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Lower Urinary Tract Injury and Pelvic Trauma
Rodrigo Donalisio da Silva, MD, Fernando J. Kim, MD, MBA, FACS
CHAPTER 32
LOWER URINARY TRACT INJURY AND PELVIC TRAUMA
1. What are the causes of bladder injury? Bladder injury can be caused by trauma or iatrogenic manipulation. Traumatic bladder injuries can be classified as intraperitoneal or extraperitoneal, blunt or penetrating. The most common sign of bladder injury is gross hematuria. Other signs of bladder injury are pelvic pain, inability to void, or incomplete recovery of catheter irrigation. 2. What types of bladder injury may occur with blunt trauma? Blunt trauma to the bladder can cause bladder contusion or intraperitoneal or extraperitoneal bladder rupture. Gross hematuria with normal cystography in the absence of upper tract injuries defines bladder contusion. Extraperitoneal injury is the most common bladder injury. Usually it is located at the bladder base. Extraperitoneal injuries can be managed conservatively with bladder drainage with a Foley catheter for 7–10 days. Intraperitoneal bladder ruptures usually occur at the bladder dome, caused by a blunt trauma in a distended bladder. These lesions should be repaired surgically using a two-layer closure with absorbable suture and bladder drainage with a Foley catheter for 7–10 days. Before removing the Foley catheter, a computerized axial tomography (CAT) cystogram should be performed to confirm proper bladder healing. 3. What is the likelihood of a bladder injury in patients with a fractured pelvis? Extraperitoneal bladder injury occurs in 10% of all pelvic fractures. Conversely, approximately 85% of blunt bladder injury is associated with pelvic fracture. Bladder injuries occur more often with parasymphyseal pubic arch fractures and more often with bilateral than unilateral fractures. Isolated ramus fractures produce bladder laceration in 10% of cases. 4. How is bladder injury evaluated? CAT cystography provides diagnostic accuracy when performed with the bladder filled with 300–400 mL of 50% diluted contrast agent using the Foley catheter under gravity. If CAT scan is not available, voiding cystogram should be performed with postvoid images. 5. What are the retrograde cystourethrographic patterns of bladder injury? Bladder contusion has a normal cystography in the presence of gross hematuria and absence of upper urinary tract injury. In the extraperitoneal bladder rupture, contrast is seen adjacent and confined to the bladder base. In intraperitoneal bladder rupture, the contrast extravasation is seen at the dome of the bladder, usually delineating bowel loops, or collected in the gutters. 6. How is bladder rupture managed? Bladder contusion requires drainage until gross hematuria is resolved. Extraperitoneal rupture can be managed conservatively with indwelling catheter for 7–10 days. If laparotomy is performed, bladder injury can be repaired. Intraperitoneal bladder injuries should be managed surgically. In selected cases, laparoscopic repair can be performed. Cystography should be performed to confirm resolution of extravasation before removing the catheter (approximately 14 days after injury and drainage). 7. When should you suspect urethral injury? The presence of blood in the urethral meatus associated with trauma mechanism (straddle injury, trauma to the genitals, pelvic fracture). Penile, scrotal swelling and ecchymosis, inability to void, and inability to pass a urethral catheter should be investigated for urethral injury. In males, digital rectal exam can reveal total disruption of the urethra when the prostate is not palpable. In females, urethral disruption results from severe mechanism of injury, and it is associated with high mortality.
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146 TRAUMA 8. When patients present with pelvic fracture, is concomitant urethral injury a major concern? Yes. Concomitant urethral injury occurs in approximately 10% of patients with pelvic fracture. It is more common in anterior disruption of the pelvic ring. Unilateral fracture is associated with 20% of urethral injury and bilateral fractures, 50%. 9. How are urethral injuries diagnosed? Retrograde urethrography (RUG) must be performed in all cases that a urethral injury is suspected. Incomplete urethral disruption will demonstrate contrast extravasation in the urethra with bladder opacification. Total disruption of the urethra will show extensive contrast extravasation, and the bladder will not receive much or any contrast. 10. How is urethral injury managed? Incomplete urethral transection can be managed by catheter stenting across the injury. This should be performed by a urologist who will use cystoscopy to pass a guide wire up to the bladder. A council tip Foley catheter will be passed using the guide wire. Complete transection of the urethra can be managed with early endoscopic urethral realignment when possible. Diversion by suprapubic cystostomy should be used when primary realignment fails or when the patient is too unstable to proceed with primary realignment. Patients often require some type of surgical reconstruction or dilatation of the urethra. 11. What are the complications of urethral injury? The most common long-term complication of urethral injury is urethral stricture. Erectile dysfunction can occur in posterior total urethral disruption associated with pelvic fracture. 12. What is the differential diagnosis of blunt scrotal trauma? Testicular rupture, hematocele, scrotal hematoma, intratesticular hematoma, and testicular torsion. Ultrasonography is a helpful diagnostic tool to differentiate among the possible diagnoses. 13. What is the sonographic sign of testicular rupture? The loss of the normal homogeneous echo texture of the testicle, with areas of hyperechogenicity or hypoechogenicity. 14. How is testicular rupture managed? When suspicious for testicular rupture in the ultrasonography, surgical exploration should be performed. Debridement of the extruded, nonviable testicular tissue should be performed, followed by tunica albuginea repair. Evacuation of the hematoma and careful hemostasis should be performed. Some cases will require orchiectomy because of the lack of viable remaining testicular tissue. 15. What is the most common cause of penile fracture? Sexual intercourse or aggressive masturbation is associated with penile fracture. Rupture of the corpus cavernosum occurs when abnormally forced bending of the erect penis. A popping sound followed by immediate penis detumescence is frequently reported by patients. 16. What are the physical examination findings in a patient with penile fracture? Hematoma and penile deviation of the penile shaft to the opposite side of the rupture. The hematoma will be confined to the penis (eggplant deformity) if the Buck’s fascia is intact. Rupture of the Buck’s fascia will cause hematoma in the perineum and abdominal wall because the blood will spread under the Colle’s and Scarpa’s fascia. 17. How do you treat a penile fracture? Treatment of penile fracture is surgical repair. The penile shaft should be exposed by degloving the penis to identify the defect(s). Concomitant urethral injury can occur in up to 20% of the cases. RUG should be performed if urethral injury is suspected. 18. In penile amputation injuries, how should the amputated portion of the penis be preserved for transport? The amputated portion of the penis should be wrapped in saline-soaked gauze and placed in a sealed sterile bag, and then the bag containing the protected penis is placed in an ice-slush bath (doublebag procedure). The ice should not be in direct contact with the penis. Penile reimplantation should be performed within the first 24 hours.
Lower Urinary Tract Injury and Pelvic Trauma 147 19. How do you manage a major scrotal loss? If primary repair is not possible, meshed split-thickness grafts may be used to cover the testis. When delayed repair is necessary, thigh pouches can be created until permanent reconstruction is feasible. 20. What are the most common causes of vesicovaginal fistulas? Obstetric (prolonged childbirth), trauma, and iatrogenic. Vesicovaginal fistula presents clinically as urinary leakage through the vagina. 21. What is the best time to repair a vesicovaginal fistula secondary to an uncomplicated hysterectomy? Although 3–6 months after injury has been recommended in the past, early repair can be successful if there is minimal inflammation and there is no complicating factors. Repair can be done with open surgery, laparoscopy, or vaginal approach.
K EY POIN T S: LOWE R UR I N A RY T R A C T I N J URY A N D P ELV IC T RAU MA 1 . Extraperitoneal bladder rupture can be managed with urinary Foley catheter only. 2. Intraperitoneal bladder rupture should be managed with surgical repair. 3. Urethral injuries should be diagnosed with RUG and managed with urinary catheter acutely. 4. Penile fracture should be managed surgically. 5. Testicular injuries should be managed surgically.
Bibliography 1. Kim FJ, Chammas Jr MF. Laparoscopic management of intraperitoneal bladder rupture secondary to blunt abdominal trauma using intracorporeal single layer suturing technique. J Trauma. 2008;65(1):234–236. 2. Kim FJ, Pompeo A, Sehrt D, et al. Early effectiveness of endoscopic posterior urethra primary alignment. J Trauma Acute Care Surg. 2013;75(2):189–194. 3. Lumen N, Kuehhas FE, Djakovic N, et al. Review of the current management of lower urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 2015;67(5):925–929. 4. Kim FJ. Genito-urinary Trauma. In: Moore EE, Feliciano DV, eds. Trauma, 8th ed. McGraw Hill. (in press). 5. Morey AF, Brandes S, Dugi DD, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327–335.
CHAPTER 32
LOWER URINARY TRACT INJURY AND PELVIC TRAUMA
1. What are the causes of bladder injury? Bladder injury can be caused by trauma or iatrogenic manipulation. Traumatic bladder injuries can be classified as intraperitoneal or extraperitoneal, blunt or penetrating. The most common sign of bladder injury is gross hematuria. Other signs of bladder injury are pelvic pain, inability to void, or incomplete recovery of catheter irrigation. 2. What types of bladder injury may occur with blunt trauma? Blunt trauma to the bladder can cause bladder contusion or intraperitoneal or extraperitoneal bladder rupture. Gross hematuria with normal cystography in the absence of upper tract injuries defines bladder contusion. Extraperitoneal injury is the most common bladder injury. Usually it is located at the bladder base. Extraperitoneal injuries can be managed conservatively with bladder drainage with a Foley catheter for 7–10 days. Intraperitoneal bladder ruptures usually occur at the bladder dome, caused by a blunt trauma in a distended bladder. These lesions should be repaired surgically using a two-layer closure with absorbable suture and bladder drainage with a Foley catheter for 7–10 days. Before removing the Foley catheter, a computerized axial tomography (CAT) cystogram should be performed to confirm proper bladder healing. 3. What is the likelihood of a bladder injury in patients with a fractured pelvis? Extraperitoneal bladder injury occurs in 10% of all pelvic fractures. Conversely, approximately 85% of blunt bladder injury is associated with pelvic fracture. Bladder injuries occur more often with parasymphyseal pubic arch fractures and more often with bilateral than unilateral fractures. Isolated ramus fractures produce bladder laceration in 10% of cases. 4. How is bladder injury evaluated? CAT cystography provides diagnostic accuracy when performed with the bladder filled with 300–400 mL of 50% diluted contrast agent using the Foley catheter under gravity. If CAT scan is not available, voiding cystogram should be performed with postvoid images. 5. What are the retrograde cystourethrographic patterns of bladder injury? Bladder contusion has a normal cystography in the presence of gross hematuria and absence of upper urinary tract injury. In the extraperitoneal bladder rupture, contrast is seen adjacent and confined to the bladder base. In intraperitoneal bladder rupture, the contrast extravasation is seen at the dome of the bladder, usually delineating bowel loops, or collected in the gutters. 6. How is bladder rupture managed? Bladder contusion requires drainage until gross hematuria is resolved. Extraperitoneal rupture can be managed conservatively with indwelling catheter for 7–10 days. If laparotomy is performed, bladder injury can be repaired. Intraperitoneal bladder injuries should be managed surgically. In selected cases, laparoscopic repair can be performed. Cystography should be performed to confirm resolution of extravasation before removing the catheter (approximately 14 days after injury and drainage). 7. When should you suspect urethral injury? The presence of blood in the urethral meatus associated with trauma mechanism (straddle injury, trauma to the genitals, pelvic fracture). Penile, scrotal swelling and ecchymosis, inability to void, and inability to pass a urethral catheter should be investigated for urethral injury. In males, digital rectal exam can reveal total disruption of the urethra when the prostate is not palpable. In females, urethral disruption results from severe mechanism of injury, and it is associated with high mortality.
145
146 TRAUMA 8. When patients present with pelvic fracture, is concomitant urethral injury a major concern? Yes. Concomitant urethral injury occurs in approximately 10% of patients with pelvic fracture. It is more common in anterior disruption of the pelvic ring. Unilateral fracture is associated with 20% of urethral injury and bilateral fractures, 50%. 9. How are urethral injuries diagnosed? Retrograde urethrography (RUG) must be performed in all cases that a urethral injury is suspected. Incomplete urethral disruption will demonstrate contrast extravasation in the urethra with bladder opacification. Total disruption of the urethra will show extensive contrast extravasation, and the bladder will not receive much or any contrast. 10. How is urethral injury managed? Incomplete urethral transection can be managed by catheter stenting across the injury. This should be performed by a urologist who will use cystoscopy to pass a guide wire up to the bladder. A council tip Foley catheter will be passed using the guide wire. Complete transection of the urethra can be managed with early endoscopic urethral realignment when possible. Diversion by suprapubic cystostomy should be used when primary realignment fails or when the patient is too unstable to proceed with primary realignment. Patients often require some type of surgical reconstruction or dilatation of the urethra. 11. What are the complications of urethral injury? The most common long-term complication of urethral injury is urethral stricture. Erectile dysfunction can occur in posterior total urethral disruption associated with pelvic fracture. 12. What is the differential diagnosis of blunt scrotal trauma? Testicular rupture, hematocele, scrotal hematoma, intratesticular hematoma, and testicular torsion. Ultrasonography is a helpful diagnostic tool to differentiate among the possible diagnoses. 13. What is the sonographic sign of testicular rupture? The loss of the normal homogeneous echo texture of the testicle, with areas of hyperechogenicity or hypoechogenicity. 14. How is testicular rupture managed? When suspicious for testicular rupture in the ultrasonography, surgical exploration should be performed. Debridement of the extruded, nonviable testicular tissue should be performed, followed by tunica albuginea repair. Evacuation of the hematoma and careful hemostasis should be performed. Some cases will require orchiectomy because of the lack of viable remaining testicular tissue. 15. What is the most common cause of penile fracture? Sexual intercourse or aggressive masturbation is associated with penile fracture. Rupture of the corpus cavernosum occurs when abnormally forced bending of the erect penis. A popping sound followed by immediate penis detumescence is frequently reported by patients. 16. What are the physical examination findings in a patient with penile fracture? Hematoma and penile deviation of the penile shaft to the opposite side of the rupture. The hematoma will be confined to the penis (eggplant deformity) if the Buck’s fascia is intact. Rupture of the Buck’s fascia will cause hematoma in the perineum and abdominal wall because the blood will spread under the Colle’s and Scarpa’s fascia. 17. How do you treat a penile fracture? Treatment of penile fracture is surgical repair. The penile shaft should be exposed by degloving the penis to identify the defect(s). Concomitant urethral injury can occur in up to 20% of the cases. RUG should be performed if urethral injury is suspected. 18. In penile amputation injuries, how should the amputated portion of the penis be preserved for transport? The amputated portion of the penis should be wrapped in saline-soaked gauze and placed in a sealed sterile bag, and then the bag containing the protected penis is placed in an ice-slush bath (doublebag procedure). The ice should not be in direct contact with the penis. Penile reimplantation should be performed within the first 24 hours.
Lower Urinary Tract Injury and Pelvic Trauma 147 19. How do you manage a major scrotal loss? If primary repair is not possible, meshed split-thickness grafts may be used to cover the testis. When delayed repair is necessary, thigh pouches can be created until permanent reconstruction is feasible. 20. What are the most common causes of vesicovaginal fistulas? Obstetric (prolonged childbirth), trauma, and iatrogenic. Vesicovaginal fistula presents clinically as urinary leakage through the vagina. 21. What is the best time to repair a vesicovaginal fistula secondary to an uncomplicated hysterectomy? Although 3–6 months after injury has been recommended in the past, early repair can be successful if there is minimal inflammation and there is no complicating factors. Repair can be done with open surgery, laparoscopy, or vaginal approach.
K EY POIN T S: LOWE R UR I N A RY T R A C T I N J URY A N D P ELV IC T RAU MA 1 . Extraperitoneal bladder rupture can be managed with urinary Foley catheter only. 2. Intraperitoneal bladder rupture should be managed with surgical repair. 3. Urethral injuries should be diagnosed with RUG and managed with urinary catheter acutely. 4. Penile fracture should be managed surgically. 5. Testicular injuries should be managed surgically.
Bibliography 1. Kim FJ, Chammas Jr MF. Laparoscopic management of intraperitoneal bladder rupture secondary to blunt abdominal trauma using intracorporeal single layer suturing technique. J Trauma. 2008;65(1):234–236. 2. Kim FJ, Pompeo A, Sehrt D, et al. Early effectiveness of endoscopic posterior urethra primary alignment. J Trauma Acute Care Surg. 2013;75(2):189–194. 3. Lumen N, Kuehhas FE, Djakovic N, et al. Review of the current management of lower urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 2015;67(5):925–929. 4. Kim FJ. Genito-urinary Trauma. In: Moore EE, Feliciano DV, eds. Trauma, 8th ed. McGraw Hill. (in press). 5. Morey AF, Brandes S, Dugi DD, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327–335.