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Difficulty: MediumUrologic Surgery

Following a head-on motor vehicle collision, a 3434-year-old female driver is evaluated in the trauma bay. She complains of worsening diffuse abdominal discomfort and pain radiating to her right shoulder. Her temperature is 37.3∘C37.3^\circ\text{C} (99.1∘F99.1^\circ\text{F}), blood pressure is 110/70110/70 mmHg, pulse is 112112/min, and respiratory rate is 1818/min. Physical examination reveals a lap-belt mark across the lower abdomen, generalized abdominal tenderness with guarding, and suprapubic rebound tenderness. After ensuring the urethral meatus is normal, a urinary catheter is inserted and immediately drains frankly bloody urine. A computed tomography (CT) cystography is performed and demonstrates contrast dye extravasation into the peritoneal cavity, outlining the loops of the small bowel. Based on the clinical and imaging findings, which of the following is the most appropriate next step in management?

  1. Exploratory laparotomy and layered surgical closure of the bladder defectAnswer
  2. B
    Continuous indwelling Foley catheter drainage for 14 days
  3. C
    Intravenous broad-spectrum antibiotics and close clinical observation
  4. D
    Magnetic resonance imaging of the pelvis to characterize tissue injury
  5. E
    Bilateral percutaneous nephrostomy tube placement

Answer

Exploratory laparotomy and layered surgical closure of the bladder defect
The correct response identifies the need for immediate surgical repair of an intraperitoneal bladder rupture. Bladder ruptures are classified as either extraperitoneal or intraperitoneal. Intraperitoneal ruptures typically occur when a full bladder is subjected to blunt force, causing a blowout at the bladder dome (the weakest point). The classic presentation includes gross hematuria, acute abdomen, and occasionally referred shoulder pain (Kehr sign) due to urine irritating the diaphragm. CT cystography showing contrast outlining the small bowel confirms the intraperitoneal nature of the leak. Because intraperitoneal urine causes severe chemical peritonitis and risks sepsis, the standard of care is emergent exploratory laparotomy with multi-layered surgical closure of the bladder wall.

Step-by-Step Solution

1
Analyze the mechanism of injury and physical exam findings.
The patient experienced blunt lower abdominal trauma (lap-belt injury) and presents with gross hematuria, suprapubic tenderness, and referred right shoulder pain (Kehr sign).
These findings raise high suspicion for a severe urologic injury, specifically bladder rupture, and diaphragmatic irritation from intraperitoneal fluid.
2
Interpret the diagnostic imaging (CT cystography).
The CT scan shows contrast outlining the small bowel loops.
Contrast outlining the bowel confirms that urine is leaking from the bladder dome directly into the peritoneal cavity, diagnostic of an intraperitoneal bladder rupture.
3
Determine the standard surgical management for the identified injury.
The patient requires immediate exploratory laparotomy with multilayer closure of the bladder dome.
Unlike extraperitoneal ruptures, intraperitoneal ruptures do not heal spontaneously with catheter drainage alone and will cause fatal chemical peritonitis if not surgically repaired.

Key Concept

Management of Intraperitoneal Bladder Rupture
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Topics

Urologic Surgery

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