What is the next step in management for a trauma patient with an extraperitoneal (outside the peritoneum) bladder injury?

Management of Extraperitoneal Bladder Injury in Trauma

For an uncomplicated extraperitoneal bladder injury, place a urethral Foley catheter for 2-3 weeks and confirm healing with follow-up cystography—this is the standard of care and avoids unnecessary surgery. 1

Initial Decision Algorithm

The critical first step is determining whether the extraperitoneal bladder injury is uncomplicated or complicated, as this completely changes management:

Uncomplicated Extraperitoneal Bladder Injury

• Conservative management with urethral catheter drainage is the treatment of choice 1
• More than 85% of uncomplicated extraperitoneal bladder ruptures heal within 10 days with catheter drainage alone 1
• Standard catheter duration is 2-3 weeks, though longer duration is acceptable with significant concurrent injuries 1, 2
• A suprapubic catheter is NOT routinely necessary—urethral catheterization alone has equivalent efficacy with shorter hospital stays and lower morbidity 1, 2

Complicated Extraperitoneal Bladder Injury (Requires Surgical Repair)

Surgical exploration and repair are mandatory in these specific scenarios 1:

• Bladder neck injuries (may not heal with catheter drainage alone) 1, 3
• Pelvic fractures with exposed bone spicules protruding into the bladder lumen 1
• Concurrent rectal or vaginal lacerations (risk of fistula formation) 1
• Patient undergoing laparotomy for other indications (repair can be performed quickly with little added morbidity) 1
• Patient requiring open reduction internal fixation of pelvic fractures 1
• Non-healing injuries unresponsive to catheter drainage after 4 weeks 1

Post-Treatment Drainage Strategy

After either conservative management or surgical repair:

• Use urethral catheter alone in adults—this is now the standard of care 1, 2
• Multiple studies demonstrate no advantage of combined suprapubic and urethral catheterization over urethral catheter alone 1, 4, 5, 6
• Suprapubic tubes may actually increase morbidity without improving healing time 5

Exceptions where suprapubic catheter may be considered 1:

• Severe neurological injuries (head or spinal cord trauma requiring long-term catheterization)
• Patients immobilized due to orthopedic injuries
• Complex bladder repairs with tenuous closures or significant hematuria
• Concomitant urethral injury 1

Follow-Up Protocol

• Perform follow-up cystography to confirm healing before catheter removal 1, 2
• CT scan with delayed phase imaging is the preferred method for follow-up 2
• Standard timing is after 2-3 weeks of catheter drainage 1, 2

Critical Pitfalls to Avoid

• Do not place a suprapubic catheter routinely—this is outdated practice that increases complications without benefit 1, 4, 5
• Do not surgically repair uncomplicated extraperitoneal injuries—conservative management has excellent outcomes 1
• Do not miss complicated features that mandate surgical repair (bladder neck involvement, rectal/vaginal injury, bone spicules) 1, 3
• Do not remove the catheter without confirming healing via cystography, as premature removal can lead to complications 1, 2

Answer to the Question

The correct answer is C: Catheter drainage and assess after 2 weeks. This represents urethral Foley catheter placement for 2-3 weeks with follow-up cystography to confirm healing, which is the evidence-based standard for uncomplicated extraperitoneal bladder injuries. 1