Current Evidence During childhood, the bladder has a higher abdominal location, which renders the organ more susceptible to injury than in adults The bladder can also be more easily damaged when full The risk for this injury is especially increased in the setting of improperly fastened seat belts and lap belts Bladder injuries are classified as extraperitoneal, intraperitoneal, or combined Extraperitoneal injuries are more frequently associated with pelvic fractures of the anterior ring and may be related to either laceration or penetration from a bone spike, irrespective of bladder volume at the time of injury In contrast, intraperitoneal injuries, which account for approximately two-thirds of major bladder injuries, are usually caused by blunt trauma, resulting in a burst mechanism to a full, distended bladder Combined injuries are usually seen with gunshot wounds Bladder injuries may range from contusions to rupture Contusions are incomplete, nonperforating tears of the mucosa Complicated injuries may involve the bladder, urethra, sacral plexus, and supporting structures of the anorectal region Bladder neck injuries are uncommon, but serious as this may affect continence or lead to extravasation into other areas such as the medial thigh Such injuries have been reported to be more common in children than in adults because of the undeveloped prostate and are often in association with a pelvic fracture The injury may be due to longitudinal lacerations or lacerations that extend to the proximal urethra Clinical Considerations Clinical Recognition Hematuria and dysuria are symptoms commonly seen at presentation Nearly 100% of patients with rupture of the bladder have gross hematuria Microscopic hematuria is associated with less severe injuries such as contusions Patients with intraperitoneal ruptures may develop a palpable fluid wave from extravasation of urine into the peritoneal cavity and peritoneal irritation with signs of peritonitis Elevated levels of blood urea nitrogen in the serum are out of proportion to creatinine resulting from more rapid peritoneal reabsorption of urea Patients with myelodysplasia who have undergone bladder augmentation may experience spontaneous bladder rupture in the presence of infection, bacteremia, or overdistension Suspicion must be high as they may lack the classic presentation seen in sensate patients Symptoms and signs of sepsis, as well as shoulder pain, may be encountered at presentation Emergent exploration is indicated after a cystogram is completed