Follow-up cystography confirms healing before catheter removal
Complicated extraperitoneal rupture requires surgery
Bladder neck injuries require operative repair to preserve continence
Concurrent injuries that require operative exploration drive decision
Timing of repair
Immediate repair for intraperitoneal rupture
Delay worsens peritonitis and metabolic derangements
Creatinine and potassium normalize within 48 hours of successful repair
Damage control approach in hemodynamically unstable polytrauma
Temporary suprapubic catheter with urinary diversion
Definitive repair deferred until patient stabilized
Elective repair considerations
Complex anatomy patients benefit from planned urology subspecialty involvement
Neobladder or augmentation repairs require experienced surgeon
Anticoagulation reversal
Warfarin reversal for urgent surgery
Vitamin K 10 mg IV plus 4-factor prothrombin complex concentrate 25-50 units per kg
Target INR less than 1.5 before elective repair
Direct oral anticoagulant reversal
Dabigatran reversal with idarucizumab 5g IV
Factor Xa inhibitor reversal with andexanet alfa per weight-based protocol
Antiplatelet considerations
Aspirin generally continued perioperatively unless bleeding is severe
P2Y12 inhibitors held 5-7 days if elective setting allows
Patient Discharge Instructions
copy discharge instructions
Discharge criteria and home care instructions
Catheter management at home
Catheter must remain in place until follow-up appointment and cystogram confirms healing
Secure catheter to inner thigh to prevent traction injury
Empty drainage bag when two-thirds full to prevent reflux
Hydration and activity instructions
Drink 8-10 glasses of water per day to keep catheter flowing and prevent blockage
Avoid heavy lifting or strenuous activity until cleared by your urologist
Shower with catheter in place using mild soap around insertion site
Monitoring catheter function
Urine should flow continuously into the drainage bag
Blood-tinged urine initially expected but should gradually clear
Catheter obstruction signs include lower abdominal pain without urine output
Return to emergency department criteria
Fever above 38 degrees Celsius or chills
May indicate urinary tract infection or wound infection
Requires immediate medical evaluation
Worsening abdominal pain or distension
Possible recurrent leak or peritonitis
Do not delay seeking care
No urine draining from catheter for more than 2 hours
Catheter may be blocked or displaced
Gentle irrigation with 60 mL normal saline if instructed by provider
Increasing blood in urine after initial clearing
Possible re-injury or catheter trauma
Report to emergency department promptly
Signs of wound infection after operative repair
Redness, warmth, swelling, or drainage from incision
Fever with wound changes requires early assessment
Follow-up instructions
Urology follow-up appointment
Scheduled within 7-14 days for catheter check and cystogram planning
Cystogram required to confirm bladder healing before catheter removal
Expected recovery timeline
Most uncomplicated injuries heal within 2-3 weeks
Complex repairs may require 3-4 weeks of catheter drainage
Activity restrictions
No driving while catheter in place
Avoid sexual activity until catheter removed and physician clearance given
Long-term monitoring
Report recurrent urinary tract infections to your urologist
Monitor for urinary incontinence or new voiding difficulty after catheter removal
Report any blood in urine after catheter removal
References
Guidelines and key sources
American College of Surgeons Best Practices Guidelines for Genitourinary Injuries 2025
Johnsen N, Wessells H, Archer-Arroyo K et al.
Covers operative and nonoperative management decisions
Includes specific surgical technique recommendations
Available at facs.org genitourinary guidelines
Endorsed for trauma center use
Primary reference for intraperitoneal vs extraperitoneal management algorithm
AUA Urotrauma Guideline 2020
Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L
Journal of Urology 2021
Systematic review basis for imaging and operative recommendations
Indications for cystography
Gross hematuria with pelvic fracture as primary indication
Microhematuria threshold guidance
EAST Practice Management Guidelines for Blunt Force Bladder Injuries 2019
Yeung LL, McDonald AA, Como JJ et al.
Journal of Trauma and Acute Care Surgery 2019
Evidence-based recommendations for trauma management
Key conclusions
Intraperitoneal rupture requires operative repair
Uncomplicated extraperitoneal rupture managed with catheter drainage
WSES-AAST Kidney and Uro-Trauma Guidelines 2019
Coccolini F, Moore EE, Kluger Y et al.
World Journal of Emergency Surgery 2019
Covers pseudo-AKI and electrolyte management from urinary reabsorption
Available at NCBI PubMed PMC6886230
International consensus panel recommendations
Graded evidence levels for management decisions
ACR Appropriateness Criteria
Major Blunt Trauma: Shyu JY, Khurana B, Soto JA et al. 2020
Journal of the American College of Radiology 2020
CT cystography classified as usually appropriate for suspected bladder injury
Penetrating Trauma Lower Abdomen and Pelvis: Expert Panel on Urological Imaging 2019
Imaging pathway for penetrating mechanisms
Role of retrograde urethrogram and cystography defined
Spontaneous Bladder Rupture Systematic Review
Reddy D, Laher AE, Lawrentschuk N, Adam A
BJU International 2023
64% initial misdiagnosis rate and 15% mortality data
Epidemiology data including radiation and alcohol associations
Risk factor prevalence quantified from pooled case series
Supports high clinical suspicion threshold in at-risk populations
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