Editing AUA: Urotrauma (2020) (section)

===== '''Bladder trauma''' =====

* '''Bladder rupture can occur into the peritoneal cavity (intraperitoneal bladder rupture) or outside the peritoneal cavity (extraperitoneal rupture).'''
** '''Bladder injuries are:'''
*** '''Extraperitoneal in ≈60%'''
*** '''Intraperitoneal in ≈30%'''
*** '''Both intraperitoneal and extraperitoneal in ≈10%'''

* '''Diagnosis and Evaluation'''
** '''History and physical exam'''
*** '''Indicators of potential bladder rupture (9):'''
***# '''Gross hematuria'''
***#* '''Most common indicator of bladder injury'''
***#* A limited number of pelvic fracture patients with bladder injuries will present with microscopic hematuria
***# '''Abdominal distention'''
***# '''Suprapubic pain'''
***# '''Inability to void'''
***# '''Low urine output'''
***# '''Pubic symphysis diastasis'''
***# '''Obturator ring fracture displacement >1 cm'''
***# '''Increased creatinine and BUN''' (secondary to peritoneal absorption of urine)
***# '''Intraperitoneal low density free fluid on abdominal imaging (urinary ascites)'''
** '''Imaging'''
*** '''Indications for cystography in stable patients'''
**** '''2020 AUA Guidelines'''
***** '''Absolute (1):'''
*****# '''Gross hematuria and pelvic fracture'''
***** '''Relative (2):'''
*****# '''Gross hematuria and a mechanism concerning for bladder injury'''
*****# '''Pelvic ring fractures and clinical indicators (see above) of bladder rupture'''
*****#* '''The vast majority of bladder injuries are associated with pelvic fractures because the bladder is well protected within the pelvis, however, pelvic fracture alone does not warrant radiologic evaluation of the bladder'''
** '''Modality: retrograde cystography (CT or plain film)'''
*** '''Critical as it can determine the presence of an injury and whether it is intraperitoneal or extraperitoneal.'''
*** '''Plain film and CT cystography have similar specificity and sensitivity, and are both highly accurate for the diagnosis of bladder rupture'''
*** '''Technique'''
**** '''The volume instilled should be a minimum of 300 mL''' or until the patient reaches tolerance in order to maximally distend the bladder
***** Clamping a Foley catheter to allow excreted IV-administered contrast to accumulate in the bladder is not appropriate. 
**** '''With plain film cystography, a minimum of 2 views are required, the first at maximal fill and the second after bladder drainage.'''

* '''Managment'''
** '''Based on extraperitoneal vs. intraperitoneal'''
*** '''Uncomplicated extraperitoneal bladder ruptures: Foley catheter left in place 2-3 weeks'''
**** 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
**** '''Consideration for open repair may be appropriate in those patients with non-healing bladder injuries who are unresponsive to Foley catheter drainage >4 weeks.'''
**** '''Follow-up cystography'''
***** '''Should be done''' to confirm that the injury has healed with catheter drainage
*** '''Intraperitoneal bladder rupture: prompt surgical repair'''
**** '''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
**** '''Follow-up cystography'''
***** '''Should be done in complex repairs'''
***** '''May not be necessary in more simple repairs'''
** '''Indications for immediate surgical repair of bladder (7)§: Immediate Bladder Repair NOVA'''
**# '''Intraperitoneal bladder rupture'''
**# '''Exposed Bone spicules in the bladder lumen'''
**# '''Concurrent Rectal injury'''; may lead to fistula formation to the ruptured bladder
**# '''Bladder Neck injuries'''; may not heal with catheter drainage alone and repair should be considered
**# '''Patient undergoing Open reduction internal fixation;''' to reduce risk of infection to hardware)
**# '''Concurrent Vaginal injury'''; may lead to fistula formation to the ruptured bladder
**# '''Patient undergoing repair ofAbdominal injuries''', consider performing bladder repair for extraperitoneal bladder injury given that the typical bladder repair can be performed quickly and with little morbidity.
*** Follow-up cystography should be used to confirm that the complex, extraperitoneal bladder injury has healed
** '''Surgical management'''
*** '''The integrity of the bladder neck and ureteral orifices should be confirmed and repair considered if injured'''
*** '''Following surgical repair for bladder injuries, urethral catheter drainage alone without suprapubic (SP) cystostomy is recommended'''
**** '''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'''