NC.com

Bladder Trauma

	IF...	THEN...
Diagnosis	Pelvic fracture + gross hematuria	Retrograde cystography
	Penetrating injury to butt, pelvis, lower abdomen + any hematuria
Management	Intraperitoneal injury	Immediate surgical repair
	Pelvic fracture + bone fragments in bladder
	Simultaneous rectal/vaginal injury
	Bladder neck injury
	Laparotomy for non-bladder reasons
	Inadequate drainage or clots
	Penetrating trauma
	Extraperitoneal injury	Catheter x2-3 weeks (avoid exploration if possible to prevent severe bleeding)
	Prolonged catheterization required	Consider suprapubic tube placement
	Neurologic injuries
	Orthopedic injury + immobility
	Complex bladder closure

Iatrogenic endoscopic injury

Extraperitoneal perforation	Catheter drainage
Small intraperitoneal perforation without: Protruding abdominal contents Intraabdominal organ injury Poorly draining catheter Ileus/peritonitis	Catheter drainage + antibiotics
Large intraperitoneal perforation	Surgical repair
Small intraperitoneal perforation with above criteria
Extraperitoneal perforation failing to heal

Cystography tips

• Technique: fill w/ 300-350mL or to discomfort, do not fill passively with IV contrast
• XR Cystography: image at pre-fill, max fill, and after emptying, obtain 2-view images
• CT cystography: drainage films not required, dilute contrast 6:1 otherwise can create scatter artifact
• Findings: extraperitoneal injury with flame-shaped collection in pelvis, intraperitoneal injury with contrast outlining bowel loops

Bladder injury tips

• Hematuria: not always present (77-100%)
• Bladder rupture: > 90% will have gross hematuria, 0.6-5% will have microscopic hematuria only, seen with 29% patients with pelvic fracture + gross hematuria
• Pelvic fracture: seen in 83-95% bladder injuries, but bladder injury present in 5-10% pelvic fractures, suspect if circle displacement > 1cm, pubic symphysis diastasis > 1cm, or pubic rami fracture
• Unrecognized bladder injury signs: acidosis, azotemia, fever, sepsis, low UOP, peritonitis, ileus, ascites, respiratory distress, incontinence, fistula, stricture

Surgery tips

• Principles: place catheter, inspect bladder neck and ureteral orifices for injury, minimize debridement, close with absorbable suture, perform leak-test
• Simultaneous vaginal/rectal injury: place omental flap or other interposition to prevent fistula
• Catheter duration: obtain cystogram 10-21 days after surgery to assess for leak

Urethral Trauma

	IF...	THEN...
Diagnosis	Blood at meatus	Immediate retrograde urethrogram Do not place catheter before RUG
	Pelvic fracture
	Bladder rupture
	Genital/perineal hematoma
	Penile fracture
	High-riding prostate
	Penetrating penile injury
	Distended bladder
Management	Partial urethral disruption	Attempt catheter placement once Then place SPT
	Penetrating anterior injury	Consider immediate repair if able Delay if unstable, extensive tissue loss, or lack of experience
	Pelvic fracture + urethral injury	Place SPT (preferred options) Primary repair if rectal/bladder neck injury present
	Straddle injury	Place urethral or SP catheter
	Penile fracture with urethral injury	Immediate repair

Retrograde urethrogram instructions

1. Bottom leg flexed, top leg straight, oblique angle
2. Small catheter placed in meatus (12Fr)
3. Gentle traction, inject 20mL undiluted contrast
4. If catheter already placed, use 3Fr catheter next to indwelling catheter

Urethral injury tips

• Pelvic orthopedic repair: NOT a contraindication to SPT placement
• Delayed repair: perform 2-3mo after injury (stable scar tissue), evaluate with simultaneous urethrogram and VCUG
• Primary realignment: high risk for stenosis, place and maintain SPT, can remove 1-2 weeks later
• Endoscopic stricture management: rarely successful
• Long term management: monitor for ED (50-82%), strictures (5-15%), incontinence (< 4%) for at least 1yr after injury