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Blunt traumatic bladder rupture: The role of retrograde cystogram
ORIGINAL CONTRIBUTION bladder, rupture; retrograde cystogram, bladder rupture; trauma, blunt, bladder
Blunt Traumatic Bladder Rupture: The Role of Retrograde Cystogram Study objective: We evaluated the importance of microscopic and gross hematuria and the role of retrograde cystography and computed tomography (CT) in the diagnosis of blunt traumatic bladder rupture. Design: All cases at a Level I trauma center between January 1, 1986, and March 31, 1989, were reviewed retrospectively. Setting: Level I trauma center, university hospital. Type of participants: All patients with acute blunt abdominal trauma admitted to this Eevel [ trauma center. Interventions: The patients' charts were reviewed with emphasis on mode of diagnosis, treatment, and outcome. Measurements and main results: Twenty-one patients had bladder rupture. All 21 had hematuria with more than 50 RBCs/high-power field, 17 gross and four microscopic. TWenty patients underwent retrograde cystography, which accurately identified bladder rupture, and one was found at laparotomy for other injuries. Seven patients had CT of the abdomen and pelvis, which failed to demonstrate bladder rupture. There were no associated urethral injuries in any of the patients with bladder rupture. Conclusion: Significant (more than 50 RBCs/high-power field) hematuria is the principal indication ,for evaluation for blunt bladder injury, and retrograde cystography is the diagnostic procedure of choice. CT is neither sensitive nor specific enough as primary diagnostic modality, [Rehm CG, Mure AJ, O'Malley KF, Ross SE: Blunt traumatic bladder rupture: The role of retrograde cystogram. Ann Emerg Med August 1991; 20:845-847.]
Christina G Rehm, MD Anthony J Mure, MD, FACS Keith F O'Malley, MD, FACS Steven E Ross, MD, FACS Camden, New Jersey From the UMDNJ/Robert Wood Johnson Medical School at Camden; and Department of Surgery, Division of Trauma, Cooper Hospital/University Medical Center, Camden, New Jersey. Received for publication May 23, 1990. Revision received January 14, 1991. Accepted for publication February 17, 1991. Presented at the Society for Academic Emergency Medicine Annual Meeting in Minneapolis, Minnesota, May 1990. Address for reprints: Christina G Rehm, MD, Division of Trauma, Three Cooper Plaza, Suite 411, Camden, New Jersey 08103.
INTRODUCTION Ruptures of the urinary bladder are most frequently seen in the multiply injured patient, ~ and associated injuries may lead to a mortality rate as high as 44%.2 Delay in the diagnosis and treatment of the ruptured bladder may substantially increase expected mortality. 2,g Early diagnosis demands a highly sensitive, specific, and expeditious plan of identification and management, balanced with the requirements of care for concomitant severe injuries. To evaluate the significance of gross and microscopic hematuria in the identification of patients with bladder rupture secondary to blunt injury as well as the role of retrograde cystogram and computed tomography (CT) in the radiographic evaluation of these patients, we undertook a retrospective review of all cases of bladder rupture managed at our Level I trauma center. MATERIALS A N D M E T H O D S During the 39-month study period of January 1, I986, through March 31, 1989, patients at risk for bladder rupture because of blunt abdominal trauma and/'or pelvic fracture underwent anteroposterior radiographs of the pelvis and complete urinalysis with microscopic examination. 4,5 Retrograde cystogram with 300 mL of contrast material (43% i o t h a l a m a t e meglumine)6, 7 including a post-void or washout film was performed in the resuscitation area on patients suspected of having bladder injury on the basis of pelvic fracture and hematuria or hematuria combined with a highrisk mechanism of injury (ie, direct blow to the lower abdomen). Cystograms were performed in the anteroposterior projection only because of the
48/845
Annals of Emergency Medicine
20:8 August I991
BLADDER RUPTURE Rehm et al
risk associated with positioning hemodynamically unstable multiply injured patients, especially with a pelvic fracture. Therefore, a post-void or washout film was m a n d a t o r y for complete radiographic evaluation. CT of abdomen and pelvis with IV contrast also was obtained, for evaluation of a pelvic fracture, in a number of these patients.
RESULTS Seven hundred nineteen patients were at risk for bladder rupture because of blunt abdominal t r a u m a and/or pelvic fracture during the study period. Twenty-one patients had bladder injury with diagnosed bladder rupture, and all had associated major injuries; 18 {86%) presented with pelvic fracture. Seven patients arrived at the center in hypovolemic shock (systolic blood pressure of less than 90 m m Hg), all of whom had unstable pelvic fractures. I n j u r y Severity Score (ISS) ranged from 9 to 75, with a mean of 30. Mean ISS for the 13 survivors was 23, and for the eight mortalities was 48. There were 11 male patients and ten female patients; ages ranged from 14 to 87 years. All patients had RBCs in their urine. S e v e n t e e n p r e s e n t e d w i t h gross hematuria and four with microhematuria (more than 50 RBCs/highpower field [hpf]). None had fewer than 50 RBCs/hpf. All four cases with microhematuria had an associated unstable pelvic fracture. The three patients with bladder ruptures occurring without pelvic fracture presented with gross hematuria. Cystography performed in 20 patients accurately identified bladder rupture in each case. No patients were determined clinically or by postmortem examination to have a missed bladder injury, and no patient had the diagnosis delayed because of the absence of signs or symptoms. There were no associated urethral injuries in any of the patients with bladder rupture, and none of them showed clinical signs of a possible urethral injury such as blood at the meatus, genital or perineal swelling, or free-floating prostate, all of which would have warranted a retrograde urethrography. All intraperitoneal bladder ruptures w e r e r e p a i r e d s u r g i c a l l y , whereas all of the extraperitoneal bladder ruptures healed with catheter 20:8 August 1991
drainage only; none required surgical repair. Seven of the 21 patients with bladder rupture underwent CT scan of the abdomen and pelvis with W and oral contrast for further delineation of their pelvic fracture. CT scan failed to demonstrate bladder rupture in every patient undergoing this examination. Five patients undergoing CT had intraperitoneal rupture, and CT demonstrated free intraperitoneal fluid. Two patients sustained extraperitoneal ruptures with no abnormality found on CT. DISCUSSION Blunt injury to the bladder is most often seen in combination with a pelvic fracture, and the reported association ranges from 70% to 95%. 2,8,9 Conversely, 5% to 30% of patients with pelvic fractures will have a bladder injury, lo, 11 Most authors recommend a properly performed retrograde cystogram as the mainstay of diagnosis.2,~2, L3 This study must include adequate distension of the bladder with at least 300 mL of contrast and avoidance of overlying objects or spilled contrast medium. The use of postvoid or washout films is mandatory, as explained previously. This study is the keystone to diagnosis 7 and resulted in 100% accuracy in this series, detecting both intraperitoneal and extraperitoneal bladder ruptures. An undisputed indication for such evaluation of the bladder is gross hematuria, m but controversy exists regarding the need for retrograde cystogram in patients with microscopic hematuria. Cass maintained that the presence of microscopic hematuria is an indication for immediate retrog r a d e cystogram,2,6,14 w h e r e a s Fallon 14 and Antoci 15 concluded that only gross hematuria or other clinical signs such as blood at the meatus, genital or perineal swelling, or freefloating prostate warrant evaluation of the lower genitourinary tract. In a series of 417 injured patients with bladder rupture, Cass documented 12 cases with fewer than 50 RBCs/hpf and 13 cases with no blood in the urine. 6 This was a mixed series of blunt and penetrating trauma, and it is uncertain whether any of those injuries with few or no RBCs in the urine may have resulted from penetrating trauma. In Fallon's series of 77 patients with microhematuria, Annals of Emergency Medicine
only one sustained a serious urologic injury, and none of Antoci's 120 patients with pelvic fractures and mic r o h e m a t u r i a had significant uropathology. The use of abdominal CT for the diagnosis of intra-abdominal injury is well established. This has been espec i a l l y a t t r a c t i v e in t h e h e m o dynamically stable patient with pelvic fracture and hematuria, where CT not only provides information regarding the extent of the bony injury but also substitutes for diagnostic peritoneal lavage and IV pyelogram. Some authors support this technique for the diagnosis of bladder rupture;3,16 however, use of CT scan for this purpose is not widely accepted. Serious shortcomings in assessing injuries of the urinary bladder have been reported. The findings in this series support those of Mee et al.t7 In our patients with known bladder rupture undergoing CT, the diagnosis of a r u p t u r e d bladder could not be made, even in retrospect. As stated by Mee et al, although CT depicts int r a p e r i t o n e a l and e x t r a p e r i t o n e a l fluid sensitively, it cannot differentiate urine from ascites and is not helpful in determining the source of this fluid. In addition, during routine abdominopelvic C% the bladder may not be distended sufficiently to demonstrate leak of contrast material through an existing bladder rupture. This could be corrected by also injecting contrast directly into the bladder through a Foley catheter to distend the bladder beyond the volume an excretory urogram is capable of doing during a CT scan. CONCLUSION Based on these data, we conclude that l) gross h e m a t u r i a or microhematuria (more than 50 RBCs/hpf) is the principal indication for evaluation for bladder injury in a patient after blunt trauma, particularly when associated with pelvic fracture; 2) properly performed retrograde cystography is the diagnostic procedure of choice - it is highly reliable, sensitive, and specific in diagnosing intraperitoneal and extraperitoneal rup~ tures of the urinary bladder; and 3) CT failed to show the presence of bladder rupture in each case; this modality was used in our series, and we therefore believe that it should not be considered a reliable method of diagnosing a bladder rupture. 846/49
BLADDER RUPTURE Rehm et al
REFERENCES 1. Carroll PR, Taylor SR, McAninch JW: Major Bladder Trauma: Trauma Maz2agement. Volume II. UrogenitaJ Tratzma. New York, Thieme Stratton, 1985, p 69-80. 2. Cass AS: Bladder trauma in the multiple injured patient. / Uro] 1976;115:667-669.
trauma. J Trazzraa 1984;24:731-734. 7. McMahon R, Hosking D, Ramsey EW, et al: Management of blunt injury to the lower urinary tract. Can J Szzrg 1983;26:415,418.
M e c h a n i s m of d i a g n o s i s and repair. [ Uro] 1984; 132:254-257. 13. Carroll PR, McAninch IW: Major bladder trauma: The accuracy of cystography. J Uro] 1983;130:887 888.
8. Corriene JN, Sandier CM: Management of the ruptured bladder: Seven years of experience with 111 cases. f Trauma 1986~26:830-833.
I4. Fallon B, Wendt TC, Hawtrey CE, et al: Urologic iniury and assessment in patients with fractured pelvis. [ Uro] 1984;131:712-714.
9. Brosman SA: Trauma of the bladder. Surg Gyneco] Obstet 1976;i43:605-608.
15. Antoci JP, Schiff M: Bladder and urethral injuries in patients with pelvic fractures. J Urol 1982;128:25-26.
4. Civil ID, Ross SE, Botehlo G, et al: Routine pelvic radiography in severe blunt trauma: Is it necessary? Ann Eraerg Med 1988;17:488-490.
10. Clark SS, Pruencio RF: Lower urinary tract injuries associated with pelvic fractures: Diagnosis and managernent. Surg Clin North A m 1972;52:I83 201.
16. Sclafani SJA, Beeker JA: Radiologic diagnosis of ex terna] genitourinary trauma. Urol Radiol t985;7:201-~10.
5. Buchholz RW: Injuries of the pelvis and hip. Emerg Med C]in North A m 1984;2:330-346.
It. Tile M: Pelvic fractures: Operative vs nonoperative treatment. Orthop Cffn North A m 1980;11:423-434.
6. Cass AS: The multiple injured patient with bladder
[2. Carroll PR, McAuinch JW: Major bladder trauma:
3. Lowe FC, Fishman EK, Oesterling JE, et a[: Computerized tomography in diagnosis of bladder rupture. Uro]ogy 1989~33:341-343.
50/847
Annals of Emergency Medicine
17. Mee SL, McAninch JW, Federle MP, et al: Computerized tomography in bladder rupture: Diagnostic limitations. J Uro] 1987;137:207209.
20:8 August 1991
Blunt Traumatic Bladder Rupture: The Role of Retrograde Cystogram Study objective: We evaluated the importance of microscopic and gross hematuria and the role of retrograde cystography and computed tomography (CT) in the diagnosis of blunt traumatic bladder rupture. Design: All cases at a Level I trauma center between January 1, 1986, and March 31, 1989, were reviewed retrospectively. Setting: Level I trauma center, university hospital. Type of participants: All patients with acute blunt abdominal trauma admitted to this Eevel [ trauma center. Interventions: The patients' charts were reviewed with emphasis on mode of diagnosis, treatment, and outcome. Measurements and main results: Twenty-one patients had bladder rupture. All 21 had hematuria with more than 50 RBCs/high-power field, 17 gross and four microscopic. TWenty patients underwent retrograde cystography, which accurately identified bladder rupture, and one was found at laparotomy for other injuries. Seven patients had CT of the abdomen and pelvis, which failed to demonstrate bladder rupture. There were no associated urethral injuries in any of the patients with bladder rupture. Conclusion: Significant (more than 50 RBCs/high-power field) hematuria is the principal indication ,for evaluation for blunt bladder injury, and retrograde cystography is the diagnostic procedure of choice. CT is neither sensitive nor specific enough as primary diagnostic modality, [Rehm CG, Mure AJ, O'Malley KF, Ross SE: Blunt traumatic bladder rupture: The role of retrograde cystogram. Ann Emerg Med August 1991; 20:845-847.]
Christina G Rehm, MD Anthony J Mure, MD, FACS Keith F O'Malley, MD, FACS Steven E Ross, MD, FACS Camden, New Jersey From the UMDNJ/Robert Wood Johnson Medical School at Camden; and Department of Surgery, Division of Trauma, Cooper Hospital/University Medical Center, Camden, New Jersey. Received for publication May 23, 1990. Revision received January 14, 1991. Accepted for publication February 17, 1991. Presented at the Society for Academic Emergency Medicine Annual Meeting in Minneapolis, Minnesota, May 1990. Address for reprints: Christina G Rehm, MD, Division of Trauma, Three Cooper Plaza, Suite 411, Camden, New Jersey 08103.
INTRODUCTION Ruptures of the urinary bladder are most frequently seen in the multiply injured patient, ~ and associated injuries may lead to a mortality rate as high as 44%.2 Delay in the diagnosis and treatment of the ruptured bladder may substantially increase expected mortality. 2,g Early diagnosis demands a highly sensitive, specific, and expeditious plan of identification and management, balanced with the requirements of care for concomitant severe injuries. To evaluate the significance of gross and microscopic hematuria in the identification of patients with bladder rupture secondary to blunt injury as well as the role of retrograde cystogram and computed tomography (CT) in the radiographic evaluation of these patients, we undertook a retrospective review of all cases of bladder rupture managed at our Level I trauma center. MATERIALS A N D M E T H O D S During the 39-month study period of January 1, I986, through March 31, 1989, patients at risk for bladder rupture because of blunt abdominal trauma and/'or pelvic fracture underwent anteroposterior radiographs of the pelvis and complete urinalysis with microscopic examination. 4,5 Retrograde cystogram with 300 mL of contrast material (43% i o t h a l a m a t e meglumine)6, 7 including a post-void or washout film was performed in the resuscitation area on patients suspected of having bladder injury on the basis of pelvic fracture and hematuria or hematuria combined with a highrisk mechanism of injury (ie, direct blow to the lower abdomen). Cystograms were performed in the anteroposterior projection only because of the
48/845
Annals of Emergency Medicine
20:8 August I991
BLADDER RUPTURE Rehm et al
risk associated with positioning hemodynamically unstable multiply injured patients, especially with a pelvic fracture. Therefore, a post-void or washout film was m a n d a t o r y for complete radiographic evaluation. CT of abdomen and pelvis with IV contrast also was obtained, for evaluation of a pelvic fracture, in a number of these patients.
RESULTS Seven hundred nineteen patients were at risk for bladder rupture because of blunt abdominal t r a u m a and/or pelvic fracture during the study period. Twenty-one patients had bladder injury with diagnosed bladder rupture, and all had associated major injuries; 18 {86%) presented with pelvic fracture. Seven patients arrived at the center in hypovolemic shock (systolic blood pressure of less than 90 m m Hg), all of whom had unstable pelvic fractures. I n j u r y Severity Score (ISS) ranged from 9 to 75, with a mean of 30. Mean ISS for the 13 survivors was 23, and for the eight mortalities was 48. There were 11 male patients and ten female patients; ages ranged from 14 to 87 years. All patients had RBCs in their urine. S e v e n t e e n p r e s e n t e d w i t h gross hematuria and four with microhematuria (more than 50 RBCs/highpower field [hpf]). None had fewer than 50 RBCs/hpf. All four cases with microhematuria had an associated unstable pelvic fracture. The three patients with bladder ruptures occurring without pelvic fracture presented with gross hematuria. Cystography performed in 20 patients accurately identified bladder rupture in each case. No patients were determined clinically or by postmortem examination to have a missed bladder injury, and no patient had the diagnosis delayed because of the absence of signs or symptoms. There were no associated urethral injuries in any of the patients with bladder rupture, and none of them showed clinical signs of a possible urethral injury such as blood at the meatus, genital or perineal swelling, or free-floating prostate, all of which would have warranted a retrograde urethrography. All intraperitoneal bladder ruptures w e r e r e p a i r e d s u r g i c a l l y , whereas all of the extraperitoneal bladder ruptures healed with catheter 20:8 August 1991
drainage only; none required surgical repair. Seven of the 21 patients with bladder rupture underwent CT scan of the abdomen and pelvis with W and oral contrast for further delineation of their pelvic fracture. CT scan failed to demonstrate bladder rupture in every patient undergoing this examination. Five patients undergoing CT had intraperitoneal rupture, and CT demonstrated free intraperitoneal fluid. Two patients sustained extraperitoneal ruptures with no abnormality found on CT. DISCUSSION Blunt injury to the bladder is most often seen in combination with a pelvic fracture, and the reported association ranges from 70% to 95%. 2,8,9 Conversely, 5% to 30% of patients with pelvic fractures will have a bladder injury, lo, 11 Most authors recommend a properly performed retrograde cystogram as the mainstay of diagnosis.2,~2, L3 This study must include adequate distension of the bladder with at least 300 mL of contrast and avoidance of overlying objects or spilled contrast medium. The use of postvoid or washout films is mandatory, as explained previously. This study is the keystone to diagnosis 7 and resulted in 100% accuracy in this series, detecting both intraperitoneal and extraperitoneal bladder ruptures. An undisputed indication for such evaluation of the bladder is gross hematuria, m but controversy exists regarding the need for retrograde cystogram in patients with microscopic hematuria. Cass maintained that the presence of microscopic hematuria is an indication for immediate retrog r a d e cystogram,2,6,14 w h e r e a s Fallon 14 and Antoci 15 concluded that only gross hematuria or other clinical signs such as blood at the meatus, genital or perineal swelling, or freefloating prostate warrant evaluation of the lower genitourinary tract. In a series of 417 injured patients with bladder rupture, Cass documented 12 cases with fewer than 50 RBCs/hpf and 13 cases with no blood in the urine. 6 This was a mixed series of blunt and penetrating trauma, and it is uncertain whether any of those injuries with few or no RBCs in the urine may have resulted from penetrating trauma. In Fallon's series of 77 patients with microhematuria, Annals of Emergency Medicine
only one sustained a serious urologic injury, and none of Antoci's 120 patients with pelvic fractures and mic r o h e m a t u r i a had significant uropathology. The use of abdominal CT for the diagnosis of intra-abdominal injury is well established. This has been espec i a l l y a t t r a c t i v e in t h e h e m o dynamically stable patient with pelvic fracture and hematuria, where CT not only provides information regarding the extent of the bony injury but also substitutes for diagnostic peritoneal lavage and IV pyelogram. Some authors support this technique for the diagnosis of bladder rupture;3,16 however, use of CT scan for this purpose is not widely accepted. Serious shortcomings in assessing injuries of the urinary bladder have been reported. The findings in this series support those of Mee et al.t7 In our patients with known bladder rupture undergoing CT, the diagnosis of a r u p t u r e d bladder could not be made, even in retrospect. As stated by Mee et al, although CT depicts int r a p e r i t o n e a l and e x t r a p e r i t o n e a l fluid sensitively, it cannot differentiate urine from ascites and is not helpful in determining the source of this fluid. In addition, during routine abdominopelvic C% the bladder may not be distended sufficiently to demonstrate leak of contrast material through an existing bladder rupture. This could be corrected by also injecting contrast directly into the bladder through a Foley catheter to distend the bladder beyond the volume an excretory urogram is capable of doing during a CT scan. CONCLUSION Based on these data, we conclude that l) gross h e m a t u r i a or microhematuria (more than 50 RBCs/hpf) is the principal indication for evaluation for bladder injury in a patient after blunt trauma, particularly when associated with pelvic fracture; 2) properly performed retrograde cystography is the diagnostic procedure of choice - it is highly reliable, sensitive, and specific in diagnosing intraperitoneal and extraperitoneal rup~ tures of the urinary bladder; and 3) CT failed to show the presence of bladder rupture in each case; this modality was used in our series, and we therefore believe that it should not be considered a reliable method of diagnosing a bladder rupture. 846/49
BLADDER RUPTURE Rehm et al
REFERENCES 1. Carroll PR, Taylor SR, McAninch JW: Major Bladder Trauma: Trauma Maz2agement. Volume II. UrogenitaJ Tratzma. New York, Thieme Stratton, 1985, p 69-80. 2. Cass AS: Bladder trauma in the multiple injured patient. / Uro] 1976;115:667-669.
trauma. J Trazzraa 1984;24:731-734. 7. McMahon R, Hosking D, Ramsey EW, et al: Management of blunt injury to the lower urinary tract. Can J Szzrg 1983;26:415,418.
M e c h a n i s m of d i a g n o s i s and repair. [ Uro] 1984; 132:254-257. 13. Carroll PR, McAninch IW: Major bladder trauma: The accuracy of cystography. J Uro] 1983;130:887 888.
8. Corriene JN, Sandier CM: Management of the ruptured bladder: Seven years of experience with 111 cases. f Trauma 1986~26:830-833.
I4. Fallon B, Wendt TC, Hawtrey CE, et al: Urologic iniury and assessment in patients with fractured pelvis. [ Uro] 1984;131:712-714.
9. Brosman SA: Trauma of the bladder. Surg Gyneco] Obstet 1976;i43:605-608.
15. Antoci JP, Schiff M: Bladder and urethral injuries in patients with pelvic fractures. J Urol 1982;128:25-26.
4. Civil ID, Ross SE, Botehlo G, et al: Routine pelvic radiography in severe blunt trauma: Is it necessary? Ann Eraerg Med 1988;17:488-490.
10. Clark SS, Pruencio RF: Lower urinary tract injuries associated with pelvic fractures: Diagnosis and managernent. Surg Clin North A m 1972;52:I83 201.
16. Sclafani SJA, Beeker JA: Radiologic diagnosis of ex terna] genitourinary trauma. Urol Radiol t985;7:201-~10.
5. Buchholz RW: Injuries of the pelvis and hip. Emerg Med C]in North A m 1984;2:330-346.
It. Tile M: Pelvic fractures: Operative vs nonoperative treatment. Orthop Cffn North A m 1980;11:423-434.
6. Cass AS: The multiple injured patient with bladder
[2. Carroll PR, McAuinch JW: Major bladder trauma:
3. Lowe FC, Fishman EK, Oesterling JE, et a[: Computerized tomography in diagnosis of bladder rupture. Uro]ogy 1989~33:341-343.
50/847
Annals of Emergency Medicine
17. Mee SL, McAninch JW, Federle MP, et al: Computerized tomography in bladder rupture: Diagnostic limitations. J Uro] 1987;137:207209.
20:8 August 1991