What is the management approach for gross hematuria (visible blood in urine) following a pelvic fracture?

From the Guidelines

The management of gross hematuria following a pelvic fracture should prioritize hemodynamic stabilization and prompt imaging with CT cystography to evaluate for bladder injuries, as recommended by the most recent guidelines 1. The initial approach to managing gross hematuria after a pelvic fracture involves stabilizing the patient's hemodynamics with intravenous fluids and blood products as needed.

• Continuous bladder irrigation using a three-way Foley catheter with normal saline can help prevent clot formation.
• A retrograde urethrogram may be necessary before catheter placement if urethral injury is suspected.
• Patients require close monitoring of vital signs, urine output, and hemoglobin levels. The choice of imaging modality is crucial, with CT cystography being the preferred method to evaluate for bladder injuries, as it provides high sensitivity and specificity for diagnosing bladder rupture 1.
• Contrast-enhanced CT can also identify vascular injuries. For persistent bleeding, interventional procedures such as angioembolization for arterial bleeding sources or surgical exploration for severe cases may be necessary.
• Antibiotics, such as cefazolin 1-2g IV every 8 hours, are often administered prophylactically to prevent urinary tract infections. The underlying mechanism of gross hematuria in pelvic fractures involves direct trauma to the bladder or urethra, shearing forces disrupting blood vessels, or bone fragments lacerating urologic structures.
• Most cases of hematuria resolve with conservative management within 24-72 hours, but persistent bleeding requires more aggressive intervention, as outlined in the European guideline on management of major bleeding and coagulopathy following trauma 1.

From the Research

Management Approach for Gross Hematuria after Pelvic Fracture

The management of gross hematuria following a pelvic fracture involves several key considerations, including:

• Evaluation of the patient's overall condition and stability
• Assessment of the severity of the hematuria and associated injuries
• Use of diagnostic imaging to identify potential causes of the hematuria

Diagnostic Imaging

Diagnostic imaging plays a crucial role in the management of gross hematuria after pelvic fracture. Studies have shown that:

• Cystography is indicated in cases of gross hematuria or when other clinical signs indicate a high likelihood of bladder or urethral trauma 2
• The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims 3
• Risk factors associated with the likelihood of bladder rupture include gross hematuria, the number of fractured pubic rami, tachycardia, hypotension, and declining hematocrit 4

Treatment Options

Treatment options for gross hematuria after pelvic fracture depend on the underlying cause and severity of the injury. Possible treatments include:

• Suprapubic catheter drainage without local exploration for urethral injuries associated with pelvic fractures 5
• Pelvic exploration with open cystotomy and hardware removal for cases where orthopedic hardware is eroding into the bladder 6
• Delayed primary repositioning of a dislocated bladder base or urethra may be considered in some cases 5

Key Considerations

Key considerations in the management of gross hematuria after pelvic fracture include:

• The need for prompt evaluation and treatment to prevent complications and improve outcomes
• The importance of diagnostic imaging in identifying potential causes of the hematuria and guiding treatment decisions
• The role of suprapubic catheter drainage and other treatment options in managing urethral injuries and other complications associated with pelvic fractures 5, 2, 3, 4