Key Points
Exam Focus:
Intraperitoneal rupture is characterized by urine spillage into the peritoneal cavity, necessitating surgical repair
CT cystography is the investigation of choice
Post-operative suprapubic catheter drainage is essential
Differentiate from extraperitoneal rupture management.
Clinical Pearls:
Always consider bladder rupture in patients with gross hematuria and pelvic trauma
Do not routinely insert a Foley catheter in the setting of significant pelvic trauma and gross hematuria until bladder integrity is confirmed
A laparotomy is usually required for IP rupture.
Common Mistakes:
Delaying surgical intervention
Assuming absence of bladder rupture based solely on gross hematuria
imaging is crucial
Inadequate bladder closure or drainage post-operatively
Failure to identify and manage associated injuries.