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Traumatic injury of the bladder and urethra

Definition

Traumatic injury of the bladder and urethra involves damage caused by an outside force.

Alternative Names

Injury - bladder and urethra; Bruised bladder; Urethral injury; Bladder injury; Pelvic fracture; Urethral disruption

Causes, incidence, and risk factors

Injuries to the bladder can be divided into:

• Blunt trauma (such as a blow to the body)
• Penetrating wounds (such as bullet or stab wounds)

The nature of the injury to the bladder depends on how full the bladder was at the time of injury and what caused the injury.

Traumatic injury to the bladder is uncommon. Only about 8 - 10% of pelvic fractures are associated with bladder injury. Because the bladder is located within the bony structures of the pelvis, it is protected from most outside forces. Injury may occur if there is a blow to the pelvis that is severe enough to break the bones and cause bone fragments to penetrate the bladder wall.

Other causes of bladder or uretal injury include:

• Surgeries of the pelvis or groin (including hernia repair and abdominal hysterectomy)
• Tears, cuts, bruises, and other injuries to the urethra (the tube that carries urine out of the body) -- most common in men.
• Straddle injuries (direct force accidents that injury the scrotum area between a man's legs)

• Deceleration injury (for example, a motor vehicle accident that occurs with a full bladder while wearing seatbelt)

Injury to the bladder or urethra may cause urine to leak into the abdomen, leading to infection (peritonitis). This type of injury is more common if the bladder is full.

Symptoms

• Abdominal pain, lower
• Blood in the urine or at the urethral opening
• Difficulty beginning to urinate or inability to empty the bladder
• Loss of fluids
• Painful urination
• Pelvic pain
• Severe bleeding
• Small, weak urine stream

Emergency symptoms indicating shock or hemorrhage:

• Decreased alertness
  • Coma
  • Drowsiness, lethargy
• Increased heart rate
• Pale skin
• Sweating
• Skin cool to touch

Note: Symptoms follow a history of injury.

Scarring (stricture) or obstruction of the bladder or urethra from swelling may develop.

If urine retention occurs, there may be an increased risk of urinary tract infections (UTI).

Signs and tests

An examination of the genitals may show injury to the urethra. If the health care provider suspects an injury, an x-ray of the urethra using dye (retrograde urethrogram) should be done to show the structure of the lower urinary tract.

Examination may also show:

• Bladder injury or swollen (distended) bladder
• If the bladder lining has been disturbed, urine may escape from the bladder into the abdominal cavity.
• Other signs of pelvic injury, such as brusing over the penis, scrotum, and perineum
• Signs of hemorrhage or shock, including decreased blood pressure -- especially in cases of pelvic fracture
• Tenderness and bladder fullness when touched (caused by urine retention)
• Tender and unstable pelvic bones

A catheter (a tube that drains urine from the body) may be inserted once an injury has been ruled out. An x-ray of the bladder using dye to highlight any damage can then be done.

Treatment

The goals of treatment are to:

• Control symptoms
• Repair the injury
• Prevent complications

Emergency treatment of bleeding or shock may include:

• Blood transfusions
• Intravenous (IV) fluids
• Monitoring in the hospital

Treatment of peritonitis (inflammation of the abdominal cavity) may include emergency surgery to repair the injury and drain the urine from the abdominal cavity. Antibiotics may be given to treat peritonitis and to prevent urinary tract infections.

Surgical repair of the injury is usually successful. The bladder may be drained by a catheter through the urethra or the abdominal wall over a period of days to weeks. This will prevent urine from building up in the bladder, allowing the injured bladder or urethra to heal. This also prevents swelling in the urethra from blocking urine flow.

If the urethra has been cut, a urological specialist can place a catheter. If this cannot be done, a tube will be inserted through the abdominal wall and directly into the bladder. This is called a suprapubic tube. It will be left in place until swelling goes away and the urethra can be surgically repaired. This typically takes 3 - 6 months.

Support Groups

Expectations (prognosis)

Traumatic injury of the bladder and the urethra may range from minor to major and life-threatening. There may be severe, immediate, or long-term complications.

Complications

• Acute bilateral obstructive uropathy
• Bleeding, hemorrhage, shock
• Chronic bilateral obstructive uropathy
• Peritonitis
• Scar formation, obstruction of the urethra
• Urinary retention
• Vesicoureteric reflux

Calling your health care provider

Go to the emergency room or call the local emergency number (such as 911), if you have symptoms of traumatic injury of the bladder or urethra -- particularly if there is a history of injury to the area.

Call your health care provider if symptoms worsen or new symptoms develop, including:

• Decrease in urine production
• Fever
• Severe abdominal pain
• Severe flank or back pain
• Shock or hemorrhage

Prevention

Prevent outside injury to the bladder and urethra by using general safety precautions:

• Do not insert objects into the urethra
• If you need self-catheterization, follow the instructions of your health care provider
• Use appropriate safety equipment during work and play

References

Morey AF, Rozanski TA. Genital and lower urinary tract trauma. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 83.

Runyon MS. Genitourinary system. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 44.