Management of Lower Urinary Tract Trauma – A Practical Perspective Jeremy Grummet St Vincent’s Hospital Melbourne

Scenario 1 Called to ED at 2am to see Mr F-W Male, 30 Buck’s night for mate at Amanda’s Steak and Grill

Scenario 1 Decided to drive home thinking only had 6 beers in 4 hrs Forgot about Depth Charges in each one Mistook phone booth for freeway entrance

Scenario 1 Slight confusion (shaving cream and D cups) Stable: BP 110/70, HR 100 Suprapubic pain, tender

Scenario 1 IDC had been inserted by ED staff Gross haematuria in bag PXR shows stable pelvic #

Scenario 1 Suspect LUT injury  Order cystogram Radiology reg: Cystogram NAD, presumed bladder contusion Admit for observation

Scenario 1 3 days later, more generalised abdo pain Continued gross haematuria Febrile Rigid abdomen Exploratory laparotomy

Scenario 1 Intraperitoneal bladder rupture Infected urine Repaired SPC No other injury found

Scenario 1 IV AB Prolonged ileus TPN D/C 3 weeks later

Issues Raised Initial assessment Investigation Treatment

Initial Assessment When suspect LUT trauma, must bear in mind: Risk of multiple trauma Anatomical sites Mechanism of injury Physical signs Safety of catheterisation

Risk of Multiple Trauma Bladder trauma series of 51 pts: Mortality 22% (Carroll 1984) None due to bladder injury itself Must suspect other life-threatening injuries E.g. Massive haemorrhage 2° to unstable pelvic #

Anatomical Sites Bladder Posterior urethra (prostatic/membranous) Anterior urethra (distal to urogenital diaphragm)

Mechanism of Injury Blunt vs Penetrating Implications for further assessment Blunt far more common 66-88% in US bladder studies (Carroll 1984, Cass 1987) Likely more so in Australia (100% - small series) (Chan 1994)

Blunt Bladder Trauma Mechanism 85-90% bladder rupture  pelvic # (Morey 2001) Usu. burst or shear (intra- and extra-peritoneal (Corriere 1988) Occ. 2° to spicules from pelvic # if extraperitoneal MVA, esp. if been drinking Fall from height

Posterior Urethra Trauma Mechanism Blunt  pelvic # Membranous urethra passes through urogenital diaphragm  attached to pubic rami Shear usu. at prostatomembranous junction

Anterior Urethra Trauma Mechanism More common than posterior urethra trauma Straddle injuries, e.g. fall off bicycle “Common in Texas if pt is kicked with the toe of a boot” (Campbell’s Urology) Urethra crushed against inf. symphysis

LUT Physical Signs Gross haematuria Pelvic # Inability to void 15% all pelvic #  bladder/urethra injury Inability to void Suprapubic tenderness

LUT Physical Signs Blood at meatus Perineal swelling/haematoma High riding prostate or indistinct landmarks on PR exam

LUT Physical Signs Problems (not covered well in texts): Signs alert you to LUT injury, but do not differentiate well between bladder and urethra E.g. Inability to void

LUT Physical Signs Absence of a sign does not always exclude LUT injury E.g. Does pt with pelvic # and unable to void but no other signs have urethral injury?

LUT Physical Signs Cannot determine ability to void when pt obtunded head trauma intoxication How to assess for haematuria in such a pt?

Catheterisation Often not a priority in trauma setting Risk: Conversion of partial urethral tear to complete When safe if suspect LUT trauma?

Catheterisation When NOT safe: Blood at meatus Pelvic # + gross haematuria/unable to void/perineal haematoma (Chan 1994)

Investigations CXR, PXR RUG indicated when catheterisation unsafe 20-30 ml water-soluble contrast

RUG – Posterior Rupture

RUG – Disrupted Diaphragm

Cystography Performed retrograde Commonly preceded by RUG Indications controversial A former recommendation: all trauma pts with macro- or micro-haematuria (Cass 1987)

Cystography Problems: Pts in series not stratified to blunt vs penetrating Not stratified by degree of haematuria 2/3 pts had bladder contusion only Expensive

Cystography More recent studies show that in pts with pelvic #, risk of bladder rupture if: Gross haematuria: 13-55% Microscopic haematuria: 0-1% (True for blunt trauma, but lower threshold if penetrating)

Cystography Current absolute indication for blunt trauma cystography: pelvic # + gross haematuria (Morey 2001) Softer indications: e.g. micro-haematuria in combination with suprapubic tenderness and inability to void

Cystography Technique crucial Papers advise at least 250-300 ml contrast Less may not expand bladder enough to open up tear Post-drainage film Filling film may obscure extravasation

Types of Bladder Rupture As mentioned before, intra-and extra-peritoneal Extra-peritoneal twice as common Occ. combined

Extra-peritoneal Rupture

Extra-peritoneal Rupture

Intra-peritoneal Rupture

CT Cystography Appears to be as good as cystography Indicated when injury to other abdominal organs also suspected Again, must ensure adequate distension with contrast Conventional cystography still preferred when only looking for bladder rupture

IVP When unable to perform cystography due to urethral injury Still need to exclude concomitant bladder trauma  IVP

Treatment – Intraperitoneal Bladder Rupture Surgery Transperitoneal repair Keep suprapubic cystostomy extraperitoneal Use absorbable sutures

Treatment - Extraperitoneal Bladder Rupture Controversial Proponents of surgical repair: Avoid pelvic haematoma Repair intravesically – midline incision Peritoneotomy

Treatment - Extraperitoneal Bladder Rupture Other option is catheterisation only Only if uninfected urine and no other reason for exploratory surgery Series of 41 extraperitoneal ruptures Healing in all pts with no complications (Corriere 1988)

Treatment – Posterior Urethral Injury Highly controversial Range from immediate repair to suprapubic cystostomy and delayed repair In between, immediate urethral catheter railroading and delayed repair  good results (Devine 1989) Need urologist experienced in urethral reconstruction

Treatment – Anterior Urethral Injury Suprapubic cystostomy catheter Any strictures usu. not severe enough to warrant surgical reconstruction

Mr F-W Similar presentation: Haemodynamically stable Too concussed/drunk to void Tender suprapubically Pelvic # on PXR

Mr F-W You arrive before a catheter has been inserted After ABCs, how would you manage pt?  Panel

Conclusions Think of LUT trauma in the trauma pt Conversely, suspect other more life-threatening injuries in pt with LUT trauma, and manage accordingly

Conclusions Never catheterise before obtaining a negative RUG when blood at meatus Think carefully before catheterising when NO blood at meatus Ensure proper cystography or CT cystography technique

Conclusions Refer to urologist preferably once LUT injury suspected, certainly for treatment As a general rule, avoid instruments as shown at beginning of presentation