Guideline sources The following summarized guidelines for the evaluation and management of bladder trauma are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022), the Eastern Association for the Surgery of Trauma (EAST 2019), the World Society of Emergency Surgery (WSES/AAST 2019), the American College of Radiology (ACR 2019), and the American Urological Association (AUA 2014). 1 2 3 4 5 Guidelines 1. Diagnostic investigations Computed tomography: As per ACR 2019 guidelines, obtain pelvic CT with bladder contrast (CT cystography) for initial evaluation of suspected penetrating trauma to the lower urinary tract. B As per EAST 2019 guidelines: Obtain CT cystography for the diagnosis of bladder rupture in moderate-risk (gross hematuria) and high-risk (gross hematuria and pelvic fracture) patients. B Avoid obtaining routine retrograde CT cystography or radiography for the diagnosis of bladder rupture in low-risk patients (microscopic hematuria only). D https://web.pathway.md/diseases/rec7YPY5Fwjw3naVV 1/4 6/29/23, 3:18 AM Bladder trauma Pathway As per WSES 2019 guidelines, recognize that IV contrast-enhanced CT with delayed phase is less sensitive and specific than retrograde cystography in detecting bladder injuries. B Retrograde cystography: As per EAU 2022 guidelines, obtain cystography with active retrograde filling of the bladder with dilute contrast (300-350 mL): in the presence of visible hematuria and pelvic fracture in case of suspected iatrogenic bladder injury in the postoperative setting to rule out bladder injury during retropubic suburethral sling procedures. A As per ACR 2019 guidelines, obtain fluoroscopy retrograde cystography for initial evaluation of suspected penetrating trauma to the lower urinary tract. B As per WSES 2019 guidelines, obtain retrograde cystography (conventional radiography or CT) as the diagnostic procedure of choice in patients with bladder injuries. B Show 2 more As per AUA 2014 guidelines: Obtain retrograde cystography (plain film or CT) in stable patients with gross hematuria and pelvic fracture. B Obtain retrograde cystography in stable patients with gross hematuria and a mechanism concerning for bladder injury and in patients with pelvic ring fractures and clinical indicators of bladder rupture. B 2. Medical management Non-operative management: As per EAU 2022 guidelines: Offer nonoperative management in patients with uncomplicated blunt extraperitoneal bladder injuries. B Offer nonoperative management in patients with small uncomplicated intraperitoneal bladder injuries during endoscopic procedures. B As per EAST 2019 guidelines, consider offering nonoperative management to decrease complications from bladder injury in patients sustaining blunt abdominopelvic trauma with simple extraperitoneal bladder ruptures. C As per WSES 2019 guidelines: Consider observing patients with bladder contusion clinically with no specific treatment. B Consider managing patients with uncomplicated blunt or penetrating extraperitoneal bladder injuries nonoperatively with urinary drainage via a urethral or suprapubic catheter, in the absence of other indications for laparotomy. B 3. Surgical interventions https://web.pathway.md/diseases/rec7YPY5Fwjw3naVV 2/4 6/29/23, 3:18 AM Bladder trauma Pathway Indications for surgery: As per EAU 2022 guidelines: Perform surgery in patients with blunt extraperitoneal bladder injuries in cases of bladder neck involvement and/or associated injuries requiring surgical intervention. A Perform surgical exploration and repair in patients with blunt intraperitoneal injuries. A As per EAST 2019 guidelines: Perform surgery to decrease complications from bladder injury in patients sustaining blunt abdominopelvic trauma with intraperitoneal bladder rupture. B Consider performing an operative repair to decrease complications from the bladder injury in patients with complex extraperitoneal injuries. C As per WSES 2019 guidelines, perform direct inspection of the intraperitoneal bladder, whenever feasible, during emergency laparotomy in patients with suspected bladder injury. Consider using methylene blue or indigo carmine during intraoperative investigation. B Show 7 more As per AUA 2014 guidelines, perform surgical repair of intraperitoneal bladder rupture in patients with blunt or penetrating external trauma. B Show 3 more 4. Follow-up and surveillance Serial imaging assessment: As per EAU 2022 guidelines, obtain cystography to assess bladder wall healing after repair of a complex injury or in case of risk factors for wound healing. A As per EAST 2019 guidelines, avoid obtaining routine follow-up cystography in low-risk patients (operative repair of simple intraperitoneal or extraperitoneal bladder ruptures) in the absence of clinical signs or symptoms concerning for urinary leakage. D Show 2 more As per WSES 2019 guidelines, obtain CT with delayed phase as the choice of follow-up imaging in patients with bladder injuries. B Clinical findings Symptoms Past medical history Difficulty urinating Abdominal trauma Dysuria Kidney trauma Hematuria Pelvic fracture Suprapubic pain Pelvic trauma Sepsis Past events Traumatic injury https://web.pathway.md/diseases/rec7YPY5Fwjw3naVV 3/4 6/29/23, 3:18 AM Bladder trauma Pathway Motor vehicle accident Ureteral injury Genitourinary exam Abdominal exam urine output Abdominal distension Ascites Peritoneal findings Suprapubic tenderness Lab findings serum creatinine References 1. Lawrence L Yeung, Amy A McDonald, John J Como et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019 Feb;86 2 326 336. Open 2. N.D. Kitrey Chair), F. Campos-Juanatey, P. Hallscheidt et al. EAU Guidelines on Urological Trauma. EAU. 2022. Open 3. Morey AF, Brandes S, Dugi DD rd et al. Urotrauma: AUA guideline. J Urol. 2014 Aug;192 2 327 35. Open 4. Federico Coccolini, Ernest E Moore, Yoram Kluger et al. Kidney and uro-trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 2;14 54. Open 5. Expert Panel on Urological Imaging, Matthew T Heller, Aytekin Oto et al. ACR Appropriateness Criteria Penetrating Trauma-Lower Abdomen and Pelvis. J Am Coll Radiol. 2019 Nov;16 11S S392 S398. Open https://web.pathway.md/diseases/rec7YPY5Fwjw3naVV 4/4