From the Guidelines
The next step in managing this 24-year-old man with pelvic fracture and gross hematuria after a normal cystogram is to perform a retrograde urethrogram to evaluate for urethral injury. Since the cystogram showed no bladder rupture or extravasation, the hematuria is likely due to either a urethral injury or renal trauma. A retrograde urethrogram should be done before attempting urethral catheterization to avoid converting a partial urethral tear into a complete disruption, as suggested by the guidelines for managing severe pelvic trauma patients with clinical symptoms of lower urinary tract injury 1.
The patient's presentation with gross hematuria and a pelvic fracture warrants further evaluation of the urethra, as posterior urethral injuries are commonly associated with pelvic fractures, particularly those with bilateral ischio-pubic rami and sacro-iliac dislocation 1. The guidelines recommend performing a retrograde urethral and bladder opacification, ideally with a CT-scan, in severe pelvic trauma patients with clinical symptoms of lower urinary tract injury, particularly before attempting urinary catheterization in men 1.
If the urethrogram is normal, a CT scan with IV contrast (CT urogram) should be performed to assess for upper urinary tract injuries, particularly renal trauma. The patient should be hemodynamically stabilized with IV fluids and blood products as needed. Pain management with appropriate analgesics is important. Broad-spectrum antibiotics (such as cefazolin 1g IV every 8 hours) should be considered to prevent infection, especially if urologic procedures are performed, as recommended by the guidelines for managing kidney and uro-trauma 1.
Close monitoring of vital signs, urine output, and hemoglobin levels is essential. The rationale for this approach is that pelvic fractures are commonly associated with genitourinary injuries, and proper diagnosis of the source of hematuria is crucial for appropriate management and to prevent complications such as strictures, incontinence, or ongoing bleeding. Uncomplicated blunt or penetrating extraperitoneal bladder injuries may be managed non-operatively, with urinary drainage via a urethral or suprapubic catheter in the absence of other indications for laparotomy, as stated in the guidelines for managing kidney and uro-trauma 1.
Key considerations in managing this patient include:
- Evaluating for urethral injury with a retrograde urethrogram before attempting urethral catheterization
- Assessing for upper urinary tract injuries with a CT scan with IV contrast if the urethrogram is normal
- Hemodynamic stabilization and pain management
- Consideration of broad-spectrum antibiotics to prevent infection
- Close monitoring of vital signs, urine output, and hemoglobin levels.
From the Research
Next Steps in Management
Given the patient's pelvic fracture and gross hematuria, with a normal cystogram showing no extravasation, the next steps are crucial for appropriate management. The key considerations include:
- The presence of gross hematuria indicates a significant injury to the urinary tract, which requires careful evaluation and management 2, 3, 4.
- A normal cystogram with no extravasation suggests that there is no immediate need for surgical intervention for a bladder rupture, but it does not rule out other injuries such as urethral disruptions 2, 5.
Considerations for Urethral Injury
Urethral injury is a significant concern in males with pelvic fractures and gross hematuria. The studies suggest:
- 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 2.
- If the urethra is normal, a catheter may be passed, and in the presence of gross hematuria, a cystogram must be performed 2.
Appropriate Action
Based on the evidence, the appropriate next step would be to:
- Place an indwelling urinary catheter, as the cystogram has already been performed and showed no extravasation, and there's an indication for continuous bladder drainage in the setting of gross hematuria and pelvic fracture 3, 6.
- Consider further evaluation for urethral injury, such as retrograde urethrography, given the high risk of urethral disruption in males with pelvic fractures and gross hematuria 2, 5.
Options Analysis
- Option B (place an indwelling urinary catheter) seems appropriate given the need for continuous bladder drainage and monitoring.
- Option D (retrograde urethrography) may be considered if there's a high suspicion of urethral injury, despite the normal cystogram.
- Options A, C, and E may not be the immediate next steps based on the information provided and the normal cystogram result.