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Bladder and urethral trauma
Extraperitoneal bladder rupture (the common type, with pelvic fracture) is usually treated with a catheter alone, and intraperitoneal rupture (at the dome, from a blow to a full bladder) requires surgical repair; blood at the meatus after a pelvic fracture requires retrograde urethrography before any attempt to pass a catheter.
Why it matters in the exam
The exam shows a patient with a pelvic fracture, gross haematuria, inability to void or blood at the meatus. Gross haematuria with a pelvic fracture requires cystography — retrograde or CT — with filling of 300 to 350 mL of contrast and a post-drainage image; partial filling or passive cystography during routine CT may miss a rupture. In intraperitoneal rupture the contrast spreads between bowel loops, and in extraperitoneal rupture it collects around the bladder in a "flame" pattern.
Extraperitoneal rupture is treated with a urethral catheter and cystography before its removal, except when repair is needed: bladder neck involvement, a bone fragment penetrating the bladder, an associated rectal or vaginal injury, or a patient who is going to laparotomy or internal pelvic fixation anyway. Intraperitoneal rupture is always repaired, open or laparoscopically, because urine in the peritoneum causes peritonitis and a rise in creatinine by absorption.
Posterior (membranous) urethral injury occurs with a pelvic fracture: blood at the meatus, retention, and sometimes a "high-riding" prostate on rectal examination — an unreliable sign. Urethrography is performed; for a complete rupture a suprapubic catheter is placed, or early endoscopic realignment in a stable patient, and repair by direct anastomosis after 3 months. Anterior urethral injury results from a straddle injury (bulbar urethra) with a "butterfly" perineal haematoma; in blunt trauma — a suprapubic catheter, and in penetrating injury — immediate repair. Urethral injury in a woman is rare and is repaired early.
Key points
- Extraperitoneal — catheter; intraperitoneal — surgery.
- Cystography with 300 to 350 mL and a post-drainage image.
- Blood at the meatus — urethrography first.
- Posterior urethra — suprapubic catheter and repair after 3 months.
- Straddle injury — bulbar urethra.
Summary table
| Injury | Mechanism | Diagnosis | Treatment |
|---|---|---|---|
| Extraperitoneal rupture | Pelvic fracture | Cystography: contrast around the bladder | Catheter; repair at the bladder neck or with bone |
| Intraperitoneal rupture | Blow to a full bladder | Cystography: contrast between bowel loops | Surgical repair always |
| Posterior urethra | Pelvic fracture | Retrograde urethrography | Suprapubic catheter and repair after 3 months |
| Anterior urethra | Straddle injury | Urethrography | Suprapubic if blunt; immediate repair if penetrating |
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Sources
- EAU Guidelines on Urological Trauma, 2025 edition — Bladder and urethral trauma
- AUA Guideline: Urotrauma, 2020 — Bladder and urethral injuries
- ATLS Advanced Trauma Life Support Student Course Manual, 10th edition (2018) — Abdominal and Pelvic Trauma
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.