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Bladder RuptureMANAGEMENT

GENITOURINARY AND REPRODUCTIVE PRESENTATIONS · 12 SECTIONS

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746 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Acute Kidney Injury (ATN)Acute Kidney Injury (Post-renal)Acute Kidney Injury (Pre-renal)Amniotic Fluid Embolism Balanitis Bladder Rupture Breast Abscess Cystitis Dialysis access complications Ectopic pregnancy Epididymitis Glomerulonephritis Hematuria (gross)Hydrocele Interstitial Cystitis Mastitis Mittelschmerz Nephrolithiasis Nephrotic Syndrome Flare Nutcracker Syndrome Orchitis Ovarian Cyst Rupture Ovarian hyperstimulation syndrome Ovarian torsion Paraphimosis Pelvic Congestion Syndrome Pelvic Inflammatory Disease (PID)Peritoneal dialysis peritonitis Phimosis Priapism Prostatitis Pyelonephritis Renal laceration Renal transplant complications and rejection Ruptured ovarian cyst Testicular torsion Torsion of Appendix Testis Tubo-ovarian abscess Ureteral Rupture Urethritis Urinary Retention Urinary tract infection (uncomplicated)Urolithiasis (renal colic)Vaginal bleeding (non-pregnant)Vaginitis (Bacterial)Vaginitis (Candidal)Varicocele Vulvovaginal Hematoma

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp50

Immediate stabilization

›Hemorrhagic shock response

›Two large-bore IV access

›Simultaneous blood sampling

›Crystalloid bolus 1L if hypotensive

›Massive transfusion protocol activation if SBP <90 mmHg with pelvic fracture

›1:1:1 ratio packed red cells, fresh frozen plasma, platelets

›Tranexamic acid 1g IV within 3 hours of injury

›Pelvic binder or external fixation for open-book pelvic fracture

›Reduces pelvic volume and tamponades venous bleeding

›Apply before catheterization if urethral injury excluded

›Urethral injury exclusion before catheterization

›Blood at urethral meatus

›Retrograde urethrogram mandatory before Foley placement

›Do not attempt blind catheterization

›High-riding or non-palpable prostate on rectal exam

›Suspect urethral disruption

›Urology consult before instrumentation

›If urethral injury excluded, insert 18 Fr or larger Foley catheter

›Monitor urine output continuously

›Gross hematuria confirms bladder injury until proven otherwise

Monitoring and targets

›Hemodynamic monitoring

›Continuous cardiac monitoring

›Hyperkalemia ECG changes from pseudo-AKI

›Cardiac contusion screen in polytrauma

›Arterial line for continuous BP in unstable patients

›MAP target >65 mmHg

02History/hx69

Mechanism and presentation

›Mechanism of injury

›Blunt abdominal or pelvic trauma

›Motor vehicle collision with seatbelt mechanism

›Falls from height

›Crush injuries to pelvis

›Penetrating trauma

›Gunshot wound to lower abdomen or pelvis

›Stab wound trajectory assessment

›Spontaneous rupture

›No preceding trauma history

›Bladder overdistension from urinary retention

›Bladder distension at time of injury

›Last void before trauma

›Distended bladder susceptible to intraperitoneal dome rupture

›Seatbelt injury with full bladder classic mechanism

›Alcohol intoxication

›Impaired voiding sensation with overdistension

›Risk factor for both traumatic and spontaneous rupture

Symptoms and urinary function

›Hematuria characterization

›Gross hematuria

›Cardinal finding present in majority of traumatic bladder injuries

›Absent in small subset despite significant injury

›Inability to void since injury

›Disrupted urinary continuity

›Distinguish from urethral injury

›Abdominal symptoms

03Physical Exam/exam45

Vitals and hemodynamics

›Hemodynamic instability markers

›Tachycardia >100 beats per minute

›Hemorrhagic shock or sepsis

›Pain response in awake patient

›Hypotension SBP <90 mmHg

›Class III or IV hemorrhage

›Septic shock in delayed presentation

›Fever >38.5 degrees Celsius

›Peritonitis from urinary extravasation

›Systemic sepsis

Abdominal and pelvic exam

›Abdominal findings

›Suprapubic tenderness

›Bladder injury or pelvic hematoma

›Guarding and rebound indicate intraperitoneal rupture

›Abdominal distension

›Progressive increase over time suggests urinary ascites

›Percussion dullness consistent with free fluid

›Diminished or absent bowel sounds

›Ileus from peritonitis

›Chemical irritation from urine

›Pelvic exam

›Pelvic instability on compression

›Open book fracture pattern

›Avoid repeated compression testing

›Perineal ecchymosis

›Butterfly pattern suggests urethral injury

04Differential Diagnosis/ddx56

Traumatic urogenital injuries

›Urethral injury

›ICD-10 S37.30

›Blood at meatus as key differentiator

›High-riding prostate distinguishes posterior urethral disruption

›Must exclude before bladder catheterization

›Retrograde urethrogram for diagnosis

›More common in males due to longer urethra

›Renal injury

›ICD-10 S37.00

›Flank pain and hematuria

›CT with IV contrast reveals parenchymal injury

›May coexist with bladder injury in polytrauma

›AAST renal grading guides management

›Urinoma from collecting system injury mimics bladder leak

›Ureteral injury

›ICD-10 S37.10

›Rare in blunt trauma

›Deceleration mechanism with ureteropelvic junction avulsion

›Delayed diagnosis common

›Urine extravasation visible on delayed CT phase

›Hematuria may be absent

Intra-abdominal injuries and mimics

›Hollow viscus injury

›ICD-10 S36 range

›Bowel perforation with pneumoperitoneum

›Peritonitis pattern similar to intraperitoneal bladder rupture

›Differentiating features

05Laboratory Tests/lt59

Core trauma and metabolic labs

›Complete blood count

›Hemoglobin and hematocrit

›Baseline for hemorrhage quantification

›Serial monitoring during resuscitation

›Leukocytosis

›Infection or systemic inflammatory response

›Leukopenia in severe sepsis

›Platelet count

›Transfusion threshold and coagulopathy assessment

›Thrombocytopenia in massive transfusion

›Comprehensive metabolic panel

›Creatinine and BUN elevation

›May represent pseudo-AKI from peritoneal urinary reabsorption

›Creatinine normalizes within 48 hours after bladder repair

›Potassium level

›Hyperkalemia from urinary reabsorption may exceed 6.0 mmol/L

›Requires urgent ECG and treatment

›Sodium level

›Hyponatremia from dilutional effect of urinary ascites

›Corrects after definitive repair

Urine and fluid analysis

›Urinalysis

›Gross hematuria

›Cardinal finding in traumatic bladder rupture

›Degree of hematuria does not correlate with injury severity

›Microscopic hematuria threshold

›Microhematuria alone without pelvic fracture does not warrant cystography per AUA guidelines

06Diagnostic Tests/dt92

Scoring Systems

›AAST Bladder Injury Grading Scale

›Grade 1

›Contusion or partial-thickness laceration without extravasation

›Managed conservatively with catheter drainage

›Grade 2

›Extraperitoneal laceration less than 2 cm

›Nonoperative management with urethral catheter drainage

›Grade 3

›Extraperitoneal laceration greater than 2 cm or intraperitoneal laceration less than 2 cm

›Intraperitoneal component requires operative repair

›Grade 4

›Intraperitoneal laceration greater than 2 cm

›Operative repair strongly recommended per EAST and AUA

›Grade 5

›Laceration extending into bladder neck or ureteric orifice

›Complex operative repair with ureteral stenting or reimplantation

›EAST Practice Management Guidelines for blunt bladder trauma

›Indications for CT cystography

›Gross hematuria with pelvic fracture

›Microhematuria with pelvic ring disruption requiring operative fixation

›Operative repair indications

›All intraperitoneal ruptures

›Complicated extraperitoneal ruptures

MRI

›Role of MRI in bladder rupture

›Not primary modality in acute trauma setting

›CT cystography is faster and more accessible

›MRI contraindicated in unstable patients

›Potential role in delayed or equivocal cases

›Superior soft tissue characterization for bladder wall integrity

›MRI cystography with diluted gadolinium for radiation-sparing in young patients

›MRI findings in bladder injury

›Bladder wall discontinuity

›T2 hyperintensity at injury site

›Extravasated fluid in peritoneal or perivesical space

›Associated injuries

›Pelvic floor muscle disruption

›Urethral injury characterization in complex cases

›CT cystography (retrograde)

›Gold standard for bladder rupture diagnosis

›Sensitivity 95%, specificity approximately 100%

›ACR Appropriateness Criteria: Usually appropriate for suspected bladder injury

›Technique requirements

›Active retrograde filling via Foley catheter with minimum 300 mL diluted contrast

›Passive filling on standard trauma CT is inadequate with high false-negative rate

›Intraperitoneal rupture pattern

›Contrast outlines bowel loops and fills paracolic gutters

›Contrast tracks to right or left peritoneal reflection

›Extraperitoneal rupture pattern

›Flame-shaped or molar tooth contrast extravasation

›Confined to perivesical and pelvic space

›May track to scrotum or perineum in complex injuries

›Standard CT abdomen and pelvis with IV contrast

›First-line in polytrauma evaluation

›Evaluates solid organs, mesentery, and retroperitoneum simultaneously

›Cannot reliably diagnose bladder rupture without retrograde filling

›Free fluid findings

›Pelvic free fluid without solid organ injury raises bladder rupture suspicion

›Pneumoperitoneum without obvious bowel injury may indicate bladder rupture

›Retrograde urethrogram before catheterization

›Indicated when urethral injury suspected

›Blood at meatus

›High-riding prostate

›Technique

›20-30 mL diluted contrast injected into urethra under fluoroscopy

›Extravasation confirms urethral injury

›Extravasation at membranous urethra

›Posterior urethral disruption from pelvic fracture

›Suprapubic catheter placement instead of urethral catheter

Ultrasound

›Extended FAST (E-FAST) examination

›Role in initial bladder rupture evaluation

›Detects free intraperitoneal fluid but cannot distinguish blood from urine

›Low specificity for bladder rupture diagnosis

›Pelvic view findings

›Free fluid in rectovesical or rectouterine pouch

›Cannot characterize bladder wall integrity reliably

›Limitations

›Operator-dependent in obese or gaseous abdomen

›Does not replace CT cystography for definitive diagnosis

›Point-of-care ultrasound adjuncts

›IVC assessment for fluid responsiveness

›IVC collapsibility >50% suggests preload responsiveness

›Guides resuscitation decisions in unstable patients

›Bladder volume estimation

›Confirms bladder distension in spontaneous rupture cases

›Not useful after Foley catheter placement

›Fluoroscopic cystography

›Alternative when CT unavailable

›Similar sensitivity and specificity to CT cystography

›Retrograde fill with minimum 300 mL contrast required

›Interpretation patterns identical to CT cystography

›Intraperitoneal extravasation around bowel loops

›Extraperitoneal flame-shaped extravasation

07Disposition/dispo36

Operative patients

›Immediate operative disposition

›Intraperitoneal bladder rupture

›Emergency laparotomy without delay

›Trauma surgery and urology joint operative planning

›Complicated extraperitoneal rupture criteria

›Bladder neck involvement

›Bone fragments within bladder lumen

›Concurrent rectal or vaginal injury

›Pelvic hardware placement planned at same operative setting

›Penetrating bladder injury

›All penetrating injuries require operative repair

›Exploration for concurrent bowel or vascular injury

ICU and floor admission

›ICU admission indications

›Hemodynamic instability requiring vasopressor support

›MAP <65 mmHg despite resuscitation

›Massive transfusion protocol activation

›Sepsis or urosepsis

›Lactate >=2 mmol/L with suspected infection

›Organ dysfunction from urinary peritonitis

›Significant polytrauma

›Multiple system injuries requiring monitoring

›Neurological injury with GCS <13

›Ward or step-down admission

›Uncomplicated extraperitoneal rupture

›Hemodynamically stable with adequate urine drainage

›Urethral catheter in place with confirmed flow

08Treatment/t77

Intraperitoneal rupture repair

›Operative repair

›Midline laparotomy approach

›Evacuation of urinary peritonitis

›Inspection of all intraperitoneal structures

›Bladder closure technique

›Two-layer closure with absorbable suture

›2-0 or 3-0 polyglycolic acid or chromic catgut

›Inner layer mucosal closure followed by outer muscular layer

›Additional intraoperative steps

›Transvesical inspection for concomitant extraperitoneal injury

›Inspection of ureteral orifices for bilateral ureteral jets

›Intraoperative methylene blue or indigo carmine instillation to confirm watertight closure

›Drain placement

›Closed-suction pelvic drain near repair site

›Foley catheter drainage maintained postoperatively for minimum 10-14 days

›Outcomes

›100% successful closure rate with operative repair

Extraperitoneal rupture management

›Nonoperative management for uncomplicated extraperitoneal rupture

›Large-bore urethral catheter placement

›Minimum 18 Fr Foley catheter

›Continuous drainage for minimum 7 days

›Typically 2-3 weeks until cystographic healing confirmed

›Operative intervention rate

›Only 2.4% ultimately require operative repair

›Failure of nonoperative management indicates operative repair

›Follow-up cystography requirements

›Confirm healing before catheter removal

›Repeat at 7-14 days for uncomplicated cases

›Extend to 3-4 weeks for complex injuries

›Operative repair for complicated extraperitoneal rupture

›Indications for operative exploration

›Bladder neck injury with continence mechanism involvement

›Bone fragments protruding into bladder lumen

›Concurrent rectal injury requiring operative repair

›Pelvic ring fixation planned with hardware near injury

›Repair technique

›Primary closure with absorbable suture

›Concomitant pelvic fracture fixation coordination with orthopedics

›Suprapubic catheter as adjunct to urethral catheter in complex repairs

Antibiotic therapy

›Perioperative prophylaxis

›Cefazolin 2g IV within 60 minutes before skin incision

›Redose every 4 hours for prolonged operations

›Weight-based dosing: 3g for patients >120 kg

›Allergic penicillin alternatives

›Clindamycin 900 mg IV plus gentamicin 5 mg/kg IV

›Vancomycin 15 mg/kg IV for MRSA coverage if colonized

›Therapeutic antibiotics for urosepsis or urinary peritonitis

›Empiric broad-spectrum coverage

›Piperacillin-tazobactam 4.5g IV every 6-8 hours

›Alternative: meropenem 1g IV every 8 hours for high-risk patients

›Cultures to guide de-escalation

›Blood cultures before antibiotics when feasible

›Urine culture from catheter specimen

›De-escalate based on sensitivities at 48-72 hours

Resuscitation and supportive care

›Fluid resuscitation

›Balanced crystalloid preferred over normal saline

›Lactated Ringer's 1-2L initial bolus for hypotension

›Avoid large volumes of normal saline due to hyperchloremic acidosis risk

›Blood product resuscitation for hemorrhagic shock

›Packed red blood cells transfusion threshold hemoglobin <70 g/L in stable patients

›Hemoglobin <80 g/L threshold in cardiac disease or active hemorrhage

›Electrolyte management

›Hyperkalemia treatment if potassium >6.0 mmol/L

›Calcium gluconate 1g IV over 10 minutes for cardiac membrane stabilization

›Sodium bicarbonate 50 mmol IV for transcellular shift

›Insulin 10 units IV with dextrose 50% 50 mL for cellular uptake

›Definitive treatment is bladder repair with normalization within 48 hours

›Hyponatremia management

›Typically mild and resolves with repair

›Avoid rapid correction to prevent central pontine myelinolysis

›Pain management

›Multimodal analgesia

›Acetaminophen 1g IV every 6 hours as baseline

›Opioid titration for breakthrough pain with hemodynamic caution

›Regional anesthesia consideration

›Epidural or TAP block in stable patients planned for surgery

›Reduces systemic opioid requirements

09Special Populations/sp84

Pregnancy

›Anatomic and physiologic considerations

›Bladder displacement

›First trimester bladder remains pelvic and is relatively protected

›Late second and third trimester bladder displaced superiorly and anteriorly

›Increased vulnerability to direct trauma in late pregnancy

›Urinary frequency and partial bladder filling

›Fetal head pressure reduces functional bladder capacity

›Full bladder less likely in late pregnancy reducing intraperitoneal dome rupture risk

›Diagnostic approach modifications

›Radiation considerations

›CT cystography remains indicated for hemodynamically unstable or high-suspicion patients

›Lead shielding where feasible

›MRI cystography as radiation-sparing alternative in stable low-suspicion cases

›Fetal monitoring

›Cardiotocography after blunt trauma from 23 weeks gestation

›Kleihauer-Betke test for fetomaternal hemorrhage

›Obstetric consultation mandatory for all pregnant trauma patients

›Cesarean delivery may be required if fetal compromise during laparotomy

›Uterine relaxation agents if preterm labor triggered by repair

›Treatment considerations in pregnancy

›Standard operative repair principles apply

›Intraperitoneal rupture requires emergency surgery regardless of gestational age

›Position left lateral tilt to avoid aortocaval compression during surgery

›Antibiotic safety

›Cephalosporins are Category B and safe for perioperative prophylaxis

›Avoid fluoroquinolones and tetracyclines in pregnancy

Geriatric

›Physiologic vulnerability

›Reduced bladder wall compliance with aging

›Chronic bladder outlet obstruction from BPH increases overdistension risk

›Detrusor hypocontractility impairs voiding sensation

›Blunted hemodynamic response

›Baseline hypertension masks relative hypotension from hemorrhage

›Beta-blocker use limits tachycardic response to shock

›Reduced physiologic reserve

›Frailty increases surgical morbidity and mortality

›Preoperative optimization may not be possible in emergency setting

›Diagnostic considerations

›Chronic creatinine elevation

›Baseline renal function must be established before attributing elevation to pseudo-AKI

›Previous laboratory values essential for interpretation

›Spontaneous rupture more common in elderly

›Alcohol-related and neurogenic bladder both more prevalent

›Lower threshold for diagnosis in elderly with abdominal pain and oliguria

›Treatment modifications

›Fluid resuscitation caution

›Reduced cardiac reserve increases risk of fluid overload

›Hemodynamic monitoring with early vasopressor consideration

›Antibiotic dosing adjustments

›Renal function-based dosing essential

›Avoid aminoglycosides as monotherapy due to nephrotoxicity risk

›Thromboprophylaxis

›High VTE risk in immobilized elderly patients

›Mechanical prophylaxis immediately and pharmacologic when hemostasis confirmed

Pediatrics

›Anatomic differences increasing susceptibility

›Bladder position more abdominal than pelvic in children under 6 years

›Less bony pelvic protection compared to adults

›Higher risk of intraperitoneal rupture from direct abdominal trauma

›Underdeveloped pelvic musculature

›Less soft tissue protection from direct impact

›Pubic symphysis more pliable allowing greater deformation

›Mechanism considerations

›Lap belt injury pattern

›Chance fracture of lumbar spine associated with bladder injury

›Abdominal wall bruising from lap belt

›Bicycle handlebar and sporting injuries

›Straddle injury pattern

›Urethral injury concern in male children

›Non-accidental trauma consideration

›Bladder injury without plausible mechanism requires child protection evaluation

›Multidisciplinary team notification

›Diagnostic approach

›CT cystography technique adapted for age

›Fill volume calculated as age plus 2 multiplied by 30 mL, maximum 300 mL

›Proportional contrast dilution maintained

›Radiation dose reduction

›Pediatric CT protocols with lowest diagnostic radiation dose

›ALARA principle application

›Weight-based dosing

›Cefazolin perioperative prophylaxis

›25-30 mg/kg IV maximum 2g per dose

›Redose every 4 hours intraoperatively

›Acetaminophen analgesia

›15 mg/kg IV every 6 hours maximum 75 mg/kg per day

›Avoid NSAIDs in significant hemorrhage due to platelet effects

10Background/b93

Epidemiology

›Traumatic bladder rupture incidence

›Bladder injury occurs in 1.6% of all abdominal trauma cases

›Represents significant urologic emergency

›Pelvic fracture is most common associated injury

›Classification frequency

›Extraperitoneal rupture accounts for 60-90% of traumatic bladder injuries

›Intraperitoneal rupture accounts for 15-25% of traumatic cases

›Combined injuries occur in less than 5-12% of cases

›Pelvic fracture association

›6-8% of pelvic fractures have associated bladder injury

›30% of patients with gross hematuria and pelvic fracture have bladder injury

›Spontaneous bladder rupture epidemiology

›Rare condition with high diagnostic challenge

›Misdiagnosed in 64% of initial presentations

›15% mortality rate from delayed diagnosis and sepsis

›Contributing factors

›Alcohol ingestion present in approximately 11% of cases

›Prior pelvic radiation in 13% of cases

›Bladder diverticula, tumors, and prior augmentation as structural predispositions

›Demographics

›Male predominance in traumatic bladder rupture

›Higher exposure to high-energy trauma mechanisms

›Female urethra shorter and less susceptible to concurrent urethral injury

›Pediatric cases

›Children under 6 have higher risk from abdominal rather than pelvic anatomy

›Lap belt injury pattern in restrained child passengers

Pathophysiology

›Intraperitoneal rupture mechanism

›Sudden intravesical pressure rise

›Distended bladder subjected to compressive force

›Dome is thinnest and most mobile bladder wall segment

›Classic mechanism

›Lap belt or steering wheel compression of lower abdomen against full bladder

›Intraperitoneal extravasation of urine into free peritoneal space

›Consequences

›Urinary peritonitis develops from chemical irritation

›Peritoneal reabsorption of urine causes pseudo-AKI and electrolyte derangements

›Hyperkalemia and hyponatremia from bidirectional solute transfer

›Extraperitoneal rupture mechanism

›Pelvic fracture fragment laceration

›Direct laceration of anterolateral bladder wall by bone fragment

›Pubic rami fractures most commonly responsible

›Shear forces from pelvic ring disruption

›Ligamentous and bladder wall avulsion from displacement

›Perivesical space fills with blood and urine mixture

›Extravasation pattern

›Urine confined to perivesical space and pelvic extraperitoneal fat

›May track along fascial planes to scrotum, perineum, or anterior abdominal wall

›Spontaneous rupture pathophysiology

›Bladder wall weakening combined with overdistension

›Radiation fibrosis impairs wall compliance and vascularity

›Neurogenic dysfunction impairs the urge-to-void reflex allowing severe overdistension

›Pressure-volume relationship

›Normal bladder accommodates 400-600 mL at low pressure

›Impaired compliance causes pressure rise at lower volumes

›Dome rupture occurs at intravesical pressures exceeding wall tensile strength

›Pseudo-AKI mechanism

›Reverse peritoneal dialysis phenomenon

›Urea and creatinine from urinary ascites reabsorbed across peritoneum

›Serum creatinine rises proportionally to volume of intraperitoneal urine

›Electrolyte derangements

›Potassium reabsorbed causing hyperkalemia

›Sodium diluted by osmotic water movement causing hyponatremia

›Rapid normalization within 24-48 hours after bladder repair and drainage

Therapeutic Considerations

›Operative versus nonoperative decision framework

›Intraperitoneal rupture always requires surgery

›No evidence supports nonoperative management for intraperitoneal injuries

›Strong recommendation per EAST, AUA, ACS, and WSES-AAST guidelines

›Uncomplicated extraperitoneal rupture primarily nonoperative

›2.4% failure rate with catheter drainage alone

›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

11Patient Discharge Instructions/pdi43

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

12References/r42

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

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Comprehensive Clinical Review

Structured, evidence-informed, long-form analysis for deeper understanding.

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.