Delayed Presentation of Traumatic Bladder Injury: A case report and review of current treatment trends

摘要

Bladder injuries in trauma are well documented and usually easily diagnosed with appropriate imaging. The modality of imaging in suspected bladder injury is evolving rapidly to CT cystogram as the primary imaging of choice in most facilities. After diagnosing a bladder injury the treatment depends on the injury being either intraperitoneal or extraperitoneal. Most extraperitoneal injuries are treated with catheter drainage, antibiotics and rest. We present a case of traumatic extraperitoneal bladder injury likely secondary to a pelvic fracture that was discovered more than a week after the inciting event. An uncommon approach was taken to repair the injury primarily. The case presents negative imaging studies prior to the diagnosis as well as discusses our reason for aggressive treatment for this patient. A review of current diagnostic modalities and therapeutic treatment methods is discussed. Introduction Bladder injuries are rarely seen in blunt abdominal trauma and usually are identified during initial evaluation. Prolonged delay in diagnosis of bladder injury has been reported but only in case studies. We present a young lady with a high index of suspicion for traumatic bladder injury after a motor vehicle accident. Despite multiple imaging modalities we were unable to diagnose the injury until ten days after arrival. An open approach was chosen for her extra peritoneal injury due to associated orthopedic injuries. We discuss our case here as a delayed presentation of an infrequently diagnosed injury. Case Study A 38-year-old Caucasian female presented as a restrained passenger involved in a high-speed single motor vehicle accident with multiple rollovers and a prolonged extrication time. There was a brief loss of consciousness reported; however on arrival she was alert but intoxicated. Her primary survey showed hemodynamic stability with systolic blood pressure on arrival of 109 mmHg and a pulse of 84. She complained of pain down her spine, in her right pelvis and lower abdomen. Chest and pelvic x-rays revealed right pneumothorax and right pubic rami fracture. After uncomplicated placement of a Foley catheter there was immediate return of frank blood. She was subsequently placed in a pelvic binder apparatus and taken to the CT scanner for trauma scans. Contrasted CT of the abdomen and pelvis revealed multiple injuries including a comminuted fracture of the sacrum with diastasis of the sacroiliac joint as well as right superior and inferior pubic rami fractures. A large pelvic hematoma just superior to the symphysis pubis with suspected active extravasation of arterial contrast was seen with compression of the urinary bladder medially by the hematoma. CT cystogram was then performed after instilling an additional 150 mL of contrast into the bladder. This revealed a well distended bladder with no evidence of a leak (Figure 1). Subsequently, she was taken to the Angiography suite for pelvic embolization by vascular surgery, but this proved to be negative for active hemorrhage.She was admitted to the intensive care unit and treated for her other injuries at which time she did become hypotensive and require blood transfusion. The gross hematuria did dilute over the next 24 hours. A formal radiographic cystogram was performed her second hospital day to confirm the initial CT cystogram findings and this was negative for bladder injury (Figure 2). Orthopedic Surgery repaired her sacroiliac joint on hospital day four after she had stabilized and was adequately resuscitated. Her pubic rami fractures were initially considered stable and managed conservatively. The next day bladder irrigation with saline was being performed every four hours and the dilute hematuria continued. Urology consult was made with initial diagnosis of resolving hematoma of the bladder wall with recommendation for continued irrigation and eventual cystoscopy. Over the next few days the hematuria slowly became thicker.Ten days after initial presentation, a thir