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Lower Urinary Tract Injury and Pelvic Trauma
1
What are the causes of bladder injury?
Bladder injury can be caused by trauma or iatrogenic manipulation. Traumatic bladder injuries can be classified as intraperitoneal or extraperitoneal, blunt or penetrating. The most common sign of bladder injury is gross hematuria. Other signs of bladder injury are pelvic pain, inability to void, or incomplete recovery of catheter irrigation.
2
What types of bladder injury may occur with blunt trauma?
Blunt trauma to the bladder can cause bladder contusion or intraperitoneal or extraperitoneal bladder rupture. Gross hematuria with normal cystography in the absence of upper tract injuries defines bladder contusion. Extraperitoneal injury is the most common bladder injury. Usually it is located at the bladder base. Extraperitoneal injuries can be managed conservatively with bladder drainage with a Foley catheter for 7–10 days. Intraperitoneal bladder ruptures usually occur at the bladder dome, caused by a blunt trauma in a distended bladder. These lesions should be repaired surgically using a two-layer closure with absorbable suture and bladder drainage with a Foley catheter for 7–10 days. Before removing the Foley catheter, a computerized axial tomography (CAT) cystogram should be performed to confirm proper bladder healing.
3
What is the likelihood of a bladder injury in patients with a fractured pelvis?
Extraperitoneal bladder injury occurs in 10% of all pelvic fractures. Conversely, approximately 85% of blunt bladder injury is associated with pelvic fracture. Bladder injuries occur more often with parasymphyseal pubic arch fractures and more often with bilateral than unilateral fractures. Isolated ramus fractures produce bladder laceration in 10% of cases.
4
How is bladder injury evaluated?
CAT cystography provides diagnostic accuracy when performed with the bladder filled with 300–400 mL of 50% diluted contrast agent using the Foley catheter under gravity. If CAT scan is not available, voiding cystogram should be performed with postvoid images.
5
What are the retrograde cystourethrographic patterns of bladder injury?
Bladder contusion has a normal cystography in the presence of gross hematuria and absence of upper urinary tract injury. In the extraperitoneal bladder rupture, contrast is seen adjacent and confined to the bladder base. In intraperitoneal bladder rupture, the contrast extravasation is seen at the dome of the bladder, usually delineating bowel loops, or collected in the gutters.
6
How is bladder rupture managed?
Bladder contusion requires drainage until gross hematuria is resolved. Extraperitoneal rupture can be managed conservatively with indwelling catheter for 7–10 days. If laparotomy is performed, bladder injury can be repaired. Intraperitoneal bladder injuries should be managed surgically. In selected cases, laparoscopic repair can be performed. Cystography should be performed to confirm resolution of extravasation before removing the catheter (approximately 14 days after injury and drainage).
7
When should you suspect urethral injury?
The presence of blood in the urethral meatus associated with trauma mechanism (straddle injury, trauma to the genitals, pelvic fracture). Penile, scrotal swelling and ecchymosis, inability to void, and inability to pass a urethral catheter should be investigated for urethral injury. In males, digital rectal exam can reveal total disruption of the urethra when the prostate is not palpable. In females, urethral disruption results from severe mechanism of injury, and it is associated with high mortality.
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