Bladder and urethral injury !

Bladder or urethra torn by trauma, usually with a pelvic fracture. Blood at the urethral opening means no urinary catheter until imaging.

Updated 2026-11-01

Structures involved

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What it is

Rupture or contusion of the bladder, or partial or complete disruption of the urethra, most often linked to pelvic fractures. Bladder rupture is intraperitoneal or extraperitoneal; urethral injuries are posterior (membranous and prostatic urethra, with pelvic fracture) or anterior (bulbar and penile urethra, typically after a straddle fall).

Who gets it

Bladder injury occurs in a minority of pelvic fractures, and pelvic fracture urethral injury happens almost only in men. In Colombia these injuries follow mainly motorcycle crashes, run-over pedestrians and falls, and straddle injuries occur in work and cycling accidents.

Causes

Pelvic ring fracture from road traffic crashes or crush injuries (posterior urethra, extraperitoneal bladder)
Blow to a full bladder, e.g. seatbelt or kick (intraperitoneal rupture at the dome)
Straddle falls onto a bar or beam (bulbar urethra)
Penetrating wounds to the lower abdomen, perineum or buttocks
Iatrogenic: catheterisation, pelvic surgery, endoscopic procedures

Risk factors

Pelvic fracture, especially symphysis diastasis or pubic rami fractures
Full bladder at the time of injury, often with alcohol intake
Male sex (longer, more fixed urethra)
Penile fracture during intercourse (anterior urethra)

Pathophysiology

A blow to a distended bladder raises its internal pressure and bursts the weakest part, the dome, leaking urine into the peritoneum. Pelvic fracture fragments and ligament shearing tear the extraperitoneal bladder wall or the membranous urethra where it crosses the urogenital diaphragm. Urine extravasation causes chemical peritonitis, infection and, through peritoneal reabsorption, rising creatinine.

Classification

Bladder: contusion, extraperitoneal rupture (most common, with pelvic fracture) and intraperitoneal rupture (dome)
Urethra: posterior (membranous or prostatic) versus anterior (bulbar or penile)
Partial versus complete urethral disruption

Symptoms and signs

Blood at the urethral meatus
Visible haematuria (the classic sign of bladder rupture)
Inability to void despite a full bladder
Suprapubic pain and tenderness
Perineal or scrotal bruising (butterfly pattern) or swelling
High-riding or non-palpable prostate on rectal examination

Diagnosis

Clinical: Inspect the meatus and perineum in every pelvic trauma. A rectal examination can show a high-riding prostate, though it is unreliable. Urethral injury must be excluded before a urethral catheter is placed.
Tests: Urinalysis, haemoglobin, creatinine and electrolytes. Urinary drainage volume and colour are tracked.
Imaging: Retrograde urethrogram for suspected urethral injury. Retrograde cystography (plain or CT) with adequate bladder filling for visible haematuria with pelvic fracture; extravasation around the bowel loops means intraperitoneal rupture, a flame-shaped pattern in the pelvis means extraperitoneal rupture.

Differential diagnosis

Renal or ureteric injury as the source of haematuria
Pelvic haematoma compressing the bladder
Acute urinary retention without injury
Rectal injury

Goal of treatment

Drain urine safely, repair injuries that need it, and prevent stricture, incontinence and erectile dysfunction.

Treatment

Surgical: Intraperitoneal bladder rupture: surgical repair of the bladder wall with urinary catheter drainage.
Conservative: Uncomplicated extraperitoneal bladder rupture: urethral catheter drainage with follow-up cystography before removal.
Surgical: Complex extraperitoneal rupture (bladder neck, bone fragments, rectal or vaginal injury, or open pelvic fixation): surgical repair.
Procedure: Posterior urethral injury: early urinary drainage with a suprapubic catheter, sometimes primary endoscopic realignment in stable patients; definitive urethroplasty later.
Surgical: Anterior urethral injury: prompt repair of uncomplicated penetrating injuries; urinary drainage for straddle injuries with delayed reconstruction if a stricture forms.
Follow-up: Nursing priorities: do not attempt urethral catheterisation with blood at the meatus, record urine output and colour, care for the suprapubic tube, and watch for fever and abdominal signs.

Complications

Urethral stricture
Erectile dysfunction
Urinary incontinence
Urinary tract infection, pelvic abscess and urinary fistula
Urinary ascites and peritonitis

Prognosis

Bladder injuries heal well when diagnosed and drained or repaired early. Pelvic fracture urethral injuries often lead to stricture needing reconstruction, and erectile dysfunction is common, so follow-up for at least a year is recommended.

Prevention

Road safety measures
Safe work practices at height
No blind urethral catheterisation in pelvic trauma

Test yourself

Think of the answer, then tap the question to see it.

What must be done before a urethral catheter is placed in a pelvic trauma patient with blood at the meatus?

A retrograde urethrogram to rule out urethral injury.

Which type of bladder rupture always needs surgical repair?

Intraperitoneal rupture, usually at the dome after a blow to a full bladder.

How is an uncomplicated extraperitoneal bladder rupture usually managed?

With urethral catheter drainage and follow-up cystography.

Which urethral segment is injured in a straddle fall?

The bulbar (anterior) urethra, crushed against the pubic bone.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: Urotrauma Guideline - American Urological Association (American Urological Association, 2020); Kidney and uro-trauma: WSES-AAST guidelines (World Journal of Emergency Surgery, 2019).

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Representative model, for educational purposes only.

Urinary bladder highlighted on the Durgical 3D model