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# 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

Tap one to see what it is and open it in 3D.

- [Urinary bladder](https://durgical.com/en/anatomy/urinary-bladder/)
- [Membranous urethra](https://durgical.com/en/anatomy/intermediate-part-of-male-urethra/)
- [Prostate](https://durgical.com/en/anatomy/prostate/)
- [Pubic symphysis](https://durgical.com/en/anatomy/pubic-symphysis/)
- [Hip bone](https://durgical.com/en/anatomy/hip-bone/)
- [Prostatic urethra](https://durgical.com/en/anatomy/prostatic-urethra-seminal-colliculus/)
- [Spongy urethra](https://durgical.com/en/anatomy/spongy-urethra/)
- [External urethral sphincter](https://durgical.com/en/anatomy/female-external-urethral-sphincter/)
- [Perineal membrane](https://durgical.com/en/anatomy/perineal-membrane/)
- [Urethra (male)](https://durgical.com/en/anatomy/male-urethra/)

## 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](https://durgical.com/en/anatomy/prostatic-urethra-seminal-colliculus/), 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](https://durgical.com/en/anatomy/region/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](https://durgical.com/en/anatomy/peritoneum/). Pelvic fracture fragments and ligament shearing tear the extraperitoneal bladder wall or the [membranous urethra](https://durgical.com/en/anatomy/intermediate-part-of-male-urethra/) where it crosses the urogenital [diaphragm](https://durgical.com/en/anatomy/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

## Red flags

- Blood at the meatus after pelvic trauma: do not insert a urethral catheter until a retrograde urethrogram is done
- Signs of peritonitis with haematuria (intraperitoneal rupture)
- Rising creatinine without [kidney](https://durgical.com/en/anatomy/kidney/) injury (peritoneal urine reabsorption)
- Failed or bloody catheter insertion
- Associated rectal or vaginal injury

## Diagnosis

**Clinical**
Inspect the meatus and perineum in every pelvic trauma. A rectal examination can show a high-riding [prostate](https://durgical.com/en/anatomy/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](https://durgical.com/en/anatomy/region/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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## Related conditions

- [Pelvic fracture](https://durgical.com/en/conditions/pelvic-fracture/)
- [Major trauma (polytrauma): ATLS primary survey](https://durgical.com/en/conditions/major-trauma-atls-primary-survey/)
- [Renal trauma](https://durgical.com/en/conditions/renal-trauma/)
- [Acute urinary retention](https://durgical.com/en/conditions/acute-urinary-retention/)
- [Erectile dysfunction](https://durgical.com/en/conditions/erectile-dysfunction/)
- [Urinary tract infection (acute cystitis)](https://durgical.com/en/conditions/urinary-tract-infection/)
- [Peritonitis](https://durgical.com/en/conditions/peritonitis/)
- [Acute kidney injury](https://durgical.com/en/conditions/acute-kidney-injury/)

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

Sources: [Urotrauma Guideline - American Urological Association](https://www.auanet.org/guidelines-and-quality/guidelines/urotrauma-guideline) (American Urological Association, 2020); [Kidney and uro-trauma: WSES-AAST guidelines](https://pmc.ncbi.nlm.nih.gov/articles/PMC6886230/) (World Journal of Emergency Surgery, 2019).

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/bladder-and-urethral-injury/