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The physical examination may be unremarkable. However, an enlarging flank
mass in the absence of signs of retroperitoneal bleeding suggests urinary
extravasation. Hematuria is an unreliable sign. The urinalysis may be normal in
30% of confirmed cases. When the diagnosis has been delayed, ureteral injury
may manifest with fever, chills, lethargy, leukocytosis, pyuria, bacteriuria, flank
mass or pain, fistulas, urinoma, peritonitis, and ureteral strictures.

Management/Diagnostic Testing
As mentioned above, the diagnosis of ureteral injury should be entertained when
children present with penetrating abdominal injuries. A CT urogram can suggest
the presence of ureteral injury when the ureter does not opacify with contrast on
delayed images and/or there is urinary extravasation medial to the renal hilum or
along the length of the ureter.
Retrograde pyelogram may be considered if ureteral injury is suspected. This
generally requires sedation or anesthesia, and involves passing dye in a retrograde
fashion from bladder into the ureter with fluoroscopic evaluation.

Clinical Indications for Discharge or Admission
Given the strong association of ureteral injuries with other severe abdominal
injuries, most children with ureteral injury are admitted to the hospital. Urologic
consultation is necessary for children with suspected ureteral injury. These
injuries require diversion of urine with a ureteral stent or nephrostomy tube.
Extensive injuries may require definitive repair in an immediate or delayed
fashion.

BLADDER
Goal of Treatment
The goal of evaluation in the ED is recognition of bladder injuries, determining if
they are extra- or intraperitoneal, and obtaining prompt urologic consultation.
CLINICAL PEARLS AND PITFALLS
Bladder injuries may occur after blunt or penetrating trauma. Blunt

trauma secondary to motor vehicle accidents is the leading cause. More
than 80% of bladder injuries are associated with pelvic fractures;
however, only 10% of patients with pelvic fractures sustain lower urinary
tract injury. The probability of having an associated bladder injury
increases proportionally with the number of fractured pubic rami.