Editing Lower Urinary Tract Trauma (section)

== Bladder Injury ==

=== Background ===

* '''<span style="color:#ff0000">Bladder rupture can be classified as intraperitoneal (into the peritoneal cavity) vs. extraperitoneal (outside the peritoneal cavity)</span>'''

* '''<span style="color:#ff0000">Bladder injuries are:</span>'''
** '''<span style="color:#ff0000">Extraperitoneal in ≈60%</span>'''
** '''<span style="color:#ff0000">Intraperitoneal in ≈30%</span>'''
** '''<span style="color:#ff0000">Both intraperitoneal and extraperitoneal in ≈10%</span>'''
* '''<span style="color:#ff0000">Extraperitoneal bladder injury</span>'''
** '''<span style="color:#ff0000">Usually associated with pelvic fracture</span>'''
* '''<span style="color:#ff0000">Intraperitoneal bladder injury</span>'''
** '''Can be associated with pelvic fracture but are <span style="color:#ff0000">more commonly due to penetrating injuries or burst injuries at the dome by direct blow to a full bladder.</span>'''
=== Pathogenesis ===
* '''<span style="color:#ff0000">Penetrating trauma</span>'''
** '''Bladder is generally protected from external trauma because of its deep location in the bony pelvis'''
* '''<span style="color:#ff0000">Blunt trauma</span>'''
** Most blunt bladder injuries are the result of rapid-deceleration motor vehicle collisions, but many also occur with falls, crush injuries, assault, and blows to the lower abdomen
** '''<span style="color:#ff0000">Bladder injuries that occur with blunt trauma are rarely isolated injuries</span>'''
*** '''<span style="color:#ff0000">Most common associated injury is pelvic fracture</span>, but pelvic fracture is not often associated with bladder injury'''
**** 83-95% of bladder injuries are associated with pelvic fractures
**** 5-10% of pelvic fractures are associated with bladder injury
* '''Iatrogenic'''
** '''Obstetric and gynecologic complications are the most common causes of bladder injuries during open surgery'''

=== Grading ===
* [https://www.aast.org/resources-detail/injury-scoring-scale#bladder AAST Bladder Injury Scale:]
**Grade I
*** Contusion, intramural hematoma
*** Partial thickness laceration
** Grade II
*** Extraperitoneal bladder wall laceration <2 cm
** Grade III
*** Extraperitoneal (>2cm) or intraperitoneal (<2cm) bladder wall laceration
** Grade IV
*** Intraperitoneal bladder wall laceration >2cm
** Grade V
*** Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral orifice (trigone)
** *Advance one grade for multiple lesions up to grade III

=== Diagnosis and Evaluation ===

==== History and Physical Exam ====

===== Physical Exam =====
* '''<span style="color:#ff0000">Indicators of potential bladder rupture (12):</span>'''
*# '''<span style="color:#ff0000">Gross hematuria'''
*#* '''<span style="color:#ff0000">Most common indicator of bladder injury</span>'''
*#* A limited number of pelvic fracture patients with bladder injuries will present with microscopic hematuria
*# '''<span style="color:#ff0000">Lower abdominal bruising</span>'''
*# '''<span style="color:#ff0000">Abdominal distention</span>'''
*# '''<span style="color:#ff0000">Suprapubic pain</span>'''
*# '''<span style="color:#ff0000">Muscle guarding and rigidity</span>'''
*# '''<span style="color:#ff0000">Inability to void</span>'''
*# '''<span style="color:#ff0000">Low urine output</span>'''
*# '''<span style="color:#ff0000">Diminished bowel sounds</span>'''
*# '''<span style="color:#ff0000">Pubic symphysis diastasis</span>'''
*# '''<span style="color:#ff0000">Obturator ring fracture displacement >1 cm</span>'''
*# '''<span style="color:#ff0000">Increased creatinine</span> and BUN''' (secondary to peritoneal absorption of urine)
*# '''<span style="color:#ff0000">Intraperitoneal low density free fluid on abdominal imaging</span> (urinary ascites)'''

==== Imaging ====
* '''<span style="color:#ff0000">Indications for cystography in stable patients</span>'''
** '''<span style="color:#ff0000">2020 AUA Guidelines</span>'''
*** '''<span style="color:#ff0000">Absolute (1):</span>'''
***# '''<span style="color:#ff0000">Gross hematuria and pelvic fracture</span>'''
*** '''<span style="color:#ff0000">Relative (2):</span>'''
***# '''<span style="color:#ff0000">Gross hematuria and a mechanism concerning for bladder injury</span>'''
***# '''<span style="color:#ff0000">Pelvic ring fractures and clinical indicators (see above) of bladder rupture</span>'''
***#* '''The vast majority of bladder injuries are associated with pelvic fractures because the bladder is well protected within the pelvis, however, <span style="color:#ff0000">pelvic fracture alone does not warrant radiologic evaluation of the bladder</span>'''
** '''Campbell's 11th edition'''
*** '''Absolute (2):'''
***# '''Gross hematuria with pelvic fracture'''
***# '''Penetrating injuries with any degree of hematuria'''
*** '''Relative (2):'''
***# '''Blunt trauma with gross hematuria without pelvic fracture'''
***# '''Microscopic hematuria with pelvic fracture'''
* '''<span style="color:#ff0000">Modality: retrograde cystography (CT or plain film)</span>'''
** '''<span style="color:#ff0000">Critical as it can determine the presence of an injury and whether it is intraperitoneal or extraperitoneal.</span>'''
** '''Plain film and CT cystography have similar specificity and sensitivity, and are both highly accurate for the diagnosis of bladder rupture'''
** '''<span style="color:#ff0000">Technique</span>'''
*** '''<span style="color:#ff0000">The bladder should be filled in cooperative and conscious patients to a sense of discomfort and otherwise to 300-350 mL</span>'''
**** '''False-negative studies have been reported with retrograde instillation of only 250 mL.'''
**** '''In CT cystography, dilution of the contrast (1:6) is mandatory''' because undiluted contrast is so dense that the CT quality is compromised by scatter artifact.
**** Clamping a Foley catheter to allow excreted IV-administered contrast to accumulate in the bladder is not appropriate.
*** '''<span style="color:#ff0000">With plain film cystography, a minimum of 2 views are required, the first at maximal fill and the second after bladder drainage.</span>'''
*** '''Drainage films are not required after CT cystography''' because the retrovesical space can be well visualized with axial images.
** '''<span style="color:#ff0000">Cystography will demonstrate:</span>'''
*** '''<span style="color:#ff0000">Extraperitoneal extravasation: dense, flame-shaped collection of contrast material in the pelvis</span>'''
**** See [https://radiopaedia.org/cases/bladder-rupture-5 Figure]
**** See [https://radiopaedia.org/cases/extraperitoneal-bladder-rupture-4 Case]
*** '''<span style="color:#ff0000">Intraperitoneal extravasation: contrast material outlines loops of bowel and/or the lower lateral portion of the peritoneal cavity</span>'''
**** See [https://radiopaedia.org/cases/intra-peritoneal-bladder-rupture Figures]
*** '''The amount of extravasation is not always proportional to the extent of bladder injury.'''

=== Management ===
* '''<span style="color:#ff0000">If blood is noted at the meatus or the catheter does not pass easily, retrograde urethrography should be performed first because urethral injuries occur concomitantly in 10-30% of patients with bladder rupture</span>'''
* '''<span style="color:#ff0000">Based on extraperitoneal vs. intraperitoneal</span>'''
** '''<span style="color:#ff0000">Uncomplicated extraperitoneal bladder ruptures: large-bore (22-Fr) Foley catheter left in place 2-3 weeks</span>'''
*** In the setting of significant concurrent injuries, it is acceptable to leave the catheter in longer.
*** Campbell’s 11th edition: if a pelvic hematoma is present, antimicrobial agents are started on the day of injury and continued for at least 1 week to prevent infection of the hematoma
*** '''<span style="color:#ff0000">Consideration for open repair may be appropriate in those patients with non-healing bladder injuries who are unresponsive to Foley catheter drainage >4 weeks.</span>'''
*** '''<span style="color:#ff0000">Follow-up cystography</span>'''
**** '''<span style="color:#ff0000">Should be done</span>''' to confirm that the injury has healed with catheter drainage
** '''<span style="color:#ff0000">Intraperitoneal bladder rupture: prompt surgical repair</span>'''
*** '''Failure to repair intraperitoneal bladder injuries can result in''' '''peritonitis''' (from translocation of bacteria from the bladder to the abdominal cavity)''', sepsis''', and other serious complications
*** Repair may need to be delayed in the unstable patient
*** Campbell’s 11th edition: in patients with intraperitoneal rupture, antimicrobial agents are administered for 3 days in the perioperative period only
*** '''<span style="color:#ff0000">Follow-up cystography</span>'''
**** '''<span style="color:#ff0000">Should be done 7-10 days after surgery in complex repairs</span>'''
**** '''<span style="color:#ff0000">May not be necessary in more simple repairs</span>'''
* '''<span style="color:#ff0000">Indications for immediate surgical repair of bladder</span>'''
** '''<span style="color:#ff0000">2020 AUA Guidelines(7)</span>[https://pubmed.ncbi.nlm.nih.gov/33053308/ §]: <span style="color:#0000ff">I</span><span style="color:#ff0000">mmediate </span><span style="color:#0000ff">B<span style="color:#ff0000">ladder </span><span style="color:#0000ff">R</span><span style="color:#ff0000">epair <span style="color:#0000ff">NOVA</span>'''
**# '''<span style="color:#0000ff">I</span><span style="color:#ff0000">ntraperitoneal bladder rupture</span>'''
**# '''<span style="color:#ff0000">Exposed </span><span style="color:#0000ff">B</span><span style="color:#ff0000">one spicules in the bladder lumen</span>'''
**# '''<span style="color:#ff0000">Concurrent </span><span style="color:#0000ff">R</span><span style="color:#ff0000">ectal injury</span>'''; may lead to fistula formation to the ruptured bladder
**# '''<span style="color:#ff0000">Bladder </span><span style="color:#0000ff">N</span><span style="color:#ff0000">eck injuries</span>'''; may not heal with catheter drainage alone and repair should be considered
**# '''<span style="color:#ff0000">Patient undergoing </span><span style="color:#0000ff">O</span><span style="color:#ff0000">pen reduction internal fixation</span>'''; to reduce risk of infection to hardware)
**# '''<span style="color:#ff0000">Concurrent <span style="color:#0000ff">V</span><span style="color:#ff0000">aginal injury</span>'''; may lead to fistula formation to the ruptured bladder
**# '''<span style="color:#ff0000">Patient undergoing repair of </span><span style="color:#0000ff">A</span><span style="color:#ff0000">bdominal injuries</span>''', consider performing bladder repair for extraperitoneal bladder injury given that the typical bladder repair can be performed quickly and with little morbidity.
** '''<span style="color:#ff0000">Additional indications for immediate repair of bladder injury (Campbell’s 11th edition):</span>'''
**# '''<span style="color:#ff0000">Penetrating or iatrogenic non-urologic injury</span>'''
**# '''<span style="color:#ff0000">Inadequate bladder drainage or clots in urine</span>'''
**# '''<span style="color:#ff0000">Open pelvic fracture</span>'''
* '''<span style="color:#ff0000">Surgical management</span>'''
** '''Step by step to repair the bladder'''
***'''Enter the anterior bladder wall'''
***'''Confirm the integrity of the bladder neck and ureteral orifices and consider repair if injured'''
***'''Close the tear intravesically with absorbable suture'''
***'''Note that the perivesical pelvic hematoma should not be disturbed'''
** '''<span style="color:#ff0000">Following surgical repair for bladder injuries, urethral catheter drainage alone without suprapubic (SP) cystostomy is recommended</span>'''
*** '''Studies have shown no advantage of combined SP and urethral catheterization'''
*** '''Exceptions in which combined SP and urethral catheterization may be considered (3)''':
***# '''Patients requiring long-term catheterization''', such as those with severe neurological injuries (i.e., head and spinal cord), those immobilized due to orthopedic injuries
***# '''Complex bladder repairs with tenuous closures'''
***# '''Significant hematuria'''