Management of Gross Hematuria with Bladder Hematoma
Immediately perform retrograde cystography with at least 300 mL of contrast via retrograde gravity filling to diagnose bladder perforation, as bladder hematomas can cause bladder wall ulceration and perforation requiring urgent surgical intervention. 1, 2
Immediate Diagnostic Evaluation
Obtain CT cystography as the gold standard imaging modality, which has 85-100% accuracy for diagnosing bladder perforation and simultaneously evaluates for other injuries. 1 Look for:
- Intraperitoneal perforation: Contrast outlining bowel loops and filling intraabdominal spaces 1
- Extraperitoneal perforation: Contrast confined to the pelvis 1
- Associated pelvic fractures: Present in 29% of patients with gross hematuria and bladder rupture 1
Critical pitfall: Do not perform inadequate cystography by clamping a Foley catheter and relying on IV contrast accumulation—this technique misses bladder injuries. 3
Risk Stratification and Urologic Referral
Refer all patients with gross hematuria for immediate urologic evaluation, even if self-limited. 4 The risk of malignancy with gross hematuria exceeds 10%, and bladder perforation from hematoma pressure represents a surgical emergency. 5, 2
Specifically inquire about:
- History of pelvic trauma or recent vascular procedures 2
- Inability to void or low urine output 3
- Abdominal distention or suprapubic pain 3
- Elevated BUN/creatinine suggesting intraperitoneal rupture 3
Management Algorithm Based on Perforation Type
Intraperitoneal Bladder Perforation
Perform immediate surgical repair for all intraperitoneal perforations (Grade B evidence) due to risk of peritonitis and sepsis. 1 This is a Standard recommendation that should not be delayed.
Extraperitoneal Bladder Perforation
Manage uncomplicated extraperitoneal injuries with catheter drainage for 2-3 weeks, as over 85% heal within 10 days with catheter drainage alone. 1
Perform surgical repair for complicated extraperitoneal injuries including: 1
- Large extraperitoneal bladder injuries
- Bladder neck involvement
- Concurrent rectal or vaginal injury
- Adjacent orthopedic implants
- Penetrating injuries with pelvic trajectories
Hemodynamically Unstable Patients
Delay surgical repair until stabilization is achieved. 1 Consider bilateral nephrostomy combined with urinary catheterization as a temporizing measure. 1
Catheter Management and Clot Prevention
Maintain continuous bladder drainage to prevent clot retention and overdistention. 1 Replace the catheter if inadequate drainage is suspected or if the current catheter is causing ongoing trauma. 3
Follow up with cystography to confirm healing in complex repairs before catheter removal. 1
Special Consideration: Hematoma Without Perforation
If imaging reveals a bladder hematoma without perforation, consider that the hematoma itself can cause delayed ulceration and perforation through pressure necrosis of the bladder wall. 2 One case report documented a pelvic hematoma from femoral artery injury that initially caused extraperitoneal perforation, which later transformed to intraperitoneal perforation through the absorbed hematoma. 2
Critical Pitfalls to Avoid
Do not attribute hematuria solely to anticoagulation without ruling out structural bladder injury, as 29% of patients with pelvic fracture and gross hematuria have bladder rupture. 1, 3
Do not delay imaging in patients with pelvic fracture and gross hematuria—this represents a surgical emergency requiring immediate diagnosis. 1, 3
Do not dismiss gross hematuria even if self-limited, as it carries significantly higher cancer risk and may indicate serious underlying pathology. 4
Follow-Up After Treatment
Pursue evaluation even if the patient is receiving antiplatelet or anticoagulant therapy, as these medications do not explain structural causes of hematuria. 4, 3
Do not obtain urinary cytology or urine-based molecular markers in the initial evaluation of gross hematuria—these are low-yield and not recommended. 4, 3