About the Author(s)


Shumani Makhadi Email symbol
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Camilla Ngobeni symbol
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Jessica Gerber symbol
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Micaela Colaco symbol
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Alisha Govender symbol
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Beauty Mahomane symbol
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Ann Varughese symbol
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Jabulani Lubisi symbol
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Ahmed Adam symbol
Department of Urology, Faculty of Health Sciences, University of the Witwatersrand, Parktown, South Africa

Maeyane S. Moeng symbol
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Citation


Makhadi S, Ngobeni C, Gerber J, et al. Retrospective review of traumatic bladder injuries in a trauma unit in Johannesburg, South Africa. J Coll Med S Afr. 2025;3(1), a272. https://doi.org/10.4102/jcmsa.v3i1.272

Original Research

Retrospective review of traumatic bladder injuries in a trauma unit in Johannesburg, South Africa

Shumani Makhadi, Camilla Ngobeni, Jessica Gerber, Micaela Colaco, Alisha Govender, Beauty Mahomane, Ann Varughese, Jabulani Lubisi, Ahmed Adam, Maeyane S. Moeng

Received: 05 Aug. 2025; Accepted: 16 Oct. 2025; Published: 03 Dec. 2025

Copyright: © 2025. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Limited studies have focused on the outcomes of traumatic bladder injuries in low- and middle-income countries (LMICs), prompting this study to describe and evaluate the management and outcomes at a trauma unit.

Methods: This retrospective study describes traumatic bladder injury management and outcomes (mortality) over a time duration of 5 years (2015–2019), addressing a gap in LMIC data. The study included adult trauma patients with confirmed traumatic bladder injuries, excluding iatrogenic cases and incomplete data. Data collected included demographics, injury mechanisms, injury types, diagnostic methods, management strategies, and associated injuries. Statistical analysis was conducted using STATA version 18.

Results: Findings showed that 49 % of injuries were caused by blunt trauma, mainly motor vehicle accidents, while 51 % resulted from penetrating trauma, mostly gunshot wounds. Injuries were categorised as extraperitoneal (39 %) and intraperitoneal (38 %). Conservative treatment was often used for extraperitoneal traumatic bladder injuries. Penetrating injuries frequently needed surgical repair, mainly two-layer suturing with absorbable material. The mortality rate was low, with two deaths because of Adult Respiratory Distress Syndrome (ARDS) and pneumonia. Complications included fistula formation in 2.6 % of patients, managed conservatively and urinary tract infections in 3.9 %. Haematuria lasting more than five days was seen in four patients and cleared with catheterisation. One patient developed a pelvic abscess after preperitoneal pelvic packing.

Conclusion: The low mortality rate and manageable complications like fistula and infections suggest outcomes can improve with proper management, even in resource-limited settings.

Contribution: This study highlights patterns, management, and outcomes of traumatic bladder injuries in LMICs, emphasising the need for ongoing research and capacity-building to improve patient care.

Keywords: traumatic bladder injury; outcomes; penetrating trauma; blunt trauma; pelvic fracture; extraperitoneal injury; intraperitoneal bladder injury.

Introduction

Traumatic bladder injuries are rare; they affect 0.7 % of trauma patients.1,2,3,4 Genitourinary trauma occurs in 10 % of patients with abdominal trauma.1,2,3,4 Traumatic bladder injuries can result from blunt or penetrating trauma. Traumatic bladder injuries caused by blunt trauma are often linked with pelvic fractures.3 Penetrating trauma can result in bladder perforations, especially with gunshot wounds and stabs.5

Traumatic bladder injuries can range from minor contusions to complex injuries involving the bladder neck (trigone).6 Early diagnosis and surgical treatment of intraperitoneal and complex traumatic bladder injuries improve outcomes.7 Traumatic bladder injuries often present with haematuria. The clinical presentation and management of traumatic bladder injuries depend on the severity and location of the injury.7

Patients with traumatic bladder injuries may present with haematuria, pelvic fractures, inability to void and suprapubic pain.3,4,5,6,7 Radiological diagnosis is confirmed using a computer tomography cystography or a conventional cystogram.4 Injuries from penetrating trauma can also be identified during laparotomy.

Management of traumatic bladder injuries in low- and middle-income countries (LMICs) varies.4,8 The mortality rate among patients with traumatic bladder injuries was 2.3 % in Nigeria and 5 % in a study conducted in South Africa.4,8 Complications for traumatic bladder injury repair were 39 % in high-income countries (HICs) and 22.5 % in LMICs.4,8,9

Traumatic bladder injuries are treated by general or trauma surgeons in the South African setting.4 The urology team is activated only for complex injuries around the neck or the trigone of the bladder. Few studies report the incidence and outcomes of such injuries, particularly in LMICs.4,8 Epidemiological patterns may differ substantially from HICs.4 For example, LMICs cohorts often face higher proportions of violence-related and transport-related injuries.4 Delays in surgery may occur because of system-level constraints, and follow-up can be inconsistent in LMICs. This study addresses these gaps by reporting LMIC data from a level-1 trauma centre. The study aimed to assess the outcomes (mortality) of traumatic bladder injuries at our institution and will contribute to the existing literature on bladder injury outcomes in LMICs.

Research methods and design

This study was a retrospective review spanning 5 years (from 01 January 2015 to 31 December 2019) at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) – a level-1 trauma centre in Johannesburg, South Africa.

The trauma unit collects data on all trauma resuscitations. Data were collected from hospital trauma registries (Medibank, REDCap) and medical records. Inclusion criteria: patients with confirmed traumatic bladder injuries admitted between 2015 and 2019. The study excluded iatrogenic traumatic bladder injuries and records lacking injury details or management information. Case identification was based on diagnostic coding cross-referenced with operative logs for bladder injury. The data included patient demographics, mechanism of injury, type of bladder injury, diagnostic modality, management and associated injuries. Injuries were graded according to the American Association for the Surgery of Trauma (AAST) system. Outcomes reported were primary – in-hospital mortality (any death during the initial admission); secondary – complications (urine leak, infection, reoperation), and length of stay.

Statistical analysis

Means (±s.d.) are reported for continuous variables, and frequencies (%) are reported for categorical variables. All analyses were conducted using STATA version 18. Continuous variables were initially tested for normality using the Shapiro–Wilk test. Statistical analysis employed chi-square or Fisher’s exact tests for categorical data, t-tests or medians with interquartile ranges (IQRs) where appropriate, with odds ratios and confidence intervals included where relevant. Univariate and multivariate analyses were conducted on the data. A p-value of < 0.05 was considered statistically significant.

Ethical considerations

Ethical clearance to conduct this study was obtained by the University of the Witwatersrand Human Ethics Committee on 26 November 2020 (No. M200634) and the hospital chief executive officer (CEO). This was a retrospective study involving human participants. As this study involved analysing existing data and did not entail direct interaction with the participants, individual consent was not required. To ensure confidentiality, all data were anonymised and securely stored, with access limited to authorised personnel.

Results

There were 55 260 patients seen at CMJAH during the study period. A total of 76 patients with traumatic bladder injuries were identified during the study period. The mean age was 32.8 ± 10.5 years, and the majority were male (60/76, 78.9 %). Six patients (7.9 %) had comorbidities, most commonly hypertension (n = 3, 3.9 %) and human immunodeficiency virus (HIV) (n = 3, 3.9 %). The median Injury Severity Score (ISS) was 17 (IQR 13–25). Pelvic fractures were associated with traumatic bladder injuries in 18 patients (23.7 %) (Table 1).

TABLE 1: Demographic and clinical characteristics of patients with traumatic bladder injuries (N = 76).

Blunt trauma accounted for 37 patients (49 %), while penetrating trauma accounted for 39 (51 %) (Figure 1). Among penetrating trauma cases, gunshot wounds were most common (32/39, 82.0 %), followed by stab wounds (7/39, 18.0 %).

FIGURE 1: Distribution of mechanisms of injury in traumatic bladder injuries.

Regarding injury type, 30 patients (39.5 %) sustained extraperitoneal traumatic bladder injuries (EBI), 29 (38.2 %) intraperitoneal traumatic bladder injuries (IPI) and 17 (22.4 %) had combined injuries involving both sites (Figure 2). All intraperitoneal and combined injuries were surgically repaired, while half of extraperitoneal injuries were treated conservatively (15/30, 50.0 %) with catheterisation alone.

FIGURE 2: Extraperitoneal and intraperitoneal bladder distributions.

Traumatic bladder injury was diagnosed by computed tomography (CT) cystogram in the majority of cases (67/76, 88.2 %), while the remainder were diagnosed intraoperatively (9/76, 11.8 %).

Sixty-one patients underwent operative bladder repair. Two-layer closure with absorbable sutures was most frequently used (29/61, 47.5 %), followed by single-layer closure (15/61, 24.6 %). In 17 cases (27.9 %), the technique was not specified. Polydioxanone (PDS) 4/0 sutures were used in 88.5 % of cases, while Vicryl 2/0 sutures were used in 11.5 %. All patients were managed with urethral catheterisation, and only three subsequently required suprapubic catheter placements because of case complexity.

Associated injuries varied significantly between blunt and penetrating trauma (Table 2). Blunt trauma was more likely associated with pelvic fractures (35.1 % vs. 7.7 %, p = 0.023), whereas penetrating trauma was significantly related to rectal injuries (46.2 % vs. 0, p < 0.001) and small bowel injuries (28.2 % vs. 2.7 %, p = 0.031).

TABLE 2: Relative frequencies of associated injuries by mechanism (N = 76).

The most common complications were urinary tract infection (3/76, 3.9 %) and prolonged haematuria (> 5 days) (4/76, 5.3 %) (Table 3). Two patients (2.6 %) developed vesico-cutaneous fistulas following complex extraperitoneal injuries; both patients were treated conservatively with catheter drainage (Table 3). One patient (1.3 %) developed a pelvic abscess secondary to preperitoneal packing for uncontrolled pelvic bleeding.

TABLE 3: Complications of traumatic bladder injuries.

The in-hospital mortality rate was 2/76 (2.6 %), both deaths resulting from Adult Respiratory Distress Syndrome (ARDS) and pneumonia rather than the bladder injury itself. The median hospital length of stay was 10 days (IQR 7–15).

Discussion

Traumatic bladder injuries accounted for 0.14 % of all trauma admissions. This rate corresponds with the literature.1,2,3,4 Traumatic bladder injuries are rare.1,2,3 This incidence is comparable with reports from other centres.4 The rarity of traumatic bladder injuries in blunt trauma is because of the bladder’s location, which is protected by the pelvic bones.10

Motor vehicle collisions (MVC) account for most traumatic bladder injuries.1 MVC can cause pelvic fractures, which may directly damage the bladder.11 Excessive compression from seatbelts, especially when the bladder is distended, can also lead to traumatic bladder injuries.1,3,9 In our study group, blunt trauma causing bladder injury was statistically linked to pelvic fractures (p = 0.023).

Penetrating traumatic bladder injuries can be challenging to manage, especially gunshot wounds.12 Bullets have an unpredictable path in the bladder, making it difficult to pinpoint the exact location of the bladder injury. They can also be associated with other injuries.4,12 In our study, they were linked to rectal and small bowel injuries. This was statistically significant (p-value < 0.01 and 0.031) (see Table 2). Untreated injuries can lead to complications including sepsis, fistula and mortality.13

Computed tomography cystogram remains the gold standard diagnostic method for traumatic bladder injuries in both blunt and penetrating trauma.4,13 The patient must be haemodynamically stable in order to safely undergo the CT scan procedure. Most of our patients underwent a CT cystogram. The bladder is filled with 300 mL of contrast or until the patient feels bladder fullness at the end of the Porto venous phase, before the delay phase is undertaken.14 Only 12 % of patients were diagnosed intraoperatively; they were mainly patients with penetrating trauma. These patients were taken to the operating theatre for an acute abdomen, and no further investigations were warranted post-operatively.

Extraperitoneal traumatic bladder injuries are usually managed non-operatively.4 Urinary catheterisation and prophylactic antibiotics are sufficient. The catheter is kept in place for 7–10 days.4 In patients with associated pelvic fractures, catheters are kept longer because of delays in pelvic fracture fixation and mobilisation.15 Surgical repair is reserved for complicated cases. Surgical repair is usually considered for injuries involving the bladder neck, bone fragments within the bladder, rectal or vaginal lacerations and when non-operative management fails.1,16 Fifteen cases required repair of extraperitoneal traumatic bladder injuries, and these were complex injuries.

Intraperitoneal traumatic bladder injuries are usually treated with surgical repair.4 In cases of penetrating trauma, the bladder was incised at the dome (cystostomy).1,4 A cystostomy allows for the exploration to identify the inflicted injuries, which could then be repaired from inside using PDS or chromic gut sutures.1 The bladder dome is repaired and a catheter is placed or left in the bladder.1,4 All patients in our study group with intraperitoneal bladder repairs had a transurethral catheter inserted.

Traumatic bladder repairs can be performed in a single or double layer.17 In the era of laparoscopy, more bladders are repaired in a single layer.17 There are no data to favour one technique over the other. In the study, 47.5 % were repaired in two layers. Two specific senior surgeons performed the single-layer repairs, with similar outcomes. Historically, suprapubic catheters were left post-repair for patient comfort.18 The standard of care currently is to leave a transurethral catheter for 7–10 days.4 Suprapubic catheters are reserved for complex cases, complex traumatic bladder injuries or those who cannot be catheterised transurethrally.1,18 Only three patients in our study had suprapubic catheters inserted.

Routine cystograms after repair are reserved for patients with complex traumatic bladder injuries or extraperitoneal traumatic bladder injuries with pelvic fractures that orthopaedic surgeons wish to fixate anteriorly after 7–10 days post-injury.1 Bladder sepsis was linked to prolonged catheter use in those needing extended hospitalisation for fractures.15

There were very few mortalities and morbidities in our study group. This aligns with a previous study by Urry et al.1 The low complication rates might be explained by the presence of specialist general or trauma surgeons at the time of repair. When traumatic bladder injuries were complex, the urology team was contacted.

Conclusion

Bladder trauma in this South African cohort showed low complication and mortality rates despite complex injuries. Further multicentre LMIC studies examining penetrating bladder injuries with longer-term follow-up are needed to validate findings and guide guideline development.

Limitations

This study is limited by its retrospective single-centre design, dependence on record completeness and potential under-ascertainment of cases. The sample size restricted subgroup analysis and prevented robust multivariable modelling. Follow-up was limited to the initial admission, which hindered assessment of late complications. Generalisability to rural or non-specialist centres may be limited.

Acknowledgements

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. The author, Ahmed Adam, serves as an editorial board member of this journal. The peer review process for this submission was handled independently, and the author had no involvement in the editorial decision-making process for this article. The author has no other competing interests to declare.

Authors’ contributions

All authors contributed to the development, drafting and finalisation of this manuscript. Shumani Makhadi was responsible for writing, reviewing and editing. Camilla Ngobeni, Jessica Gerber, Micaela Colaco, Alisha Govender, Beauty Mahomane, Ann Varughese and Jabulani Lubisi conducted data collection and curation. Ahmed Adam and Maeyane S. Moeng were responsible for conceptualisation and supervision.

Funding information

The authors received no financial support for the research, authorship and/or publication of this article.

Data availability

The data supporting the findings of this study are available from the corresponding author, S.M., upon reasonable request.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References

  1. Reddy D, Laher AE, Moeng M, Adam A. Bladder trauma: A guideline of the guidelines. BJU Int. 2024;133(4):365–374. https://doi.org/10.1111/bju.16236
  2. Sahai A, Ali A, Barratt R, Belal M, et al. Section of female, neurological, urodynamic urology, British Association of Urological Surgeons. British Association of Urological Surgeons (BAUS) consensus document: Management of bladder and ureteric injury. BJU Int. 2021;128(5):539–547. https://doi.org/10.1111/bju.15404
  3. Lynch TH, Martínez-Piñeiro L, Plas E, et al. EAU guidelines on urological trauma. Eur Urol. 2005;47(1):1–15. https://doi.org/10.1016/j.eururo.2004.07.028
  4. Urry RJ, Clarke DL, Bruce JL, Laing GL. The incidence, spectrum and outcomes of traumatic traumatic bladder injuries within the Pietermaritzburg metropolitan trauma service. Injury. 2016;47(5):1057–1063. https://doi.org/10.1016/j.injury.2016.01.020
  5. Zaid UB, Bayne DB, Harris CR, Alwaal A, McAninch JW, Breyer BN. Penetrating trauma to the ureter, bladder, and urethra. Curr Trauma Rep. 2015;1(2):119–124. https://doi.org/10.1007/s40719-015-0015-x
  6. Guttmann I, Kerr HA. Blunt bladder injury. Clin Sports Med. 2013;32(2):239–246. https://doi.org/10.1016/j.csm.2012.12.006
  7. Bryk DJ, Zhao LC. Guideline of guidelines: A review of urological trauma guidelines. BJU Int. 2016;117(2):226–234. https://doi.org/10.1111/bju.13040
  8. Salako AA, Adisa AO, Eziyi AK, Banjo OO, Badmus TA. Traumatic urologic injuries in Ile-Ife, Nigeria. J Emerg Trauma Shock. 2010;3(4):311–313. https://doi.org/10.4103/0974-2700.70742
  9. Barnard J, Overholt T, Hajiran A, et al. Traumatic bladder ruptures: A ten-year review at a level 1 trauma center. Adv Urol. 2019;2019:2614586. https://doi.org/10.1155/2019/2614586
  10. Mundy AR, Andrich DE. Pelvic fracture-related injuries of the bladder neck and prostate: Their nature, cause and management. BJU Int. 2010;105(9):1302–1308. https://doi.org/10.1111/j.1464-410X.2009.08970.x
  11. Mahat Y, Leong JY, Chung PH. A contemporary review of adult bladder trauma. J Inj Violence Res. 2019;11(2):101–106. https://doi.org/10.5249/jivr.v11i2.1069
  12. Pereira BM, Reis LO, Calderan TR, De Campos CC, Fraga GP. Penetrating bladder trauma: A high risk factor for associated rectal injury. Adv Urol. 2014;2014:386280. https://doi.org/10.1155/2014/386280
  13. Deibert CM, Spencer BA. The association between operative repair of bladder injury and improved survival: Results from the National Trauma Data Bank. J Urol. 2011;186(1):151–155. https://doi.org/10.1016/j.juro.2011.03.002
  14. Fouladi DF, Shayesteh S, Fishman EK, Chu LC. Imaging of urinary bladder injury: The role of CT cystography. Emerg Radiol. 2020;27(1):87–95. https://doi.org/10.1007/s10140-019-01739-3
  15. Patel M, McGwin G, Spitler C. Longer time to surgery for pelvic ring injuries is associated with increased systemic complications. J Trauma Acute Care Surg. 2025;98(6):921–926. https://doi.org/10.1097/TA.0000000000004547
  16. Stern N, Pignanelli M, Welk B. The management of an extraperitoneal bladder injury associated with a pelvic fracture. Can Urol Assoc J. 2019;13(6 suppl4):S56–S60. https://doi.org/10.5489/cuaj.5930
  17. Malhadi S, Moeng MS, Govender TR, Lunga ZS. Laparoscopic repair of a delayed traumatic bladder injury. S Afr J Surg. 2021;59(2):67a–67b.
  18. Naser-Tavakolian A, Masterson JM, Dallmer J, et al. Simultaneous bladder drainage via suprapubic and urethral catheters: Which drains more completely and why?. J Surg Res (Houst). 2023;6(3):317–322. https://doi.org/10.26502/jsr.10020316


Crossref Citations

No related citations found.