How to manage bladder trauma in women

Bladder injury is classified based on its location: intraperitoneal (30%), extraperitoneal (60%) or combined (10%).

• Blunt bladder injuries are most commonly associated with pelvic fractures, where the injury mechanism involves disruption of the pelvic ring. Following blunt external trauma, an intraperitoneal injury can occur due to a sudden rise in intravesical pressure from a distended bladder. Rupture typically happens at the bladder dome, as this is the weakest point of this organ.
• External iatrogenic bladder trauma (eIBT) can occur during obstetric and gynaecological procedures, urologic procedures or general surgical procedures.
• Internal iatrogenic bladder trauma (iIBT) typically arises during transurethral resection of the bladder (TURB), and is usually located extraperitoneal.

How to manage?
Management of bladder injuries is primarily guided by the location of the injury rather than the mechanism.

For extraperitoneal bladder trauma (EBT), urinary drainage resolves the injury in most cases. A catheter is usually left in place for 2-3 weeks, followed by a cystography to assess for any residual extravasation. Surgical repair is required for complicated bladder injuries, such as those involving bony fragments from a pelvic fracture in the bladder wall, associated injuries such as bladder neck damage, or large defects in the bladder wall. In recent decades there has been a trend toward early open reduction and internal fixation for pelvic fractures. During surgery for associated injuries, such as a pelvic fracture, the bladder injury can be repaired. A rare but serious complication of conservatively treated EBT is the development of a vesicocutaneous fistula.

For intraperitoneal bladder trauma (IBT), surgical repair is the indicated treatment. Conservative management can result in sepsis, peritonitis and fistula formation. However, conservative management may be considered for small intraperitoneal injuries, provided continuous urinary drainage is maintained and antibiotics are administered.

Penetrating bladder injuries generally necessitate surgical exploration. However, in hemodynamically stable patients without associated injuries, small extraperitoneal bladder injuries, can be managed non-operatively.

In case of iatrogenic bladder injury discovered during surgery, primary repair should be performed. If the injury is discovered postoperatively or results from iIBT, management is guided by the injury’s location, as previously described.

When surgical repair is indicated, the approach may be open, laparoscopic or robot-assisted, depending on available expertise. The bladder should be closed with absorbable sutures, using either a single or a double layer technique.

Bladder trauma or impaired wound healing can lead to the development of vesicovaginal (VVF) or vesicocutaneous fistulae (VCF). In high income countries, these fistulae are primarily caused by surgery, radiation therapy or malignancy. The most common procedure associated with VFF is the hysterectomy, with the laparoscopic approach carrying the highest risk. In low resource settings, obstetric complications, particularly obstructed labour, are the leading cause of VVF.

Management of VVF lacks a standardised protocol, with various approaches described in the literature, including open abdominal, open vaginal, laparoscopic and robot assisted procedures. The choice of surgical route and use of interposition flaps, depends on patient-specifi c factors and the resources available at the treatment centre. However, there is an increasing trend toward minimally invasive techniques.

Conclusion
Literature on bladder trauma in women and the subsequent formation of fistulae is limited. Reports on functional and sexual outcomes following treatment for these problems is even rarer. Collaboration among trauma and urological reconstructive centres to address this knowledge gap, could help understanding and improve the management of these conditions.

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At EAU25, Dr. Marjan Waterloos (BE) is presenting the lecture “Genital consequence of pelvic trauma” on Monday 24 March, 10:45 – 12:15 in the Purple Area, Room 2.