Pediatric emergency medicine trisk 3323 3323
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Current Evidence
During childhood, the bladder has a higher abdominal location, which renders the
organ more susceptible to injury than in adults. The bladder can also be more
easily damaged when full. The risk for this injury is especially increased in the
setting of improperly fastened seat belts and lap belts.
Bladder injuries are classified as extraperitoneal, intraperitoneal, or combined.
Extraperitoneal injuries are more frequently associated with pelvic fractures of
the anterior ring and may be related to either laceration or penetration from a
bone spike, irrespective of bladder volume at the time of injury. In contrast,
intraperitoneal injuries, which account for approximately two-thirds of major
bladder injuries, are usually caused by blunt trauma, resulting in a burst
mechanism to a full, distended bladder. Combined injuries are usually seen with
gunshot wounds. Bladder injuries may range from contusions to rupture.
Contusions are incomplete, nonperforating tears of the mucosa. Complicated
injuries may involve the bladder, urethra, sacral plexus, and supporting structures
of the anorectal region.
Bladder neck injuries are uncommon, but serious as this may affect continence
or lead to extravasation into other areas such as the medial thigh. Such injuries
have been reported to be more common in children than in adults because of the
undeveloped prostate and are often in association with a pelvic fracture. The
injury may be due to longitudinal lacerations or lacerations that extend to the
proximal urethra.
Clinical Considerations
Clinical Recognition
Hematuria and dysuria are symptoms commonly seen at presentation. Nearly
100% of patients with rupture of the bladder have gross hematuria. Microscopic
hematuria is associated with less severe injuries such as contusions. Patients with
intraperitoneal ruptures may develop a palpable fluid wave from extravasation of
urine into the peritoneal cavity and peritoneal irritation with signs of peritonitis.
Elevated levels of blood urea nitrogen in the serum are out of proportion to
creatinine resulting from more rapid peritoneal reabsorption of urea.
Patients with myelodysplasia who have undergone bladder augmentation may
experience spontaneous bladder rupture in the presence of infection, bacteremia,
or overdistension. Suspicion must be high as they may lack the classic
presentation seen in sensate patients. Symptoms and signs of sepsis, as well as
shoulder pain, may be encountered at presentation. Emergent exploration is
indicated after a cystogram is completed.
