Editing Lower Urinary Tract Trauma (section)

=== 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'''