Editing Genitourinary tract trauma (section)

== Bladder injuries ==

* Intraperitoneal (20%) or extraperitoneal (80%)
* Presentation:
** Intraperitoneal - generally secondary to a blow or fall on a distended bladder, and rarely to surgical damage - sudden severe pain in the hypogastrium, often accompanied by syncope. Shock subsides, abdomen distends, no desire to micturate. Peritonitis does not follow immediately if urine is sterile.
** Extraperitoneal - caused by blunt trauma or surgical damage
* Diagnosis:
** CT is generally diagnostic
** Indications for retrograde cystography/CT cystogram:
*** Blunt pelvic trauma with gross haematuria (>30RBC/HPF)
*** Penetrating trauma with any haematuria
*** Other concern for bladder rupture
* Management
** Extraperitoneal rupture are generally conservative with catheter drainage, as long as the rupture is uncomplicated
** Indications for surgical repair
*** Intra-peritoneal bladder rupture in setting blunt trauma (likely large rupture)
*** Extra-peritoneal injury with open pelvic fractures, UTI, bony fragments, or foreign body in bladder
*** Bladder neck injury
*** Concomitant renal injury
*** Urethral injury
*** Major vaginal laceration
** Operation for extra-peritoneal rupture
*** Pfannenstiel incision
*** Primary closure
** Operation for intra-peritoneal injuries
*** Lower midline incision
*** Debride edges of hole
*** Suture with single-layer 2/0 absorbable according to Bailey and Love
*** Place suprapubic and urethral catheter
** If bladder injury identified during operation:
*** Primary repair
*** Catheter drainage
** Repair lacerations in a two-layer closure with running slowly absorbable suture. First layer is for mucosa/submucosa, and second layer muscularis and overlying serosa. Single layer is ok if access is difficult for neck laceration.
** Should have IDC afterwards (+ also SPC?)
** Follow-up imaging should be obtained whether operative or non-operative management at about 2/52, and start trial of void at that time