Population Covered By The Guidance
This pathway provides guidance for imaging adult trauma patients with suspected injuries to their lower urinary tract.
Date reviewed: August 2013
Date Published: August 2013
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- In patients with lower urinary trauma trauma, imaging is only indicated where the patient demonstrates gross haematuria
- When performing a CT cystogram study, the bladder should be adequately filled with 250-300mL of diluted contrast, administered via catheter. The dilution ratio should be 1:10 (eg. 50 ml of Omnipaque 300 (300mg iodine/mL) mixed with 500ml normal saline)
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Holevar M, J Christopher DiGiacomo, Ebert J, Luchette F, Nagy K, Nayduch D, et al. Practice management guidelines for the evaluation of genitourinary trauma 2003. Eastern Association For The Surgery of Trauma. (Level II evidence)
- Morgan DE, Nallamala LK, Kenney PJ, Mayo MS, Rue LW. CT cystography: radiographic and clinical predictors of bladder rupture. AJR Am J Roentgenol. 2000;174(1):89-95. (Level II evidence)
- Aihara R, Blansfield J, Millham F, LaMorte W, Hirsch E. Fracture locations influence the likelihood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures. J Trauma. 2002;52(2):205-8. (Level III evidence)
- Morey AF, Iverson AJ, Swan A, Harmon WJ, Spore SS, Bhayani S, et al. Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma. 2001;51(4):683-6. (Level II evidence)
- Lynch D, Martinez-Pineiro L, Plas E, Serafetinidis E, Turkeri L, Santucci R, et al. Guidelines on urological trauma. European Association of Urology 2008. (Level II evidence)
- Cass A, Luxenberg M. Features of 164 bladder ruptures. J Urol. 1987;138(4):743-5. (Level III evidence)
- Avey G, Blackmore C, Wessells H, Wright J, Talner L. Radiographic and clinical predictors of bladder rupture in blunt trauma patients with pelvic fracture. Acad Radiol. 2006;13(5):573-9. (Level III evidence)
- Brewer ME, Wilmoth RJ, Enderson BL, Daley BJ. Prospective comparison of microscopic and gross hematuria as predictors of bladder injury in blunt trauma. Urology. 2007;69:1086-9. (Level II evidence)
- Fuhrman G, Simmons G, Davidson B, Buerk C. The single indication for cystography in blunt trauma. Am Surg. 1993;59:335-7. (Level II evidence)
- Hochberg E, Stone N. Bladder rupture associated with pelvic fracture due to blunt trauma. Urology. 1993; 41(6):531-3. (Level II evidence) View the reference
- Mee SL, McAninch JW, Federle MP. Computerized tomography in bladder rupture: diagnostic limitations. J Urol. 1987;137(2);207-9. (Level III evidence)
- Haas CA, Brown SL, Spirnak JP. Limitations of routine spiral computerized tomography in the evaluation of bladder trauma. J Urol. 1999;162(1);51-2. (Level II evidence)
- Quagliano PV, Delair SM, Malhotra AK. Diagnosis of blunt bladder injury: a prospective comparative study of computed tomography cystography and conventional retrograde cystography. J Trauma. 2006;61(2):410-21; discussion 421-2. (Level III evidence)
- Deck AJ, Shaves S, Talner L, Porter JR. Computerized tomography cystography for the diagnosis of traumatic bladder rupture. J Urol. 2000;164(1);43-6. (Level III evidence)
- Peng MY, Parisky YR, Cornwell 3rd EE, Radin R, Bragin S. CT cystography versus conventional cystography in evaluation of bladder injury. AJR Am J Roentgenol. 1999;173(5):1269-72. (Level III evidence)
- Chan DP, Abujudeh HH, Cushing GL Jr., Novelline RA. CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. AJR Am J Roentgenol. 2006;187(5):1296-302. (Level III evidence)
- del Villar RG, Ireland GW, Cass AS. Management of bladder and urethral injury in conjunction with the immediate surgical treatment of the acute severe trauma patient. J Urol. 1972;108:581-5. (Level III evidence)
- Lowe MA, Mason JT, Luna GK, Maier RV, Copass MK, Berger RE. Risk factors for urethral injuries in men with traumatic pelvic fractures. J Urol. 1988;140:506-7. (Level III evidence)
- Wirth GJ, Peter R, Poletti PA, Iselin CA. Advances in the management of blunt traumatic bladder rupture: experience with 36 cases. BJU Int. 2010:106;1344-9. (Level III evidence)
Pathway User Guide
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Emergency Retrograde Urethrogram
Emergency Retrograde Urethrogram
Retrograde urethrogram allows immediate diagnosis of urethral injury
- The presence of blood at the urethral meatus should preclude any attempts at urethral instrumentation until the entire urethra is adequately imaged. Often a suprapubic catheter is inserted and a retrograde urethrogram is performed when appropriate
- Radiologic evaluation with a cystogram and post-wash out film and a retrograde urethrogram allow immediate diagnosis of bladder and urethral injury
- Retrograde urethrogram should be performed in all patients with fracture of sacroiliac joint and pubic ramus in addition to perirectal or scrotal hematoma, blood at the meatus, and/or high riding prostate. Patients with urethral injuries examined less than 1 hour after injury may not show physical findings
Computed Tomography (CT) Abdomen / Pelvis
Computed Tomography (CT) Abdomen / Pelvis
Initial investigation to identify renal (or bladder injury)
- CT is more sensitive and specific in the diagnosis of renal trauma. It is the diagnostic modality of choice in imaging patients with suspected blunt renal trauma
- CT not only provides precise anatomic and functional information but also detects other coexisting intra-and extraperitoneal injuries at the same time
- MRI equals CT in correctly grading blunt renal injuries and detecting the presence and size of perirenal hematomas
Computed Tomography (CT) Cystogram
Delayed Pyelographic Phase Computed Tomography (CT)
Helpful in further characterising renal or bladder injury
- Conventional CT of the abdomen / pelvis has a poor sensitivity of 50-60% for detecting blunt bladder injuries. , Its role in this setting is to identify other abdominal injuries
- The accuracy of CT for detecting and categorising bladder injuries can be greatly improved with a CT cystogram
- Indications for this study include gross haematuria, pelvic fractures or high clinical suspicion of bladder injury
- Recent studies support the use of retrograde filling of the bladder with dilute iodinated contrast. Using this technique, the reported sensitivity for detecting bladder rupture ranges from 95% to 100% and the specificity is 100%. These figures are comparable to conventional retrograde cystography
- For categorising the type of bladder injury, the accuracy of a CT cystogram for identifying extraperitoneal injury is similar to conventional cystography. However, the sensitivity is slightly lower for intraperitoneal injury (94% versus 100%)
- Multidetector CT with multiplanar reformation may help better localise the site of bladder rupture
- In order to minimise exposure to radiation, time and costs, CT cystograms can be performed as part of the screening abdomino-pelvic CT without the need for post-void images ,,
Computed Tomography (CT) Cystogram
Computed Tomography (CT) Cystogram
Greatly improves the accuracy of conventional CT for detecting and categorising the type of bladder injury
- Conventional CT of the abdomen / pelvis has a poor sensitivity of 50-60% for detecting blunt bladder injuries. , Its role in this setting is to identify other abdominal injuries
- The accuracy of CT for detecting and categorising bladder injuries can be greatly improved with a CT cystogram
- Indications for this study include gross haematuria, pelvic fractures or high clinical suspicion of bladder injury
- Recent studies support the use of retrograde filling of the bladder with dilute iodinated contrast. Using this technique, the reported sensitivity for detecting bladder rupture ranges from 95% to 100% and the specificity is 100%. These figures are comparable to conventional retrograde cystography
- For categorising the type of bladder injury, the accuracy of a CT cystogram for identifying extraperitoneal injury is similar to conventional cystography. However, the sensitivity is slightly lower for intraperitoneal injury (94% versus 100%)
- Multidetector CT with multiplanar reformation may help better localise the site of bladder rupture
- In order to minimise exposure to radiation, time and costs, CT cystograms can be performed as part of the screening abdomino-pelvic CT without the need for post-void images ,,