1. Classification of bladder and urethral trauma Ivo Dukic Arie Parnham Mr Jones

2. MCQ 1. A man has sustained a urethral injury, 2 days after his injury he develops a ‘butterfly pattern of perineal bruising’ (Picture). Which eponymous anatomical layer has ruptured?Picture a)Dartos b)Scarpa’s c)Colles’ d)Camper’s e)Buck’s

4. MCQ 2. A man is brought to Accident and Emergency following a motor vehicle accident. He has extensive injuries but is stable. He has sustained a pelvic fracture and has bleeding per urethra. You decide to perform a cystogram. What is the minimum amount of dilute contrast agent that you need to instil to perform a cystogram with high accuracy : a)150 ml b)250 ml c)350 ml d)400 ml e)600 ml

5. MCQ 3. You perform a cystogram to identify a bladder rupture but forget to carry out a post-drainage film. What is the chance that you have missed a significant bladder injury? a)1% b)2% c)5% d)10% e)30%

6. MCQ 4. A patient sustains significant trauma after a fall from 4 stories. As a part of their trauma imaging you obtain a CT Cystogram (Picture). What would be your next management?Picture a)Insert a suprapubic catheter and observe on the ward b)Insert a urethral catheter and observe on the ward c)Observe on ward and watch for signs of deterioration prior to consideration of emergency surgery d)Insert a urethral catheter and ask an interventional radiologist to insert a drain into the peritoneal cavity to drain any urine e)Take the patient for an emergency exploratory laparotomy and perform a two-layer bladder wall closure

8. MCQ 4. A patient sustains significant trauma after a fall from 4 stories. As a part of their trauma imaging you obtain a CT Cystogram (Picture). What would be your next management?Picture a)Insert a suprapubic catheter and observe on the ward b)Insert a urethral catheter and observe on the ward c)Observe on ward and watch for signs of deterioration prior to consideration of a laparotomy d)Insert a urethral catheter and ask an interventional radiologist to insert a drain into the peritoneal cavity to drain the urine e)Take the patient for an emergency exploratory laparotomy and perform a two-layer bladder wall closure

9. MCQ 5. A man develops a severe penile pain during sexual intercourse. He immediately loses his erection. When he goes to pass urine he passes visible blood. You perform a urethogram (Picture). What is the correct diagnosisPicture a)Stretch injury b)Contusion c)Partial disruption of anterior urethra d)Complete disruption of anterior urethra e)Complete disruption of posterior urethra

11. EMQ 1.The patient has sustained an intra-peritoneal laceration which measures at least 4 cm in diameter. Please select the appropriate grade of injury Grade I Grade II Grade III Grade IV Grade V Grade VI

12. EMQ 2. A patient has sustained partial thickness laceration of the bladder wall on a CT Cystogram. Please select the appropriate grade of injury. Grade I Grade II Grade III Grade IV Grade V Grade VI

13. EMQ 3. A patient has sustained an extra-peritoneal laceration measuring 3 cm. Please select the appropriate grade of injury from the options below. Grade I Grade II Grade III Grade IV Grade V Grade VI

14. Bladder injury scale (EAU adaptation from AAST) GradeDescription IHaematomaContusion, intramural hematoma LacerationPartial thickness IILacerationExtraperitoneal bladder wall laceration <2 cm IIILacerationExtraperitoneal (>2 cm) or intraperitoneal (<2 cm) bladder wall laceration IVLacerationIntraperitoneal bladder wall laceration >2 cm VLacerationIntraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral orifice (trigone)

15. Urethral injuries Classification by mode –Traumatic –Iatrogenic Classification by relation to urogentinal diaphragm –Anterior –Posterior

16. Urethral trauma. Part I: introduction, history, anatomy, pathology, assessment and emergency management Contusion Partial laceration Complete laceration BJU International Volume 108, Issue 3, pages 310-327, 19 JUL 2011 DOI: 10.1111/j.1464-410X.2011.10339.x http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10339.x/full#f14 Volume 108, Issue 3, http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10339.x/full#f14

17. GradeDescriptionAppearance IContusionBlood at urethral meatus Normal urethrogram IIStretch injuryElongation of the urethra without extravasation on urethography IIIPartial disruptionExtravasation of contrast at injury site with contrast visualised in bladder IVComplete disruptionExtravasation of contrast at injury site without visualisation in the bladder, < 2 cm of urethral seperation VComplete disruptionComplete transection with >2 cm urethral seperation or extension into the prostate or vagina Urethral injury (American associatoin for Surgery of Trauma )

18. Classification of blunt anterior and posterior urethra injuries (EAU Guidelines combination of systems) GradeDescriptionAppearance IStretch injuryElongation of the urethra without extravasation on urethrography IIContusionBlood at the urethral meatus. No extravasation on urethrography IIIPartial disruption of anterior or posterior urethra Extravasation of contrast at injury site with contrast visualised in proximal urethra or bladder IVComplete disruption of anterior urethra Extravasation of contrast at injury site without visualisation of proximal urethral or bladder VComplete disruption of posterior urethra Extravasation of contrast at injury site without visualisation of bladder VIComplete partial disruption of posterior urethra with associated tear of the bladder neck or vagina

19. Management Grade I – no treatment required Grade II / III – SPC or urethral catheterisation Grade IV and V open or endoscopic treatment, primary or delayed Grade VI requires primary open repair