Classification of bladder and urethral trauma

Ivo DukicArie ParnhamMr Jones

MCQ

1. A man has sustained a urethral injury, 2 days after his injury he develops a ‘butterfly pattern of perineal bruising’ (Picture). Which eponymous anatomical layer has ruptured?

a) Dartos

b) Scarpa’s

c) Colles’

d) Camper’s

e) Buck’s

MCQ

2. A man is brought to Accident and Emergency following a motor vehicle accident. He has extensive injuries but is stable. He has sustained a pelvic fracture and has bleeding per urethra. You decide to perform a cystogram. What is the minimum amount of dilute contrast agent that you need to instil to perform a cystogram with high accuracy :

a) 150 ml

b) 250 ml

c) 350 ml

d) 400 ml

e) 600 ml

MCQ

3. You perform a cystogram to identify a bladder rupture but forget to carry out a post-drainage film. What is the chance that you have missed a significant bladder injury?

a) 1%

b) 2%

c) 5%

d) 10%

e) 30%

MCQ

4. A patient sustains significant trauma after a fall from 4 stories. As a part of their trauma imaging you obtain a CT Cystogram (Picture). What would be your next management?

a) Insert a suprapubic catheter and observe on the ward

b) Insert a urethral catheter and observe on the ward

c) Observe on ward and watch for signs of deterioration prior to consideration of emergency surgery

d) Insert a urethral catheter and ask an interventional radiologist to insert a drain into the peritoneal cavity to drain any urine

e) Take the patient for an emergency exploratory laparotomy and perform a two-layer bladder wall closure

MCQ

4. A patient sustains significant trauma after a fall from 4 stories. As a part of their trauma imaging you obtain a CT Cystogram (Picture). What would be your next management?

a) Insert a suprapubic catheter and observe on the ward

b) Insert a urethral catheter and observe on the ward

c) Observe on ward and watch for signs of deterioration prior to consideration of a laparotomy

d) Insert a urethral catheter and ask an interventional radiologist to insert a drain into the peritoneal cavity to drain the urine

e) Take the patient for an emergency exploratory laparotomy and perform a two-layer bladder wall closure

MCQ

5. A man develops a severe penile pain during sexual intercourse. He immediately loses his erection. When he goes to pass urine he passes visible blood. You perform a urethogram (Picture). What is the correct diagnosis

a) Stretch injury

b) Contusion

c) Partial disruption of anterior urethra

d) Complete disruption of anterior urethra

e) Complete disruption of posterior urethra

EMQ

1. The patient has sustained an intra-peritoneal laceration which measures at least 4 cm in diameter. Please select the appropriate grade of injury

• Grade I• Grade II • Grade III• Grade IV• Grade V• Grade VI

EMQ

2. A patient has sustained partial thickness laceration of the bladder wall on a CT Cystogram. Please select the appropriate grade of injury.

• Grade I• Grade II • Grade III• Grade IV• Grade V• Grade VI

EMQ

3. A patient has sustained an extra-peritoneal laceration measuring 3 cm. Please select the appropriate grade of injury from the options below.

• Grade I• Grade II • Grade III• Grade IV• Grade V• Grade VI

Bladder injury scale (EAU adaptation from AAST)

Grade Description

I Haematoma Contusion, intramural hematoma

Laceration Partial thickness

II Laceration Extraperitoneal bladder wall laceration <2 cm

III Laceration Extraperitoneal (>2 cm) or intraperitoneal (<2 cm) bladder wall laceration

IV Laceration Intraperitoneal bladder wall laceration >2 cm

V Laceration Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral orifice (trigone)

Urethral injuries

• Classification by mode– Traumatic– Iatrogenic

• Classification by relation to urogentinal diaphragm– Anterior– Posterior

Urethral trauma. Part I: introduction, history, anatomy, pathology, assessment and emergency management

• Contusion

• Partial laceration

• Complete laceration

BJU InternationalVolume 108, Issue 3, pages 310-327, 19 JUL 2011 DOI: 10.1111/j.1464-410X.2011.10339.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10339.x/full#f14

Grade Description Appearance

I Contusion Blood at urethral meatusNormal urethrogram

II Stretch injury Elongation of the urethra without extravasation on urethography

III Partial disruption Extravasation of contrast at injury site with contrast visualised in bladder

IV Complete disruption Extravasation of contrast at injury site without visualisation in the bladder, < 2 cm of urethral seperation

V Complete disruption Complete transection with >2 cm urethral seperation or extension into the prostate or vagina

Urethral injury (American associatoin for Surgery of Trauma )

Classification of blunt anterior and posterior urethra injuries (EAU Guidelines combination of systems)

Grade Description Appearance

I Stretch injury Elongation of the urethra without extravasation on urethrography

II Contusion Blood at the urethral meatus. No extravasation on urethrography

III Partial disruption of anterior or posterior urethra

Extravasation of contrast at injury site with contrast visualised in proximal urethra or bladder

IV Complete disruption of anterior urethra

Extravasation of contrast at injury site without visualisation of proximal urethral or bladder

V Complete disruption of posterior urethra

Extravasation of contrast at injury site without visualisation of bladder

VI Complete partial disruption of posterior urethra with associated tear of the bladder neck or vagina

Management

• Grade I – no treatment required• Grade II / III – SPC or urethral

catheterisation• Grade IV and V open or endoscopic

treatment, primary or delayed• Grade VI requires primary open repair