Lower urinary tract imaging in pelvic fracture: an 11‐year review of genitourinary complications and clinical outcomes

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Excerpt

Lower urinary tract (LUT) injury often occurs in pelvic fractures, in the setting of high‐energy trauma to the pelvic ring.1 The likelihood and complexity of an LUT injury is dependent on the type of pelvic fracture, with pubic symphysis diastasis conferring the highest risk.4 While not every patient with a pelvic fracture will have an LUT injury, the incidence of LUT injuries following pelvic fracture is estimated to be around 5%.6
While bladder and urethral injuries are relatively uncommon, they are associated with substantial morbidities. In the short term, delayed diagnosis and subsequent management of LUT injuries can lead to persistent leakage of urine, with ensuing infection and urinoma collection.8 In the longer term, it invariably results in significant urinary and sexual dysfunctions,9 adversely impacting the quality of life for both patients and their partners.
The standard of care in LUT imaging for bladder and urethral injuries is retrograde cysto‐urethrogram (CUG).11 This involves retrograde filling of the urethra with 30 mL of contrast, then direct fluoroscopy (DF) imaging in a 30‐degree oblique position. In the absence of urethral contrast extravasation, the bladder is then filled with at least 350 mL of dilute contrast to exclude bladder perforation.11 Passive bladder filling with excreted contrast from intravenous computed tomography (CT) can often be insufficient to exclude a bladder injury. After the full‐bladder findings are recorded (on radiographs or CT scans), the bladder is drained. If no residual contrast enhancement is present, the examination is completed, and the results are negative. If residual contrast enhancement is present in the bladder area, fluid (e.g. sterile water) is used to lavage the bladder. If no residual contrast enhancement is noted after drainage, the examination is completed and the results are negative. If contrast enhancement remains, a bladder wall injury is present. Cystography has generally served to greatly decrease trauma morbidity and mortality by helping to successfully screen for bladder rupture. Little doubt exists concerning the accuracy of plain‐film cystography as long as a bladder haematoma does not occlude a rift in the bladder wall and prevent dye from flowing out into the surrounding spaces.
This study evaluates the prevalence of an LUT injury and adequacy of diagnostic CUG in the initial assessment of patients who presented with pelvic fractures in a large tertiary trauma centre in Australia.
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