Urethral catheterization must be avoided if physical examination reveals blood at the urethral meatus or a high-riding prostate as urethral injury is possible Urologic consultation is required Initial Assessment/Diagnostic Testing A large, prospective series of pelvic fractures and lower genitourinary tract injury in pediatric patients found that imaging is not required if patients are stable, have a normal genitourinary examination, not have gross hematuria, and not have multiple associated injuries Diagnostic evaluation is indicated in patients who sustain pelvic or lower abdominal trauma with gross hematuria, inability to void, abnormal external genitourinary examination, or multiple associated injuries Evaluation begins with a plain radiograph to exclude a pelvic fracture Fracture types that have been associated with bladder injury include widening of the sacroiliac joint, symphysis pubis, and fractures of the sacrum If a pelvic fracture is not identified, the urethra can be catheterized and a cystogram is performed CT cystography should be performed for patients with suspected bladder injury after placement of a urethral catheter Sagittal and coronal multiplanar images may be helpful in identifying most sites of bladder rupture CT cystography does offer some advantages over plain cystography for patients undergoing CT scanning for the evaluation of other associated blunt injuries CT scanning provides expeditious scanning of the head, chest, abdomen, and pelvis; interpretation is often less affected by overlying bone fragments from pelvic fractures and spine boards than in the plain radiographic cystogram, and the CT can detect small amounts of intra- and extraperitoneal fluid, especially in the posterior position without need for a postdrainage film The disadvantages of CT cystography include the much higher radiation exposure and cost than those of plain radiographs Currently, the CT cystogram is recommended, when indicated, for patients undergoing CT scanning for other associated blunt trauma–related injuries With either modality, the bladder must be filled to an age-appropriate volume (∼350 cc in adults) to avoid missing injuries due to underdistension Management With few exceptions, treatment of bladder rupture is determined by whether the urine extravasation is confined to the extraperitoneal space or is intraperitoneal Extraperitoneal bladder rupture can generally be managed by urethral catheter or suprapubic drainage Extraperitoneal injuries with a bony fragment or foreign body in the bladder require surgical exploration