Nonoperative management of bladder rupture from external trauma

Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

The diagnostic evaluation and clinical management of bladder injuries caused by blunt force trauma are variable. We aim to formulate a practice management guideline using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

METHODS

The working group, patient, intervention, comparator, outcome (PICO), formulated four questions regarding the following topics: (1) diagnostic evaluation based on patient baseline risk of bladder injury (computed tomography cystography vs. no imaging); (2) management of intraperitoneal bladder injuries (operative versus nonoperative); (3) management of extraperitoneal bladder injuries based on complexity of injury (operative vs. nonoperative); and (4) diagnostic follow-up of bladder injuries based on complexity of repair (cystography vs. no cystography). A systematic review of the MEDLINE database for English language articles with adult patients was undertaken. RevMan 5 (Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) and GRADEpro (GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. McMaster University, 2015) software were used. Recommendations were voted on by working group members. Consensus was obtained for each recommendation.

RESULTS

Three hundred ninety-three articles were screened, resulting in a full-text review of 64 articles. Seventeen articles were used to formulate the recommendations of this guideline. Several recommendations are made. The need for initial computed tomography cystography after trauma depends on characteristics of the trauma itself, but it is not recommended in patients without gross hematuria. In general, patients with intraperitoneal bladder ruptures should undergo operative repair. This is not routinely necessary in those with extraperitoneal ruptures unless the injury is complex. The need for follow-up cystography after bladder repair depends on the risk of urine leak. Those with low risk of urine leak do not require a follow-up study.

CONCLUSION

Using the GRADE process, the panel made nine recommendations based on four PICO questions concerning the evaluation and management of blunt force bladder injuries.

Prospective comparison of microscopic and gross hematuria as predictors of bladder injury in blunt trauma

OBJECTIVES

The evaluation of the genitourinary system in patients with blunt trauma remains controversial. Historically, patients with more than 50 red blood cells on urinalysis underwent additional genitourinary imaging. Retrospective studies have demonstrated that bladder injury is almost always associated with gross hematuria. We have prospectively demonstrated that bladder imaging is required for gross hematuria and unnecessary for microscopic hematuria.

METHODS

Patients sustaining blunt trauma with hematuria were prospectively evaluated during a 3-year period. During the first 18 months of the study (first treatment arm), patients with microscopic hematuria (more than 50 red blood cells on urinalysis) underwent bladder imaging. During the second 18 months, patients underwent bladder imaging only for gross hematuria.

RESULTS

A total of 8026 patients were evaluated. In the first arm, 214 patients underwent cystography for microscopic hematuria, and no bladder injuries were identified; 78 patients underwent cystography for gross hematuria, and 21 bladder injuries were identified. Chi-square analysis revealed no difference in the presence of microscopic hematuria to predict for bladder injury. In the second arm, 308 patients presented with microscopic hematuria, none of whom underwent cystography, and 91 patients underwent cystography for gross hematuria, with 15 bladder injuries identified. The presence of gross hematuria demonstrated 100% sensitivity and 98.5% specificity as a screening test for bladder injury. No bladder injuries were missed.

CONCLUSIONS

The results of our study have shown that the presence of gross hematuria warrants evaluation of the bladder. The presence of gross hematuria demonstrated improved sensitivity, specificity, positive predictive value, negative predictive value, and accuracy over the presence of microscopic hematuria in the detection of bladder injury. Using gross hematuria as an indication for bladder imaging will eliminate unnecessary imaging without compromising the quality of patient care.

Bladder rupture after blunt trauma: guidelines for diagnostic imaging

PURPOSE

The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome.

METHODS

We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series.

RESULTS

Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates.

CONCLUSION

The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.

Workup and management of traumatic hematuria

Hematuria is an important indicator of genitourinary tract injury after trauma. Correct initial evaluation of hematuria will affect diagnosis, management, and outcome of resultant injuries. This article presents recommendations for further evaluation when hematuria is found, depending on the mechanism of injury and clinical status of the patient. Once injuries have been adequately diagnosed and staged, appropriate management decisions can be made with urologic consultation.

Morbidity associated with nonoperative management of extraperitoneal bladder injuries

Foley catheter drainage alone has become routine management for extraperitoneal bladder ruptures in many medical centers, and few reports address treatment failures with this approach. Over the last 10 years, 70 patients with bladder ruptures were managed at our institution. Thirty-six of these had extraperitoneal injuries caused by blunt trauma, and 29 of these were treated by catheter drainage alone. Of those patients managed nonoperatively, 74% had spontaneous healing within 10 to 14 days; however, 26% had significant complications, including delayed healing, vesicocutaneous fistula, septic events, bladder calculi, or death. Although our results confirm previous reports in the literature that most patients with extraperitoneal bladder ruptures do well with nonoperative management, they also point out that a significant subset of patients do not. We were unable to identify presenting features that would predict an unfavorable outcome, although patients with multiple pelvic fractures seem to be at high risk. The maintenance of adequate catheter drainage and use of antibiotic prophylaxis seems to have a significant impact on outcome.

Voiding dysfunction secondary to penetrating bony fragment 20 years after pelvic fracture

We report a case of persistent voiding dysfunction caused by an unsuspected penetrating bony spicule 20 years after extraperitoneal bladder rupture and pelvic fracture.

Pelvic fracture and injury to the lower urinary tract

The presence of a urologic injury must be considered in all patients with pelvic fracture. Uroradiographic evaluation starting with retrograde urethrography is indicated in all male patients with concomitant gross hematuria, bloody urethral discharge, scrotal or perineal ecchymosis, a nonpalpable prostate on rectal examination, or an inability to urinate. If the urethra is normal, a catheter may be passed, and in the presence of gross hematuria, a cystogram must be performed. Female patients rarely suffer urethral lacerations. The urethra is examined, and a Foley catheter may be passed without a urethrogram. The immediate management of associated urologic injuries continues to evolve and evoke controversy. Selected cases of extraperitoneal bladder perforation may be safely managed solely by catheter drainage. Intraperitoneal perforations require surgical exploration and repair. Urethral disruption (partial or complete) may be safely managed by primary cystostomy drainage with management of potential complications (stricture, impotence, incontinence) in 4 to 6 months.

Genitourinary trauma

A general review of genitourinary trauma is presented. Current practices, as well as old and more recent controversies involving diagnostic and therapeutic approaches, are discussed. The close cooperation between radiologists and urologists is essential for the most effective management of genitourinary trauma.