Editing Lower Urinary Tract Trauma (section)

=== 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.'''