antegrade ureteral stent (retrograde ureteral

for urethral injury: the finding of an inferomedial

stent is difficult and often unsuccessful in this

pubic bone fracture or symphysis diastasis pre-

situation). Urinomas can be effectively managed

dicts urethral injury with a sensitivity of 92% and

by placing a percutaneous drain. Complications

specificity of 64%.39

of nondiagnosed ureteral injuries include fistu-

An algorithm for the diagnosis and treatment

las, urinomas, and abscesses.

of bladder and urethral injuries is presented in

Fig. 36.3. It should be emphasized that CT with

Bladder and Posterior Urethra

delayed images is inadequate for the diagnosis

of bladder injuries: when bladder injury is sus-

pected, a cystogram is mandatory.40 Because

In the adult, the bladder lies in the true pelvis

coincident upper and lower tract injuries are

and, when not grossly distended, is well pro-

rare (occurring in 0.4% of all trauma patients)

tected from injury. As it fills, the dome, which is

and bladder injury from blunt abdominal

covered by peritoneum, rises into the abdomen

trauma is associated with pelvic fracture in the

and is no longer protected by the bony pelvis.

vast majority of cases, it has been suggested that

Therefore, injuries to the bladder from blunt

a cystogram should be reserved for those with

abdominal trauma in an adult nearly always

gross hematuria and concomitant pelvic frac-

result from a direct blow to the abdomen in the

ture or clinical signs of bladder injury.37

presence of a distended bladder, or from com-

Others have suggested that patients with pel-

pression of the pelvic contents following pelvic

vic fractures that are known to be associated

fracture. In the child, the bladder is almost

with bladder injury (e.g., diastasis of the pubic

entirely an abdominal organ and is much more

symphysis or SI joint and sacral fractures)

susceptible to injury from penetrating and blunt

should also be evaluated with a cystogram, even

trauma than the adult bladder. The posterior

in the absence of hematuria.41 Cystogram is rec-

urethra is also well protected by the bony pelvis,

ommended in all cases of gross or microscopic

but can be partially or completely transected in

hematuria following penetrating trauma to the

adults and children following pelvic fracture.

bladder region. The 2002 Consensus Statement

Early diagnosis and proper initial management

on Bladder Injuries42 categorizes these injuries

of bladder and posterior urethral injuries is crit-

based on appearance of the cystogram: contu-

ical to avoiding life-threatening acute complica-

sion (usually a mucosal or muscularis injury

tions and potentially debilitating long-term

without extravasation), intraperitoneal rupture,

complications.

extraperitoneal rupture, and combined intra-

Gross hematuria is the hallmark sign of injury

and extraperitoneal rupture.

to the bladder, present in greater than 95% of

All patients with suspected urethral injury

bladder ruptures from both blunt and penetrating

should undergo retrograde urethrogram (RUG).

injury37; clinical findings can include suprapubic

There are a number of classification schemes for

pain, dysuria, ileus, or an acute abdomen. The

urethral injury, most of which are modifications

triad of urinary retention, blood at the meatus,

of the system proposed in 1977 by Colapinto and

and high-riding prostate is the classic presenta-

McCallum.43 However, these have proven to be

tion of patients with injuries to the posterior ure-

complex and of minimal clinical utility, and in

thra, present in 91%, 87%, and 64% of these

2004,a consensus panel on urethral trauma44 pro-

patients,respectively.38 DRE is useful for detecting

posed a new classification system (Table 36.1).

rectal injuries, which are associated with 5% of

The essential information to be obtained from

pelvic fractures and may affect management of an

the RUG (reflected in this new scheme) is the

associated bladder injury, but is less useful in

location of the injury (anterior or posterior),

diagnosing urethral injury, as swelling and edema

extent of the injury (partial or complete), and

can obscure the exam. When urethral or bladder

whether the bladder neck is involved, as up to

injury is suspected in a female, a full pelvic exam

half of these patients have no functional distal

should be performed to rule out vaginal and rectal

sphincter at follow-up and presumably rely on

injuries. Computed tomography, which is rou-

the bladder neck for continence.45 As concomi-

tinely performed on patients with pelvic fracture,

tant bladder injuries occur in 10–20% of patients

has an increasingly important role in screening

with posterior urethral injuries, all patients with

fracture is being considered, then open repair

be performed at 7–10 days, as up to 15% may

of the bladder at the same setting should be

have a persistent leak at that time.54 If there is

strongly considered in order to minimize the

no leak, the catheter should be removed; if there

potential for infected hardware as a result of

is a leak, the cystogram can be repeated every

extravasated urine.50

3–4 days.

Maintenance of adequate bladder drainage

and minimization of infectious complications

Posterior Urethral Disruption:

are critical to successful nonoperative manage-

ment.The patient should be started immediately

Immediate Management

on prophylaxis for gram-positive and gram-

negative organisms, and the bladder should be

Patients who suffer posterior urethral distrac-

drained with a large bore Foley catheter, prefer-

tion injuries typically have a number of associ-

ably 22-fr or greater. If there is difficulty main-

ated life-threatening injuries and as many as

taining reliable drainage after the first 24–48 h,

50% of these patients will die of related injuries

the patient should undergo exploration and for-

during the initial hospitalization. Therefore,

mal closure.

the primary objective of the urologist is to

establish prompt, reliable drainage of the blad-

Bladder Injuries: Formal Repair

der so as to avoid potentially fatal complica-

tions related to urinary extravasation and to

In all cases, the bladder should be approached

facilitate stabilization of associated injuries.48

through a midline incision, with careful inspec-

This is best accomplished with immediate

tion of the peritoneal contents for associated

placement of a suprapubic catheter, though a

injuries51 or penetrating injuries; the tract should

single attempt at passing a well lubricated ure-

be carefully inspected and all foreign bodies

thral catheter is reasonable. The urethral defect

should be removed. The bladder should be

can be treated in a delayed fashion or with early

inspected for other injuries and repaired trans-

endoscopic realignment.

vesically. Intraperitoneal injuries typically have

In one large study that is consistent with sev-

large rents, which can be widened in order to

eral similar but smaller studies, 100% of patients

adequately inspect the remainder of the bladder.

who did not undergo endoscopic realignment

For penetrating and extraperitoneal injuries, we

developed clinically significant strictures and

typically make a large longitudinal incision in

47% eventually required perineal urethroplasty.

the anterior bladder.

Among patients who underwent early endo-

Following penetrating trauma, it is essential

scopic realignment, 49% developed stricture

to visualize efflux of clear urine from each ure-

and 25% eventually required perineal urethro-

teral orifice; if this is not possible, or if efflux is

plasty. The early realignment group required

bloody, retrograde pyelography is indicated to

fewer procedures (1.6 vs 3.1) and experienced a

assess for ureteral injury. Bone fragments, for-

slightly lower incidence of impotence and incon-

eign bodies, and devitalized tissue should be

tinence than the delayed reconstruction group.

removed, and injuries to the bladder neck and

Though there is a clear selection bias in these

vagina should be repaired. Pelvic hematomas

studies (stable patients were more likely to

should not be entered. The bladder should be

undergo early realignment), it is clear that early

closed in 2 layers with 3-0 absorbable suture.

endoscopic realignment is worthwhile in stable

Bladder drainage can be safely accomplished

patients with posterior urethral distraction

with a large suprapubic tube placed through a

injuries.38

separate stab incision or alternatively with a

large urethral Foley.52

Posterior Urethral Disruption:

If internal fixation is being considered, supra-

pubic drainage should be avoided because of

Endoscopic Realignment

the risk of wound infection and subsequent

hardware infection.50,53 Drains are not neces-

Endoscopic realignment can be performed as

sary. The suprapubic tube or Foley catheter can

soon as the patient is stabilized and associated

be removed 5–7 days after repair of intraperito-

intraabdominal or pelvic injuries have been

neal rupture or penetrating trauma. For extrap-

addressed. The patient should be warm, and any

eritoneal bladder ruptures, a cystogram should

coagulopathies should be corrected. Positioning