Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXI: Wounds and Injuries of the Genitourinary Tract
United States Department of Defense
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Bladder wounds are common and should always be considered in patients with lower abdominal wounds, gross hematuria, or an inability to void following abdominal or pelvic trauma. These tears may be intraperitoneal or extraperitoneal. After insuring urethral integrity in appropriate cases (see "Wounds of the Urethra" infra), the diagnosis is made radiographically. Cystography is performed by retrograde filling of the bladder via a urethral catheter with radiopaque contrast medium elevated 20-30 cm above the level of the abdomen. An X-ray of the full bladder is taken, and another X-ray is taken after draining the bladder by unclamping the urethral catheter. Small extraperitoneal areas of extravasation may be apparent only on the postevacuation film.
Penetrating injuries and blowout perforations of the bladder dome due to blunt lower abdominal trauma of a full bladder are most often intraperitoneal. Cystography reveals contrast medium interspersed between loops of bowel. Management consists of exploration, multilayer repair of the injury with absorbable sutures, suprapubic tube cystostomy, and drainage of the perivesical extraperitoneal space.
Extraperitoneal injuries to the bladder are most often the result of laceration by bony fragments of a pelvic fracture. Cystography reveals a flame-like extravasation of contrast medium on the postevacuation film. Extraperitoneal injuries may be repaired primarily as above; however, they usually heal with 10-14 days of Foley catheter drainage without the need for primary repair.
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