What is the management approach for gross hematuria following a pelvic fracture when initial imaging is normal?

From the Guidelines

Gross hematuria following a pelvic fracture with normal initial imaging necessitates retrograde cystography to evaluate for bladder injury, as it is an absolute indication for this diagnostic procedure. The presence of gross hematuria with pelvic fracture indicates a high likelihood of bladder injury, with studies showing that 29% of patients with this combination have a bladder injury 1.

Key Considerations

• Gross hematuria is the most common indicator of bladder injury, and its presence with pelvic fracture warrants further investigation.
• Pelvic fracture alone does not necessitate radiologic evaluation of the bladder, but when combined with gross hematuria, it becomes an absolute indication for retrograde cystography.
• Retrograde cystography, either plain film or CT, is the technique of choice for diagnosing bladder injury, with both methods showing similar specificity and sensitivity 1.

Diagnostic Approach

• The choice between plain film and CT cystography is left to clinician preference, equipment availability, and patient stability.
• For plain film cystography, the technique involves retrograde, gravity filling of the bladder with contrast to a minimum of 300 mL or until patient tolerance, with at least two views required: one at maximal fill and another after bladder drainage.
• CT cystogram is performed similarly, using dilute water-soluble contrast to prevent artifacts, and clamping a Foley catheter to allow excreted IV-administered contrast to accumulate in the bladder is not recommended due to inadequate bladder distention 1.

Clinical Implications

• The management approach should prioritize the detection and management of potential bladder injuries to prevent complications and improve patient outcomes.
• Given the high association of bladder injury with gross hematuria and pelvic fracture, a proactive diagnostic approach with retrograde cystography is essential, as supported by the AUA guideline 1.

From the Research

Management Approach for Gross Hematuria after Pelvic Fracture

The management of gross hematuria following a pelvic fracture when initial imaging is normal involves several considerations, including the assessment of the severity of the hematuria, the presence of other symptoms, and the potential for underlying injuries to the urinary tract.

• Diagnostic Evaluation: In cases of gross hematuria with pelvic fracture, the classic combination of these two findings constitutes an absolute indication for immediate cystography in blunt trauma victims 2. However, existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone.
• Imaging Studies: CT cystography can be useful in identifying radiographic and clinical variables that correlate with bladder rupture, such as pelvic fracture, pelvic fluid, and degree of hematuria 3. The presence of gross hematuria, pelvic fluid, and specific pelvic fractures are highly correlated with bladder rupture.
• Clinical Indicators: Clinical indicators of bladder rupture, such as the presence of blood at the introitus and gross hematuria, can be used to identify patients at higher risk of urethral and bladder neck injury associated with pelvic fracture 4.
• Treatment: The treatment of gross hematuria after pelvic fracture depends on the underlying cause and may involve surgical intervention, such as open cystotomy and hardware removal, in cases where orthopedic hardware is eroding into the bladder 5.
• Complications: Patients with urethral and bladder neck injury associated with pelvic fracture are at risk for significant sexual and lower urinary tract dysfunction, highlighting the importance of prompt and appropriate management 4.