Full text of DOI:10.1007/s00268-001-0154-9

World J. Surg. 25, 1588–1591, 2001
DOI: 10.1007/s00268-001-0154-9
WOR LD
Journal of
SURGERY
© 2001 by the Socie´te´
Internationale de Chirurgie
Radiographic Evaluation of Suspected Bladder Rupture following Blunt Trauma:
Critical Review
Alan J. Iverson, M.D., Allen F. Morey, M.D.
Urology Service, Brooke Army Medical Center, 3851 Roger Brooke Drive, Bldg. 3600, Fort Sam Houston, Texas 78234-6360, USA
Published Online: October 22, 2001
Abstract. Indications for urgent radiographic evaluation of suspected
bladder injuries are poorly defined. Review of the existing literature
reveals that traumatic bladder rupture is strongly correlated with the
combination of pelvic fracture and gross hematuria. Nearly all patients
with hematuria or pelvic fracture alone do not have bladder rupture.
Bladder rupture is commonly associated with suprapubic discomfort or
inability to void in coherent, responsive patients. Intoxicated or unre-
sponsive patients should warrant a higher index of suspicion for bladder
Patients and Methods
A MEDLINE literature search was performed for the years 1980–
2000 to evaluate the efficacy of radiographic imaging among
patients suspected of having bladder rupture after blunt trauma.
Urinalysis findings were critically assessed with regard to the
presence of microscopic or gross hematuria. Clinical presentation
injury among clinicians treating patients with pelvic trauma. Similarly, and associated urologic and nonurologic injuries were also as-
patients having neurologic or preexisting urologic co-morbidities may not
manifest typical symptoms of bladder rupture. The above clinical indica-
tors should be considered when clinicians determine the appropriateness
of urgent cystography to detect bladder rupture.
sessed. Bladder injuries that resulted from penetrating trauma or
iatrogenic causes were excluded form this analysis.
Results
A focused review of recent blunt trauma bladder rupture retro-
Bladder rupture is an uncommon injury. Because of its unique
spective series indicates that gross hematuria or pelvic fracture (or
position deep within the bony pelvis, the bladder is well protected
both) are almost always present (Table 1). Further evidence
against both blunt and penetrating traumatic injury. Bladder rup-
suggests that microhematuria is a poor indicator of bladder injury
ture remains an important injury, however, because the reported
among patients presenting with pelvic fracture (Table 2).
mortality rate among bladder rupture patients after blunt trauma
is substantial (22%) [1]. The cause of death is usually related to
hemorrhage and pulmonary complications from associated nonu-
rologic injuries. Bladder rupture after blunt trauma, in particular,
Discussion
occurs in the context of multisystem trauma, with an average of Review of the bladder trauma literature reveals that most recent
investigators have focused on the importance of proper imaging
techniques, such as adequate retrograde distension and drainage
films, or management issues [9–14]. Few authors have critically
analyzed the indications for cystography after blunt trauma. Most
have offered generalities such as that “clinical judgment” or “sus-
picion based on clinical impression” should warrant immediate
cystography [15, 16]. Although these statements are undoubtedly
true, they are not specific enough to guide the trauma surgeon
faced with weighing the relative importance of conflicting tests
that may be necessary.
more than three major associated injuries reported [1].
Because the multiply injured patient often requires multiple
diagnostic procedures for associated life-threatening injuries, it is
useful to identify the patient with a low likelihood for lower
urinary tract injury who can be spared the time and cost of
unnecessary radiographic imaging. We sought to review the exist-
ing bladder trauma literature critically in an effort to refine the
indications for cystography after blunt trauma.
Since 1972 Cass and colleagues have recommended that all
individuals with a history of trauma and the presence of macro-
scopic or microscopic hematuria undergo cystography [4]. Critical
review of the Cass et al. series, however, reveals that both pene-
trating and blunt trauma patients were included, and that urinal-
ysis findings were often not stratified according to mechanism of
injury or degree of hematuria. Moreover, most patients imaged
The opinions expressed within represent those of the authors and not
necessarily those of the Departments of the United States Army, Air
Force, or Defense.
Correspondence to: A.F. Morey, M.D., e-mail: allen.morey@cen. amedd.
army.mil

Iverson and Morey: Suspected Bladder Rupture
1589
Table 1. Meta-analysis of contemporary retrospective series: association Table 3. Guidelines for immediate cystography after blunt trauma.
of blunt trauma bladder rupture with gross hematuria and pelvic
fracture.
Clinical presentation
Indication for cystography
Gross hematuria and pelvic fracture
Gross hematuria without pelvic fracture
Pelvic fracture with microhematuria
Isolated microhematuria
Absolute
Relativea
Relativea
Relativea
Study
Year
No.
Gross hematuria
Pelvic fracture
Carroll [1]
Palmer [2]
Antoci [3]
Cass [4]
1984
1983
1982
1987
1993
32
11
16
145
34
32 (100%)
10 (91%)
30/32 (94%)
11/11 (90%)
16/16 (100%)
123 (85%)
30/34 (88%)
210/238 (88%)
16 (100%)
aImmediate imaging indicated only in the presence of clinical indica-
95/123 (77%)a
34 (100%)
tors.
Fuhrman [5]
187/216 (87%)
aIncludes 16 penetrating trauma patients and 37 others not stratified
according to degree of hematuria.
the group at highest risk of harboring a rupture injury in reported
series [2, 3, 6–8]. Morgan et al., in a review of 157 trauma patients
with hematuria, found no bladder ruptures in patients with fewer
than 25 red blood cells per high power field (RBC/hpt) [23].
Another single-institution experience from Orlando Regional
Medical Center reported a $26,000 savings over a 9-month period,
without compromising the quality of care, by eliminating cystog-
raphy in patients with microscopic hematuria [5].
Should all blunt trauma victims with gross hematuria undergo
cystography? We think not. A literature review revealed only one
small prospective series that explored the efficacy of cystography
in patients with gross hematuria without pelvic fracture: None of
the 25 patients imaged in this category had bladder rupture [5].
Our experience indicates that most patients with gross hematuria
after blunt trauma have trivial renal injuries such as contusions or
Table 2. Risk of bladder rupture in patients presenting with pelvic
fracture: meta-analysis of recent series.
Study
Gross hematuria
Microhematuria or normal urine
Antoci [3]
Fallon [6]
Traub [7]
Chan [8]
Palmer [2]
Total
21/38 (55%)
29/54 (54%)
6/44 (14%)
16/124 (13%)
10/25 (40%)
82/285 (29%)
0/192 (0%)
1/144 (1%)
0/8 (0%)
1/125 (1%)
1/34 (0%)a
3/503 (0.6%)
aNone of the counts was less than 10 red blood cells per high power
field.
had contusions only (67%), which tended to be associated with minor lacerations. The kidney has long been recognized as the
lesser degrees of hematuria. most commonly injured genitourinary organ [24]. Cass and Lux-
Recent authors have offered more stringent criteria for bladder enberg reported in a review of 2310 trauma patients that upper
trauma imaging. Carlin and Resnick in 1995 proposed that iso- and lower tract injuries almost never coexist (0.4%); and that
lated microhematuria is not an indication for bladder imaging when they did, fatality was universal [25]. As a result, they en-
after blunt trauma [17]. Similarly, Husmann [18] and Fuhrman et dorsed a policy of diagnostic inquiry limited initially only to the
al. [5] recommended screening for bladder injury exclusively in site of maximum trauma. Consequently, we believe that isolated
the presence of gross hematuria or pelvic fracture. Ullrich and gross hematuria without pelvic fracture should be considered a
Porter recommended cystography additionally for patients with relative, not absolute, indication for immediate cystography (Ta-
microhematuria and pelvic fracture [19].
We believe that guidelines for radiographic screening of sus-
ble 3).
Bladder rupture may occur with minimal urinalysis findings in
pected bladder rupture after blunt trauma are in need of clarifi- selected instances. Spontaneous bladder rupture, for example,
cation. A strong precedent exists for establishing evidence-based without a history of significant external trauma may be insidious
guidelines for radiographic imaging in our specialty. For example, and difficult to diagnose [26]. Gross hematuria is less likely to be
it has long been widely accepted that patients with isolated mi- noted in spontaneous rupture cases, probably owing to the smaller
crohematuria after blunt trauma can be safely spared urgent renal size of the laceration, similar to the penetrating bladder injury
imaging [20, 21]. A variety of other evidence-based guidelines for [27].
imaging or laboratory evaluation have recently emerged in our
We believe it is important to consider clinical indicators of
specialty [22] as well. The need for refined imaging guidelines in bladder rupture, such as suprapubic pain and tenderness, when
bladder trauma cases is especially important because of the acute evaluating atypical patients with no evidence of major pelvic
nature of associated injuries.
trauma or gross hematuria to avoid misdiagnosis. Inability to void,
Our study confirms the strong association between blunt blad- clots in the urine, low urine output, or signs of perineal trauma
der rupture and gross hematuria in blunt trauma victims reported warrant further investigation. Alcohol intoxication, head injury, or
by others [1, 4, 5, 9, 15, 16, 18, 19]. This is not surprising, as the paraplegia with concomitant altered sensation may promote delay
bladder is a highly vascular organ, and most blunt injuries produce in diagnosis and should lead to heightened suspicion. Abdominal
large lacerations of the bursting type. Penetrating injury or iatro- distension, acute abdominal signs, fever, or elevated blood urea
genic injuries, on the other hand, are typically more focal in nitrogen (BUN) or creatinine levels often develop if the diagnosis
nature [1].
is delayed. A preexisting history of bladder outlet obstruction or
Blunt trauma causing injury to the bladder is also strongly prior bladder surgery suggest an increased likelihood of rupture.
associated with pelvic fracture or lower extremity fracture. Should Alternative radiographic findings might include free abdominal
all patients presenting with pelvic fracture be screened for bladder fluid of emergent abdominal sonography or computed tomogra-
injury? We believe that only the combination of gross hematuria phy (CT) [28, 29].
and pelvic fracture after blunt trauma should be considered an How then should we advise our surgical colleagues regarding
absolute indication for immediate cystography, as this is clearly the need for immediate bladder imaging in multiply-injured blunt

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World J. Surg. Vol. 25, No. 12, December 2001
Table 4. Clinical indicators of bladder rupture.
symptômes typiques de rupture de vessie peuvent manquer chez les
patients ayant une co-morbidité urologique pré-existante. Ces données
cliniques doivent être prises en compte pour déterminer l’indication
appropriée d’une cystographie en urgence pour détecter les ruptures de
vessie.
Suprapubic pain or tenderness
Inability to void, low urine output, or clots in urine
Signs of major perineal trauma: swelling or hematoma, blood at the
urethral meatus
Unresponsiveness, intoxication, or altered sensation
Free intraperitoneal fluid on computed tomography or ultrasonography
Preexisting bladder outlet obstruction, bladder surgery, or bladder
abnormality
Resumen. Las indicaciones para evaluación radiográfica de urgencia en
pacientes en quienes se sospecha de lesión de la vejiga todavía están
pobremente definidas. La revisión de la literatura revela que la ruptura
traumática de la vejiga se correlaciona fuertemente con la combinación de
fractura pélvica y hematuria macroscópica. Casi ninguno de los pacientes
con sólo fractura pélvica o con sólo hematuria presenta ruptura de la
vejiga. La ruptura de la vejiga aparece frecuentemente asociada con
molestia suprapúbica o con incapacidad para la micción en un paciente
Abdominal distension, hypoactive bowel soundsa
Increased serum blood urea nitrogen and/or creatininea
aConsider delayed diagnosis.
trauma patients? When should bladder imaging be considered a
mentalmente coherente
y que responde. Los pacientes ebrios o
priority, and when should it not? We believe that immediate incoherentes deben incrementar el indice de sospecha de lesión de la
vejiga por parte del médico que trata un trauma pélvico. Así mismo, los
pacientes con comorbilidad neurológica o urológica pueden no manifestar
los sínotomas típicos de ruptura de la vejiga. Los indicadores clínicos
anteriores deben ser tenidos en cuenta cuando se trata de definir la
cystography is essential only in the event of gross hematuria with
pelvic fracture. Current evidence suggests that CT cystography is
equivalent to conventional radiographic cystography so long as
adequate retrograde bladder distension is achieved with at least
300 ml of dilute contrast [4, 30]. If CT is deemed necessary for
abdominal evaluation, CT cystography is preferred. If no indica-
tion exists for CT of associated injuries, conventional cystography
is preferred.
indicatión de cistografía de urgencia en la detección de ruptura de la
vejiga.
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