Bladder and urethral injuries

Dr Tim Fotheringham The Royal London Hospital, UK Nordic Trauma Society, Oslo 2008

Bladder trauma
Blunt trauma 90% Penetrating trauma 10% pelvic fractures have bladder injury 85-94% have pelvic fractures

Immediate concerns
20-44% Mortality Haemorrhage
Pelvis Abdo organs Other sites

Sepsis
Rectal injury

Cystography
No firm guidelines Retrospective studies Blunt and penetrating trauma Haematuria not quantified

4 centre experience
53/53 45/53 38/53 12/53 6/53 3/53 10% gross haematuria 85% pelvic fracture 72% axial bone fracture 23% urethral injury 11% blood at meatus 6% high riding prostate J Trauma 2001;51:683-6

Diagnosis
CT alone 13% Cystogram alone 46% CT and cystogram 13% Laparotomy 28% CT and CT cystogram now preferred J Trauma 2001;51:683-6

Blunt trauma
Pelvic fracture
Gross haematuria: 29% Microhaematuria 0.6%

Gross haematuria/no pelvic fracture

Usually renal 0.4% have bladder and renal injuries

CT classification
1 2 3 4 Bladder contusion Intraperitoneal rupture Interstitial bladder injury Extraperitoneal rupture
simple complex (bladder neck involved)
Sandler et al Radiology 1986

A B

5 Combined bladder injury

CT cystography
Urinary bladder catheterisation Contrast 50mls of 300mg/ml with 450 of saline CT scan performed after administration of 250-300mls via urinary catheter Post drainage images not required

Extraperitoneal bladder rupture

Pelvic vessels

Complex extraperitoneal injury

Bladder herniation

Post operative intraperitoneal rupture

Bladder neck injury

Management of bladder injuries

Contusions, interstitial damage and simple extraperitoneal rupture managed by bladder decompression with urinary catheter Intraperitoneal and complex extraperitoneal and combined injuries need to be managed surgically

Urethral trauma
With pelvic fracture seen in
25% males 6% females

Blind urethral catheterization in trauma patients suffering from lower urinary tract injuries not associated with worsening of injury
Shlamovitz GL and McCullough L.. J Trauma. 2007;62:330-35.

Urethral trauma
Failure of urethral catheterisation Suprapubic catheter inserted Urethrogram performed Surgical repair

Membranous urethra

Conclusion
High incidence with pelvic fractures Haematuria nearly always present Gentle urethral catheterisation Surgery for:
Haemorrhage control Intraperitoneal bladder rupture Bladder and urethral injury Urethral transection

Foley catheter initial treatment for simple extraperitoneal bladder rupture

Thank you

The END