Pediatric emergency medicine trisk 3324 3324
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Urethral catheterization must be avoided if physical examination reveals blood
at the urethral meatus or a high-riding prostate as urethral injury is possible.
Urologic consultation is required.
Initial Assessment/Diagnostic Testing
A large, prospective series of pelvic fractures and lower genitourinary tract injury
in pediatric patients found that imaging is not required if patients are stable, have
a normal genitourinary examination, do not have gross hematuria, and do not
have multiple associated injuries. Diagnostic evaluation is indicated in patients
who sustain pelvic or lower abdominal trauma with gross hematuria, inability to
void, abnormal external genitourinary examination, or multiple associated
injuries.
Evaluation begins with a plain radiograph to exclude a pelvic fracture. Fracture
types that have been associated with bladder injury include widening of the
sacroiliac joint, symphysis pubis, and fractures of the sacrum. If a pelvic fracture
is not identified, the urethra can be catheterized and a cystogram is performed.
CT cystography should be performed for patients with suspected bladder injury
after placement of a urethral catheter. Sagittal and coronal multiplanar images
may be helpful in identifying most sites of bladder rupture. CT cystography does
offer some advantages over plain cystography for patients undergoing CT
scanning for the evaluation of other associated blunt injuries. CT scanning
provides expeditious scanning of the head, chest, abdomen, and pelvis;
interpretation is often less affected by overlying bone fragments from pelvic
fractures and spine boards than in the plain radiographic cystogram, and the CT
can detect small amounts of intra- and extraperitoneal fluid, especially in the
posterior position without need for a postdrainage film. The disadvantages of CT
cystography include the much higher radiation exposure and cost than those of
plain radiographs. Currently, the CT cystogram is recommended, when indicated,
for patients undergoing CT scanning for other associated blunt trauma–related
injuries.
With either modality, the bladder must be filled to an age-appropriate volume
(∼350 cc in adults) to avoid missing injuries due to underdistension.
Management
With few exceptions, treatment of bladder rupture is determined by whether the
urine extravasation is confined to the extraperitoneal space or is intraperitoneal.
Extraperitoneal bladder rupture can generally be managed by urethral catheter or
suprapubic drainage. Extraperitoneal injuries with a bony fragment or foreign
body in the bladder require surgical exploration.
