Situations in Which the Bladder May Be Injured
Transurethral resection of bladder tumour (TURBT)
Cystoscopic bladder biopsy
Transurethral resection of prostate (TURP)
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Penetrating trauma to the lower abdomen or back
Caesarean section, especially as an emergency
Blunt pelvic trauma—in association with pelvic fracture or
'minor' trauma in the inebriated patient Total hip replacement (very rare)
Rapid deceleration injury—seat belt injury with full bladder in
the absence of a pelvic fracture Spontaneous rupture after bladder augmentation
Types of Perforation
Bladder perforations are categorised as extraperitoneal or intraperitoneal. In an intraperitoneal perforation, the peritoneum overlying the bladder, has been breached along with the wall of the bladder, allowing urine to escape into the peritoneal cavity. In an extraperitoneal perforation, the peritoneum is intact and urine escapes into the space around the bladder, but not into the peritoneal cavity. For a perforation to be intraperitoneal, it must occur in that part of the bladder that is covered by peritoneum, and the injury must, of course, be deep enough to make a hole all the way through the muscular wall of the bladder, the surrounding perivesical fat, and the peritoneum.
Making the Diagnosis
As with urological injuries in general, if you know the potential scenarios in which a bladder injury can occur, you are halfway there in terms of making a diagnosis. From the nature of the injury, which makes you suspect a possible bladder injury, you can arrange appropriate imaging studies to confirm your suspicions. Thus, the history is all-important in making the diagnosis.
The need to perform diagnostic tests depends on the clinical situation. In the case of iatrogenic injury (e.g., after a TURBT), the patient is usually anaesthetised and diagnosis is usually obvious on visual inspection alone. No diagnostic tests are required. In other situations, e.g., the drunk patient who has suffered apparently minor trauma such as a fall, the classic triad of symptoms and signs that are suggestive of a bladder rupture is suprapubic pain and tenderness, difficulty or inability in passing urine, and haematuria (or there may be just one or two of the symptoms or signs of the 'triad'). Additional signs may include abdominal distention and absent bowel sounds, occurring as a consequence of an ileus caused by urine being present in the peritoneal cavity. In these non-atrogenic causes, the great majority of patients (>95%) will have macroscopic haematuria or 'heavy'