Question

35 year-old male presents after a motor vehicle crash. No blood seen at the meatus of the penis and a Foley catheter is placed (see photo below). What's the next diagnostic step?

Answer

Answer: Retrograde cystogram

Traumatic bladder rupture

Gross or microscopic hematuria (>50 RBCs per high-power field) following blunt trauma requires a retrograde cystogram to evaluate for bladder injury. If blood is present at the meatus, however, urethral injury (not discussed) should be suspected and retrograde urethrogram should be performed before passing a Foley catheter.

A retrograde cystogram is performed by infusing diluted contrast into the bladder (200-400 mL) to gently distend the bladder and allow visualization of potential rupture(s). A CT scan of the abdomen and pelvis is then performed to determine if any contrast has leaked from the bladder; alternatively an AP pelvis can also be used, but is not as sensitive as CT.

Traumatic bladder ruptures are categorized as either intra-peritoneal or extra-peritoneal (note: X-ray below demonstrates extra-peritoneal rupture).

Treatment for bladder rupture:

• Extra-peritoneal bladder rupture typically requires only 1-3 weeks of Foley catheter; the catheter can be removed after a successful voiding trial.  
• Intra-peritoneal bladder rupture requires an exploratory laparotomy because this injury does not heal on its own. Urine draining into the abdominal cavity may cause complications such as urinary ascites and electrolyte imbalances.  

Prognosis is typically good for either injury.

References

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