Diagnosing and treatment of genitourinary bladder trauma

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An abdominal examination may reveal distention, guarding or rebound tenderness. Absent bowel sounds and signs of peritoneal irritation may indicate a possible intraperitoneal bladder rupture. Swelling of the scrotum, perineum, abdominal wall and/or thighs may occur.

Cystography
Cystography is the investigation of choice for those patients with non-iatrogenic bladder injury. Plain and CT cystography have similar sensitivities and specificities. A retrograde urethrography is the standard diagnostic investigation for the acute evaluation of a male urethral injury.

Cystoscopy
Cystoscopy is the preferred method for detection of intraoperative bladder injuries, as it may directly visualise the laceration. A routine cystoscopy is recommended at the end of a hysterectomy and every major gynaecological procedure. A flexible cystoscopy can also be used both to diagnose and to manage an acute urethral injury.

CT scan
This is the best test for assessment of stable patients. CT is more sensitive and specific than intravenous pyelogram (IVP), ultrasonography or angiography. Intravenous contrast can be given for renal evaluation.

Ultrasound scan
An ultrasound scan alone is not sufficient in the diagnosis of bladder trauma. An ultrasound scan can be useful to guide the correct placement of a catheter in the acute setting.
Retrograde urethrography: to evaluate the urethra. It is not done in an emergency setting.

Management of genitourinary bladder trauma According to The European Association of Urology, the following guidelines are designed to provide appropriate management of genitourinary trauma;

Medical therapy
Most minor bladder injuries can be managed safely with simple catheter drainage (ie urethral or suprapubic), bed rest and observation. The catheter should be left in situ for 710 days and then a cystogram should be performed.
Surgical therapy Intraperitoneal bladder rupture Intraperitoneal ruptures can lead to sepsis and carry a higher mortality than extraperitoneal injuries. They tend to be large and most commonly occur at the dome of the bladder. All these injuries should be treated with prompt surgical exploration. Urine can continue to leak into the abdominal cavity, resulting in urinary ascites, abdominal distention and electrolyte disturbances.
All gunshot wounds to the lower abdomen should be explored. Patients who have highvelocity missile trauma should be taken to theatre immediately. Here the bladder injuries can be repaired at the same time as any visceral injuries. Stab wounds to the suprapubic area involving the urinary bladder are managed selectively. Obvious intraperitoneal injuries should be surgically repaired.

Conservative treatment may be undertaken for those with uncomplicated intraperitoneal injury after transurethral resection of the bladder (TURB) or not recognised during surgery, but only in the absence of peritonitis and ileus.

Extraperitoneal injury
Extraperitoneal injuries can be managed successfully with a conservative strategy. Catheter drainage followed by a cystogram after 10 days is successful in the majority of cases, with almost all ruptures healed by three weeks. Trauma patients who require emergency laparotomy may have large or complex injuries repaired at the same time.

Urethral injuries
Management of urethral injury is based around the type of injury. Urethral or suprapubic catheterisation should be undertaken. The aim of treatment in urethral trauma is to maintain continence and potency and to reduce the occurrence of strictures. In many cases a urethroplasty is undertaken at a later stage after a stricture has developed.
Complications of bladder surgery Urinary extravasation Wound dehiscence Haemorrhage Pelvic infection Small-capacity bladder De novo urge incontinence Obstructive uropathy Pelvic haematomas may become pelvic abscesses. Impotence is common in patients with extensive perineal injuries. Erectile dysfunction occurs in 20-60% of patients after traumatic urethral rupture.