Lower Tract Trauma

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

Bladder injury tips

Surgery tips

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