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

3. 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

4. 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

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

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

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

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

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

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

11. Issues Raised
Initial assessment
Investigation
Treatment

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

13. 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 #

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

15. 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)

16. 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

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

18. 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

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

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

21. 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

22. 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?

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

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

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

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

27. RUG – Posterior Rupture

28. RUG – Disrupted Diaphragm

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

30. 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

31. 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)

32. 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

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

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

35. Extra-peritoneal Rupture

36. Extra-peritoneal Rupture

37. Intra-peritoneal Rupture

38. 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

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

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

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

42. 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)

43. 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

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

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

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

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

48. 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

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