Following an automobile accident, a 20-year-old woman is found by a retrograde urethrogram to have an extraperitoneal bladder rupture. Initial management of this injury should be
|A||celiotomy and open repair of the injury|
|B||celiotomy and placement of drains in the retropubic space|
|C||insertion of a Foley catheter through the urethra|
|D||observation for evidence of a continuing urinary leak|
a. Bladder injury after blunt trauma is relatively rare owing to the protected intrapelvic position of the bladder.
b. Bladder injuries are associated with 6% to 10% of all pelvic fractures. Conversely, in the presence of a bladder injury, most patients (83%-100%) suffer from other pelvic fractures.
c. Bladder injuries can be classified into two types: extraperitoneal and intraperitoneal.
d. Extraperitoneal ruptures
i. Are thought to result from direct laceration, usually by bone spicules from the fractured pelvis.
ii. Extraperitoneal bladder rupture can most commonly be managed conservatively with catheter drainage leading to spontaneous healing of the bladder injury.
iii. Relative indication for surgical repair of extraperitoneal bladder injury is concomitant abdominal or pelvic injuries requiring surgical management. In this setting, surgical repair of the bladder injury can potentially decrease the risk for vesicocutaneous fistula.
e. Intraperitoneal bladder rupture
i. Accounts for 25% of all bladder injuries.
ii. The postulated mechanism of intraperitoneal bladder injury is thought to be rapid rise of intra-abdominal pressure during a blunt trauma.
iii. Intraperitoneal bladder rupture requires operative repair with two-layer closure of the bladder injury and placement of a perivesical drain.
f. Retrograde cystography is the traditional imaging modality to diagnosis bladder rupture. 13% of bladder injuries are diagnosed by these plain films. CT scan can also be used for diagnosis of bladder injury .