Management of Pelvic Fracture with Gross Hematuria and Normal Cystogram
The next step in managing this 24-year-old man with pelvic fracture and gross hematuria after a normal catheterization and negative cystogram is to monitor the patient with continued bladder drainage via the indwelling catheter for 7-10 days. 1
Assessment of Current Status
- Patient has undergone appropriate initial evaluation:
- Successful urethral catheterization without difficulty
- Retrograde cystogram performed with adequate filling (250 mL)
- Post-drainage images showing no extravasation
- Gross hematuria noted in setting of pelvic fracture
Management Algorithm
Continue Foley catheter drainage
- Maintain the urinary catheter for 7-10 days to allow for healing of any minor bladder injuries 1
- Monitor urine output and character (clearing of hematuria)
Imaging follow-up
- No immediate additional imaging is needed as cystogram was negative 1
- Consider repeat cystogram before catheter removal if hematuria persists beyond 5-7 days
Clinical monitoring
- Monitor vital signs and hemoglobin levels to ensure no occult bleeding
- Watch for signs of infection (fever, increasing pain)
- Assess for adequate urine output
Rationale for Management
The combination of pelvic fracture and gross hematuria raises significant concern for urologic injury, with up to 29% risk of bladder rupture according to the American Urological Association 2. However, the negative cystogram in this case is reassuring.
According to the World Society of Emergency Surgery guidelines, a properly performed cystogram (as done in this case) has approximately 95% sensitivity and 100% specificity for identifying bladder injuries 1. The AUA guidelines specifically state that catheter drainage is the appropriate treatment for uncomplicated extraperitoneal bladder injuries 1, and by extension, this approach is appropriate for patients with suspected minor bladder trauma not visible on imaging.
Important Considerations
Proper cystogram technique: The cystogram performed appears adequate with 250 mL filling and post-drainage images, meeting the minimum requirement of proper bladder distention 2
Intraperitoneal vs. extraperitoneal injury: Had an intraperitoneal bladder rupture been detected, immediate surgical repair would have been mandatory 1
Potential pitfalls:
- False negative cystograms can occur with inadequate bladder filling or when injuries are located in the posterior wall 1
- Continued gross hematuria beyond 48-72 hours may indicate need for reassessment
Special Circumstances
If the patient develops any of the following during observation, urgent reassessment is warranted:
- Increasing abdominal pain or distension
- Peritoneal signs
- Fever or signs of sepsis
- Failure of hematuria to clear
- Abnormal renal function tests
In these cases, repeat imaging with CT cystography or direct cystoscopic evaluation may be indicated 1.