A 29-year-old woman presented to the emergency department following a motor vehicle collision in which she was the seatbelt-restrained driver. Airbags deployed when her vehicle hit a roadside tree at a high speed. Emergency medical services arrived at the scene and recommended transport to a Trauma Center, but she chose to go home against their recommendation. Over the course of the next few hours, she developed severe lower abdominal pain, gross hematuria, and called for ambulance transport.
Upon arrival as a Trauma Alert, she was in severe abdominal and flank pain. She appeared lethargic and confused, but had not experienced head trauma during the collision. She was afebrile but tachycardic, with normal blood pressure. Her abdomen was distended and guarded with rebound tenderness. There was frank blood at the urethral orifice and introduction of a bladder catheter yielded no urine. Plain radiographs of the pelvis revealed no evidence of fracture. Laboratory data were significant for a hemoglobin of 12.0 mg/dL, leukocytosis of 15.1 x 103 WBC/muL, and elevated serum creatinine of 1.57 mg/dL. Non-contrast CT abdomen and pelvis showed no evidence of acute trauma, but revealed a moderate amount of simple fluid density ascites within the abdomen and pelvis of unknown etiology (Fig. 1). At this time, diagnoses included blunt abdominal injury with free intraperitoneal fluid, peritonitis, acute kidney injury, metabolic acidosis, and dehydration.
Trauma surgery then performed an emergent exploratory laparotomy and found a full-thickness rupture across the bladder dome (Fig. 2). Approximately one liter of clear urine was drained from the abdomen. The bladder was repaired in two layers with absorbable sutures and a bladder catheter was left in place. The bladder repair was then tested intraoperatively by filling the bladder with fluid via the bladder catheter until the bladder distended and no leak was observed.
On postoperative day one, she was transferred from the ICU to the medical/surgical unit in stable condition. Laboratory data showed her leukocytosis normalized as did her serum creatinine. She continued to recover well, advancing to a regular diet on postoperative day two with her pain well controlled. By postoperative day three, hematuria resolved, and cystography showed no leakage (Fig. 3). She was discharged that day with instructions to keep the bladder catheter in place for seven more days. Follow up in the outpatient trauma clinic the following week, showed she was without complications; and the indwelling catheter was removed without incident.