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.

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.

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).

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 %).

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.

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).

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.

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).

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.

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.