Case Report: Rare Bladder Injury During Cesarean Section

Document Type : Case Report


1 Department of Urology, Tehran University of Medical Sciences, Tehran, Iran

2 Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran

3 Department of Urology, Mashhad University of Medical Sciences, Mashhad, Iran


Bladder injury is an urgent emergency case requiring urgent treatment in order to restore the normal function of the urinary system.
Case presentation
Here we present a 38-year-old woman with a history of primary infertility with a twin pregnancy following in vitro fertilization (IVF). Because of the high adhesion, the anterior wall of the bladder cut transversely instead of the anterior wall of the uterus. In this case of twin cesarean section, the anterior wall, posterior wall, and uterine wall were opened. The twins were removed from the bladder by two incisions and then the posterior and anterior wall of the bladder were repaired by an expert urologist as well as the uterus followed by medication by anticholinergic and antibiotics. This case report emphasizes the essential roles of bladder emergency repair in restoring the normal function of the urinary system.
Bladder injury is the most common complication during gyneco-genital surgery. Most of this damage is intraperitoneal that needs repair during the surgery and prolonged bladder catheterization.


  • Bladder injury is an urgent emergency that requires urgent treatment.
  • Cesarean section can injure bladder but it should be diagnosed as the case of emergency and repair is needed.
  • This 38-year-old woman with a history of primary infertility had rare bladder injury during cesarean section.


Main Subjects


Intraoperative surgical complications during cesarean section include injury to bladder urinary tract bowel or uterus and cervix are reported up to 12% in several studies (1). Despite an increasing number of cesarean sections, lower urinary tract injuries remained relatively uncommon (0.3 % of all cesarean sections) (2). The bladder is the most common organ that is injured during gyneco- genital surgeries.

Compared to other surgical subspecies, urology emergencies are limited. During blunt trauma in retroperitoneal rupture of the bladder, surgery is usually not required and only one foley catheter is sufficient. In cases of peritoneal rupture of the bladder, the patient must undergo surgery and repair of the bladder.


Case presentation

A 38-year-old woman with a history of primary infertility for about seven years was referred to the hospital for a cesarean section. The informed consent was signed by the patient and her case was reported based on CARE guidelines.

She had a history of extensive intra-abdominal manipulation undergoing in vitro fertilization (IVF) and finally had twin pregnancies followed by IVF. In her last trimester, she had obstructive urinary symptoms during urination including urinary incontinence, decreased urinary force, and a feeling of incomplete emptying of the bladder after urination. In sonography performed during pregnancy, an increase in bladder wall thickness, and compressive effects of the fetal head and uterus on the bladder neck were evident. According to the gynecologist's diagnosis, the patient was the candidate for a cesarean section. Due to the high adhesion, the diagnosis of uterine tissue at the beginning of the operation was not performed correctly and the anterior wall of the bladder was cut transversely instead of the anterior wall of the uterus. Even after opening the bladder, the gynecology resident cuts the posterior wall of the bladder and through a recent incision, a transverse incision is made in the wall of the uterus, and both embryos are removed from the posterior and anterior incisions of the bladder. During uterine wall restoration, the gynecologist realizes a medical fault and wanted an expert urologist to repair the bladder. On initial exploration by the urologist, the anterior wall of the bladder had a sharp incision.  However, the posterior wall of the bladder was severely injured by a cruciate ligament rupture in the posterior wall of the bladder and the bladder wall ruptured toward the left bladder wall 2 mm to left ureteral meatus. The double j 4.8 F, and 28 cm on the ureter placed on both sides. The double J easily passed to the kidney, and urine could be seen coming out of the double j holes. After making sure that the ureters on both sides are not damaged, they firstly separate the uterus and the posterior wall of the bladder to separate the incision site of the uterine wall and the bladder. Then, the posterior wall of the bladder is repaired in two layers with Vicryl thread 0-2. The uterine wall is then sutured. The peritoneum and a part of the momentum are located between the bladder wall and the back of the uterus. The anterior wall of the bladder is then repaired with a 0-2 vicryl thread in two layers. The 20F foil is fixed and the bladder is filled with 250cc normal saline. After making sure, that there is no liquid leak from the restorative areas, two drains are installed and then the abdominal wall is closed. The patient was transferred to the intensive care unit (ICU) and carefully monitored for urinary and drains and laboratory tests. During the 3 days and in the absence of fluid secretions inside the drains, the patient was discharged with a foil catheter and oral antibiotics, and anticholinergic. Double j removed 2 weeks after the operation. Evidence for cystoscopy did not support Fistula. Again, the foil 20F catheter was implanted for the patient and the patient was discharged. Ten days later, the patient underwent a cystography that had no evidence in favor of the Fistula, followed by Foley. After Foley's departure, the patient's urination was normal. One month after Foley's departure, the patient re-visited, where the urination was normal and there was no abnormal vesicoureteral fistula, a bladder-uterus.



Complications of gynecological and obstetric surgeries are the most important causes of bladder injury during open surgery (3). In these surgeries, urological damage is the most common complication, and in these cases, bladder injury is more common than other cases. In some countries, due to the higher number of cesarean sections than other gynecological and obstetric surgeries, this surgery is one of the most common causes of bladder damage. Despite the increase in the number of cesarean sections, bladder and lower urinary tract injury during cesarean section are uncommon, and this complication accounts for only 0.3 to 0.47% of all cesarean sections (2, 4, 5). The most common site of bladder injury during cesarean section is the bladder dome, in 60% of cases (4). Risk factors for bladder injury during cesarean section include previous history of cesarean section, adhesions, emergency cesarean section, and cesarean section in the second stage of labor; attempt to give birth vaginally after cesarean section, concomitant uterine rupture, maternal seniority, low body mass index (5, 6). The previous history of cesarean section is the highest adjusted risk for bladder trauma during cesarean section (3/82) (5-7). There was no difference in bladder injury during cesarean section in chorioamnionitis, labor induction, maternal gestational age, gestational, Fetal position (5-7). Fortunately, most bladder injuries are diagnosed during surgery. In a small number of cases, these complications were identified following postoperative gross hematuria. This early detection and repair are accompanied by a more noticeable reduction in morbidity and mortality (6). However, ureteral injuries are usually diagnosed late (8). Prognosis in bladder damage alone is good during cesarean section, and in cases of simultaneous bladder and ureter injury, the patient's prognosis will not be good (4, 9). One of the factors contributing to bladder damage during cesarean section is that the bladder is not completely emptied before surgery (10). Ureteral trauma during bladder injury during cesarean section is a rare complication and is usually in the form of complete transaction or ligation of the ureter during uterine resection extension or attempt to hemostasis during massive bleeding (9). Bladder damage during a cesarean section usually occurs when the peritoneum cavity opens and the bladder separates from the lower uterine segment. For avoiding bladder injury during cesarean section include skills of female surgeons, surgery in elective conditions, and proper emptying of the bladder before surgery (7, 11). After diagnosis, treatment involves repairing the bladder wall in two layers with absorbable floss, as well as implanting a Foley catheter and using anticholinergics at the same time. Cystography is the best procedure before the catheter is removed to examine the urine leak (3, 6, 7).     



Delayed diagnosis or treatment of bladder injuries is associated with complications. There are a number of factors that can prevent bladder damage during a cesarean section, including the skills of gynecologists, surgery in elective conditions, and proper emptying of the bladder before surgery. After diagnosing the treatment and repairing the bladder wall, a cystography is appropriate to examine the urine leakage.


Authors’ contributions

AT was responsible of study conception and design, AM wrote the manuscript and provided data,

MA supervised the process and edited the manuscript. All authors reviewed the results and approved the final version of the manuscript.



Special thanks to the Department of Urology, Mashhad University of Medical Sciences, Mashhad, Iran.


Conflict of interest

All authors declare that there are no conflicts of interest regarding the publication of this manuscript.



The authors received no financial support for this research.


Ethical statement

This manuscript is based on the CARE guidelines and informed consent was signed by the patient.


Data availability

Data will be provided by the corresponding author on request.



ICU    Intensive care unit

IVF    In vitro fertilization


1. Grivell RM, Dodd JM. Short-and long-term outcomes after cesarean section. Expert Review of Obstetrics & Gynecology. 2011;6(2):205-15.
2. Oliphant SS, Bochenska K, Tolge ME, Catov JM, Zyczynski HM. Maternal lower urinary tract injury at the time of Cesarean delivery. International urogynecology journal. 2014;25(12):1709-14.
3. Partin AW, Wein AJ, Kavoussi LR, Peters CA, Dmochowski RR. Campbell Walsh Wein Urology, E-Book: Elsevier Health Sciences; 2020.
4. Salman L, Aharony S, Shmueli A, Wiznitzer A, Chen R, Gabbay-Benziv R. Urinary bladder injury during cesarean delivery: maternal outcome from a contemporary large case series. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2017;213:26-30.
5. Phipps MG, Watabe B, Clemons JL, Weitzen S, Myers DL. Risk factors for bladder injury during cesarean delivery. Obstetrics & Gynecology. 2005;105(1):156-60.
6. M Tarney C. Bladder injury during cesarean delivery. Current women's health reviews. 2013;9(2):70-6.
7. Rahman M, Gasem T, Al SuleimanS, Al Jama FE, Burshaid S, Rahman J. Bladder injuries during cesarean section in a University Hospital: a 25-year review. Archives of gynecology and obstetrics. 2009;279(3):349-52.
8. Rajasekar D, Hall M. Urinary tract injuries during obstetric intervention. BJOG: An International Journal of Obstetrics & Gynaecology. 1997;104(6):731-4.
9. Eisenkop SM, Richman R, Platt LD, Paul RH. Urinary tract injury during cesarean section. Obstetrics and gynecology. 1982;60(5):591-6.
10. Faricy PO, Augspurger RR, Kaufman JM. Bladder injuries associated with cesarean section. The Journal of urology. 1978;120(6):762-3.
11. Alcocer JU, Bonilla MM, Gorbea VC, Velázquez BV. Risk factors for bladder injuries during cesarean section. Actas urologicas espanolas. 2009;33(7):806-10.