What is the next step in managing a patient with a pelvic fracture, gross hematuria, and a normal cystogram with 250 cc of contrast (computed tomography) dye?

Management of Pelvic Fracture with Gross Hematuria and Normal Cystogram

A repeat cystogram with at least 300 mL of contrast should be performed as the next step in managing a patient with pelvic fracture, gross hematuria, and a normal cystogram with only 250 cc of contrast. 1, 2

Why Repeat the Cystogram?

• The initial cystogram with only 250 cc of contrast is inadequate to rule out bladder injury, as guidelines clearly state a minimum of 300 mL of contrast (or until patient reaches tolerance) is required to adequately distend the bladder and detect rupture 1, 2
• Inadequate bladder filling is a common cause of false-negative results in cystography, as smaller perforations may not be visible without proper distension 2
• The combination of pelvic fracture and gross hematuria is an absolute indication for thorough evaluation of the bladder, with bladder injury present in approximately 29% of such cases 1

Proper Cystography Technique

• For accurate diagnosis, retrograde cystography should include:

  • Minimum of 300 mL of contrast or until patient reaches tolerance 1, 2
  • At least two views: one at maximal fill and one after bladder drainage 1
  • Use of dilute water-soluble contrast to prevent artifacts if performing CT cystography 1

• CT cystography and conventional cystography have similar sensitivity and specificity for detecting bladder rupture when performed correctly 1, 3

Clinical Considerations

• The presence of both gross hematuria and pelvic fracture is highly predictive of bladder injury, with bladder rupture present in up to 29% of such cases 1, 4
• No bladder ruptures have been reported in patients with <25 RBC/HPF (microscopic hematuria) 5
• Pelvic fluid on CT is another strong indicator of possible bladder rupture 5
• Certain fracture patterns increase risk of bladder injury, including pubic symphysis diastasis and obturator ring fracture displacement >1 cm 1

Evaluation for Associated Injuries

• After proper cystography, consider evaluation for urethral injury if clinically indicated 1
• Blood at the urethral meatus, especially with pelvic fractures, warrants retrograde urethrography before bladder catheter placement 1
• Direct inspection of the intraperitoneal bladder should be performed during any emergency laparotomy if bladder injury is suspected 1

Management Based on Findings

• If intraperitoneal bladder rupture is identified on proper cystography, surgical repair is mandatory 1
• Extraperitoneal bladder ruptures can typically be managed with catheter drainage alone unless complicated by bone fragments, involvement of the bladder neck, or concomitant vaginal or rectal injury 1
• Hardware from pelvic fracture fixation can occasionally erode into the bladder, causing persistent symptoms even after initial management 6

Common Pitfalls to Avoid

• Relying on passive accumulation of IV contrast in the bladder by clamping a catheter during CT is inadequate and results in missed injuries 1
• Inadequate contrast volume (<300 mL) is a major cause of false-negative cystograms 2
• Isolated acetabular fractures do not correlate strongly with bladder rupture, unlike other pelvic fracture patterns 5