What is the emergency management of a suspected bladder or urethral rupture?

Emergency Management of Suspected Bladder or Urethral Rupture

If urethral injury is suspected, perform retrograde urethrography BEFORE any catheterization attempt; if bladder rupture is suspected, perform retrograde cystography in hemodynamically stable patients—never attempt blind catheterization in trauma cases. 1

Initial Assessment and Stabilization

Hemodynamic Status Determines Immediate Actions

• In hemodynamically unstable patients, postpone all urethral/bladder investigations and establish urinary drainage immediately via suprapubic catheter 1
• In hemodynamically stable or stabilized patients, proceed with diagnostic imaging before any intervention 1

Clinical Indicators Requiring Investigation

For Urethral Injury:

• Blood at the external urethral meatus (absolute indication for imaging) 1, 2
• Suprapubic fullness, perineal laceration, or scrotal hematoma 1
• Urinary retention or difficulty inserting a urinary catheter 1
• Superiorly displaced prostate on rectal examination 1
• Pelvic fracture with any of the above findings 1

For Bladder Injury:

• Gross hematuria with pelvic fracture (bladder injury in almost one-third of cases—absolute indication for imaging) 1
• Low urine output, abdominal distension, or inability to void 1
• Suprapubic tenderness, uremia, or elevated creatinine 1
• Entrance/exit wounds in lower abdomen, perineum, or buttocks 1

Important caveat: Microhematuria alone is NOT an indication for mandatory bladder imaging 1

Diagnostic Algorithm

Step 1: Rule Out Urethral Injury FIRST (If Suspected)

Perform retrograde urethrography as the procedure of choice BEFORE any other genitourinary maneuvers 1, 2

• Retrograde urethrography and flexible urethroscopy are the diagnostic modalities of choice 1
• In penile injuries or women (due to short urethra), urethroscopy is preferred over retrograde urethrography 1
• Perform rectal and vaginal examination—associated rectal injuries occur in up to 5% of cases 1
• Contrast extravasation on retrograde urethrography confirms urethral injury 1

Critical pitfall: Never attempt catheterization before imaging in suspected urethral trauma—this may convert partial injuries to complete disruptions 1, 2

Step 2: Evaluate for Bladder Injury

Retrograde cystography (conventional or CT-scan) is the diagnostic procedure of choice for bladder injuries 1

• Both conventional and CT-scan cystography have 95% sensitivity and 100% specificity 1
• CT-scan cystography is preferred when available 1
• Critical technical point: Passive filling via IV contrast with clamped catheter is NOT adequate—high false negative rate due to low intravesical pressure 1
• Retrograde filling of the bladder with contrast is mandatory for accurate diagnosis 1

Special circumstance: If pelvic bleeding is amenable to angioembolization, postpone cystography until after angiography completion to avoid contrast interference 1

Step 3: Intraoperative Evaluation (If Laparotomy Required)

• Direct inspection of the intraperitoneal bladder should always be performed during emergency laparotomy when bladder injury is suspected 1
• Methylene blue or indigo carmine can be useful for intraoperative investigation 1
• If urethral injury is suspected during laparotomy, investigate directly whenever feasible 1

Management Based on Diagnosis

Bladder Rupture Management

Intraperitoneal Bladder Rupture:

• Requires surgical exploration and primary repair 1
• All penetrating bladder injuries require surgical repair 1
• Laparoscopic repair may be considered for isolated injuries in hemodynamically stable patients without other indications for laparotomy 1
• Repair in double-layer fashion using monofilament absorbable suture 1

Extraperitoneal Bladder Rupture:

• Uncomplicated blunt or penetrating extraperitoneal injuries may be managed non-operatively with urinary drainage via urethral or suprapubic catheter (in absence of other laparotomy indications) 1
• Injury healing occurs within 10 days in more than 85% of cases with conservative management 1
• Complex extraperitoneal ruptures require surgical exploration and repair: 1
  • Bladder neck injuries
  • Lesions associated with pelvic ring fracture requiring fixation
  • Associated vaginal or rectal injuries
• Surgical repair should be considered during laparotomy for other indications or during surgical exploration for orthopedic fixations 1

Urethral Injury Management

In Hemodynamically Stable Patients:

• For adults: urinary drainage with urethral catheter (without suprapubic catheter) after surgical endoscopic realignment; definitive surgical management delayed for 14 days if no other laparotomy indications exist 1
• For pediatric patients: suprapubic cystostomy is recommended 1

In Hemodynamically Unstable Patients:

• Insert suprapubic catheter as temporary measure 1
• Postpone definitive repair until patient stabilized 1

Immediate Hemorrhage Control

• Perineal compression can provide temporary hemorrhage control for urethral bleeding while preparing for definitive management 3
• This is particularly effective for blunt anterior urethral trauma (straddle injuries) and posterior urethral injuries with pelvic fractures 3

Critical Pitfalls to Avoid

• Never attempt blind catheterization before imaging in trauma cases—may worsen urethral injuries 1, 2
• Never perform repeated catheter placement attempts—increases injury extent 2
• Never rely on IV contrast CT alone for bladder evaluation—requires active retrograde filling 1
• Never ignore microhematuria as sole indication for bladder imaging—look for additional clinical indicators 1
• In hemodynamically unstable patients, establish suprapubic drainage immediately rather than pursuing diagnostic studies 1