How to Repair Bladder Injury During Cesarean Section?

The Caesarean section ranks amongst the most frequently performed surgical procedures worldwide. Approximately one in every four births in the UK are by C-Section, and that rate has been rising year on year for the past few decades. With its rise has come an inevitable increase in the complications associated with abdominal surgery and one that has been frequently discussed by Obstetricians is bladder injury.

Bladder injury during caesarean section is rare. It is however the most common urological complication of pelvic surgery. Knowing how it occurs, how it is recognised and how repair of CES Bladder injuries are performed can allow clinicians and patients to go into the procedure informed.

How Common Is Bladder Injury During a C-Section?

Exact figures differ slightly study to study, but overall the data is relatively uniform. Bladder injury occurs in about 0.2% of primary (first time) caesarean deliveries and in 0.6% of repeat caesarean deliveries. Multiparity, with multiple previous C-sections, becomes more difficult anatomy due to adhesions and scar tissue.

To provide some reference, one retrospective review reviewing 7,708 caesarean deliveries over 25 years found 34 cases of bladder injury (an incidence of 0.44%). 58.8% of those injuries occurred during repeat caesareans with prior abdominal adhesions from previous surgeries being present in every case. All bladder injuries were identified and repaired intraoperatively with successful outcomes.

In patients with placenta accreta spectrum (PAS) conditions, where the placenta embeds too deeply into the uterine wall, risk of bladder injury increases significantly to approximately 11.7%.

Read More: Caesarean Section Necessary

Why the Bladder Is at Risk

The bladder sits directly in front of the uterus, separated only by a thin layer of peritoneum. During a caesarean, surgeons work in a tight anatomical space, and the bladder's position means it is always in the field of view and in the field of risk.

Here is why injuries happen in certain situations more than others:

• Previous caesarean sections leave scar tissue that can cause the bladder to adhere firmly to the lower uterine segment, sometimes sitting much higher than normal

• Emergency C-sections performed under time pressure (for placental abruption or fetal bradycardia, for example) mean less careful dissection of each surgical plane

• Prolonged or obstructed labour can distort normal anatomy, pulling the bladder out of its expected position

• Intra-abdominal adhesions from previous pelvic surgeries, endometriosis, or pelvic inflammatory disease all increase surgical complexity

• Placenta accreta spectrum is one of the strongest risk factors, as the placenta may directly invade bladder tissue

The most frequent phase of injury is creation of the bladder flap or bladder displacement downwards to reach the lower uterine segment. Approximately 43% of bladder injuries occur during this phase. Entry into the peritoneal cavity is the phase during which another 33% of injuries occur. 24% occur at uterine incision or during delivery of the baby.

Where Does the Injury Usually Occur?

Location is huge with regard to both injury severity and repair. Upwards of 95% of bladder injuries at C-section occur at the dome (upper, rounded area) of the bladder. That's good news because the dome is very far away from the trigone (the sensitive base of the bladder where the ureters connect and the urethra exits). The trigone usually sits well over 6cm and often over 10cm away from the injury.

Repairing a dome injury should be well within an experienced obstetrician's capability. Repairing a trigone injury is much more complicated and generally calls for a urologist/urogynecologist.

Bladder injuries are graded by severity:

• Grade 1: Contusion or partial thickness laceration (no full tear)

• Grade 2: Extraperitoneal wall laceration under 2 cm

• Grade 3: Extraperitoneal laceration over 2 cm, or intraperitoneal under 2 cm

• Grade 4: Intraperitoneal laceration over 2 cm

• Grade 5: Any laceration involving the trigone or bladder neck

Grade 5 injuries require specialist urological involvement immediately.

Recognising a Bladder Injury Intraoperatively

Spotting a bladder injury during the operation rather than after is the single most important factor in a good outcome. Injuries repaired at the time of surgery carry a high likelihood of returning to normal urological function. Delayed recognition, on the other hand, can lead to serious complications including urinary fistula, peritonitis, sepsis, and prolonged hospitalisation.

The warning signs during surgery include:

• Visible hole or laceration in the bladder wall

• Urine in the operative field

• The Foley catheter balloon visible through a tear

• Blood in the catheter bag (haematuria)

• Detrusor muscle disruption

If injury is suspected but not immediately visible, the surgeon can perform retrograde bladder filling injecting saline through the Foley catheter to check for leakage into the peritoneal cavity. This is a simple and reliable test.

Haematuria is present in around 95% of intraoperative bladder injury cases and should always prompt the surgical team to investigate further.

How Is Cesarean Bladder Injury Repair Carried Out?

Here is the step-by-step process for repairing a bladder dome injury, which is the most common scenario:

Step 1: Confirm the Extent of Injury

Before attempting repair, the surgeon must clearly identify how large the tear is and whether it is confined to the dome. If the injury is near the posterior wall, the trigone could be involved, and specialist input should be sought before proceeding.

Step 2: Verify Ureteral Integrity

For large or posteriorly located injuries, the surgeon should check that the ureters are unaffected. The standard method is an intravenous injection of 5 mL of indigo carmine dye a blue dye that, if both ureters are intact, will appear flowing from both ureteral orifices within a few minutes. If cystoscopy is available, this provides direct visualisation. In its absence, a hysteroscope can be used as an alternative.

Step 3: Two-Layer Closure with Absorbable Suture

The repair itself is a two-layer closure using absorbable sutures. Non-absorbable sutures must never be used inside the bladder, as they can act as a focus for bladder stone formation over time.

• First layer: Closed with a simple running 3-0 absorbable suture (such as polyglycolic acid / Vicryl), approximating the bladder mucosa

• Second layer: Closed with a running imbricating 2-0 or 3-0 absorbable suture to reinforce the muscular wall

The repair is then tested by backfilling the bladder with sterile saline or diluted methylene blue through the Foley catheter to confirm there is no remaining leak.

Step 4: Drain Placement (If Needed)

After complex repairs, an intraperitoneal drain may be placed to monitor for any urine extravasation and remove accumulated fluid from the peritoneal cavity. This is not always necessary for straightforward dome repairs.

Step 5: Foley Catheter Drainage Postoperatively

After repair, continuous bladder drainage via Foley catheter is maintained. For simple dome repairs, most experts recommend at least 7 days of catheterisation. For more complex injuries, published guidance recommends 10 to 14 days, sometimes using a dual-catheter system (transurethral and suprapubic). Before catheter removal, a voiding cystogram is often performed to confirm the repair has healed completely.

Trigone and Ureteral Injuries: A Different Approach

Not all bladder injuries are straightforward. If the injury involves the trigone or if ureteral damage is suspected, a urologist or urogynecologist should be called in without delay. These injuries are considerably more complex and carry a higher risk of long-term complications including uretero-vaginal fistula, vesicovaginal fistula, and chronic urinary dysfunction.

An open surgical approach is generally preferred for bladder trauma associated with obstetric operations because these tears tend to be larger and are often accompanied by haematoma and, in some cases, concomitant ureteral involvement.

What Happens If a Bladder Injury Is Missed?

This is where outcomes diverge sharply. A bladder injury spotted and repaired during surgery carries an excellent prognosis. One missed intraoperatively can result in the following in the days after delivery:

• Abdominal pain and distension

• Oliguria (reduced urine output) or haematuria

• Signs of peritonitis, ileus, or sepsis

• Raised blood urea and creatinine

CT urography and retrograde cystography are the imaging tools of choice when delayed bladder injury is suspected postoperatively. Diagnostic laparotomy should always be considered if intraperitoneal rupture is clinically suspected, even if initial imaging is equivocal.

The lesson is straightforward: when in doubt during surgery, stop and look. The extra time spent checking is far less costly than the complications of a missed injury.

Preventing Bladder Injury During Caesarean

Prevention begins with preparation. Here are the steps surgeons take in high-risk cases:

• Sharp dissection over blunt dissection when separating an adherent bladder from the uterus gauze blunt dissection can avulse bladder tissue in the presence of dense adhesions

• Retrograde bladder filling with 200 mL of saline before the incision in placenta accreta spectrum cases, to make the bladder wall more visible and turgid

• Entering the peritoneal cavity at its most superior point to avoid the bladder during initial access

• Careful checking of surrounding viscera before each incision peritoneal, uterine, and fascial

• Thorough preoperative counselling for women having repeat caesareans, so they understand the elevated risk and consent is properly informed

  
  

Recovery After Bladder Repair: What to Expect

Women who experience a cesarean bladder injury repair typically have longer hospital stays and recoveries when compared to women who have uncomplicated C-sections. The catheter will stay in place for at least one week. Repeat urine cultures during that week are recommended to identify urinary tract infection early, as the risk of infection increases the longer a catheter is in place.

Once the catheter is removed, patients should watch for:

• Difficulty or pain when urinating

• Urinary leakage or incontinence

• Fever or lower abdominal pain

• Blood in the urine

If you experience any of these symptoms, it’s important to seek review as soon as possible. Women who visit myGynaePlus (a clinic providing specialist obstetric & gynaecological services in London as well as postnatal care), can receive appropriate follow-up care to ensure they are healing well and any urinary symptoms are managed.

The long-term prognosis after a dome rupture that has been repaired properly is usually excellent. Normal urinary function will return to most women if the rupture is recognised and repaired at the time of surgery. The outlook is more uncertain if diagnosis is delayed.

A Note for Women Preparing for a Repeat C-Section

Should you be scheduling or anticipating another caesarean particularly your third or fourth caesarean it pays to have an honest discussion with your obstetrician prior to surgery. Inquire about the likelihood of adhesions, how they manage complex dissections and what contingencies are in place should something go awry. Asking questions and being informed does not increase risk, it just ensures you are educated about what may happen.

Our teams at myGynaePlus Women's Health Clinics take the time to discuss these risks with patients pre-operatively, not to scare you, but so you can make truly informed decisions.

FAQs

1. How do surgeons know if the bladder has been injured during a C-section? 

The most obvious sign is visible urine in the operative field or a tear in the bladder wall. If injury is suspected but not clearly visible, surgeons fill the bladder with saline through the Foley catheter and look for fluid leaking into the surgical site. Haematuria blood in the catheter bag is present in roughly 95% of cases and is a key warning sign.

2. Can a bladder injury during a C-section be repaired at the same time? 

Yes, and this is the preferred approach. When the injury is spotted during the operation, the surgeon repairs it immediately using a two-layer absorbable suture technique. Intraoperative repair carries a much better outcome than delayed repair, which is associated with serious complications including fistula and infection.

3. How long does a catheter stay in after bladder repair during caesarean? 

After a straightforward dome repair, most guidelines recommend Foley catheter drainage for at least 7 days. For more complex injuries involving the trigone or larger lacerations, this can extend to 10 to 14 days. A voiding cystogram is typically done before the catheter is removed to confirm the repair has healed.

4. What are the long-term complications of a missed bladder injury after C-section? 

If a bladder injury is not caught during surgery, it can lead to peritonitis, intra-abdominal abscess, sepsis, and the formation of fistulas abnormal connections between the bladder and either the uterus (vesicouterine fistula) or the vagina (vesicovaginal fistula). These are significantly harder to treat than injuries repaired at the time of surgery.

5. Does having a previous C-section increase my risk of bladder injury in a future caesarean? 

Yes, notably. The risk of bladder injury in a primary (first) C-section is around 0.2%, but this rises to approximately 0.6% in repeat caesarean deliveries. Each subsequent caesarean increases the likelihood of adhesions forming between the bladder and uterus, making careful dissection more difficult. Women planning a repeat C-section should discuss this risk with their obstetric team well in advance. myGynaePlus offers obstetric consultations where these conversations can happen in detail.