INJURIES TO THE BLADDER
*Bladder injuries occur most often from external
force and are often associated with pelvic fractures.
*About 15% of all pelvic fractures are associated
with concomitant bladder or urethral injuries.
*Iatrogenic injury may result from gynecologic and
other extensive pelvic procedures as well as from
hernia repairs and transurethral operations.
Pathogenesis & Pathology
• When the pelvis is fractured by blunt trauma,
fragments from the fracture site may
perforate the bladder.
• These perforations usually result in
extraperitoneal rupture.
• If the urine is infected, extraperitoneal
bladder perforations may result in deep pelvic
abscess and severe pelvic inflammation.
• When the bladder is filled to near capacity, a
direct blow to the lower abdomen may result
in bladder disruption(intraperitoneal).
• Since the reflection of the pelvic peritoneum
covers the dome of the bladder, a linear
laceration will allow urine to flow into the
abdominal cavity.
• If the urine is infected, immediate peritonitis
and acute abdomen will develop.
Clinical Findings
• Pelvic fracture accompanies bladder rupture
in 90% of cases.
• The diagnosis of pelvic fracture can be made
initially in the emergency room.
• A. SYMPTOMS:
There is usually a history of
lower abdominal trauma.Blunt injury is the
usual cause.
• Patients ordinarily are unable to urinate, but
when spontaneous voiding occurs, gross
hematuria is usually present.
• Most patients complain of pelvic or lower
abdominal pain.
• B. SIGNS:
Heavy bleeding associated with
pelvic fracture may result in hemorrhagic
shock, usually from venous disruption of
pelvic vessels.
• Evidence of external injury from a gunshot or
stab wound in the lower abdomen.
• Tenderness of the suprapubic area and lower
abdomen.
• An acute abdomen may occur with
intraperitoneal bladder rupture.
• On rectal examination, landmarks may be
indistinct because of a large pelvic hematoma.
C. LABORATORY FINDINGS
• Catheterization usually is required in patients
with pelvic trauma but
not if bloody urethral
discharge is noted.
• Bloody urethral discharge indicates urethral
injury, and a
urethrogram
is necessary before
catheterization.
• When catheterization is done, gross or, less
commonly, microscopic
hematuria
is usually
present.
• Urine taken from the bladder at the initial
catheterization should be cultured to
determine whether infection is present.
D. X-RAY FINDINGS:
A plain abdominal film generally demonstrates
pelvic fractures.
• There may be haziness over the lower
abdomen from blood and urine extravasation.
• Bladder disruption is shown on cystography.
The bladder should be filled with 300 mL of
contrast material and a plain film of the lower
abdomen obtained.
• The drainage film is extremely important,
because it demonstrates areas of
extraperitoneal extravasation of blood
andurine that may not appear on the filling
film.
• With intraperitoneal extravasation, free
contrast medium is visualized in the abdomen.
• CT cystography is an excellent method for
detecting bladder rupture; however,
retrograde filling of the bladder with 300 mL
of contrast medium is necessary to distend
the bladder completely.
Complications
• A pelvic abscess may develop from
extraperitoneal bladder rupture.
• Intraperitoneal bladder rupture with
extravasation of urine into the abdominal
cavity causes delayed peritonitis.
• Partial incontinence may result from bladder
injury when the laceration extends into the
bladder neck.
Treatment
A. EMERGENCY MEASURES:
Shock and
hemorrhage should be treated.
B. SURGICAL MEASURES:
*
A lower midline abdominal incision should be
made.
* Pelvic hematoma, which is usually lateral,
should be avoided.
• Entering the pelvic hematoma can result in
increased bleeding from release of
tamponade and in infection of the hematoma,
with subsequent pelvic abscess.
• The bladder should be opened in the midline
and carefully inspected.
• After repair, a suprapubic cystostomy tube is
usually left in place to ensure complete
urinary drainage and control of bleeding.
• 1. Extraperitoneal bladder rupture:
• Extraperitoneal bladder rupture can be
successfully managed with urethral catheter
drainage only. (Typically 10 days will provide
adequate healing time).
• As the bladder is opened in the midline, it
should be carefully inspected and lacerations
closed from within.
• 2. Intraperitoneal rupture:
• Intraperitoneal bladder ruptures should be
repaired via a transperitoneal approach after
careful transvesical inspection and closure of
any other perforations.
• The peritoneum must be closed carefully over
the area of injury.
• All extravasated fluid from the peritoneal
cavity should be removed before closure.
3. Pelvic fracture:
Stable fracture of the pubic rami,the
patient can be ambulatory within 4–5 days without
damage or difficulty.
• Unstable pelvic fractures requiring external fixation.
• 4. Pelvic hematoma:
At exploration and bladder repair,
packing the pelvis with laparotomy tapes often
controls the problem.
• If bleeding persists, it may be necessary to leave the
tapes in place for 24 hours and operate again to
remove them. Embolization of pelvic vessels with
Gelfoam or skeletal muscle under angiographic control
is useful in controlling persistent pelvic bleeding.
Indications of immediate repaire of
blaader injury
1-Intraperitoneal injury from external trauma.
2-Penetrating or iatrogenic nonurologic injury.
3-Inadequate bladder drainage or clots in urine.
4-Bladder neck injury.
5-Rectal or vaginal injury.
6-Open pelvic fracture.
7-Bone fragments projecting into bladder.
• Prognosis:
With appropriate treatment, the
prognosis is excellent. The suprapubic
cystostomy tube can be removed within 10
days, and the patient can usually void
normally.
• At the time of discharge, urine culture should
be performed to determine whether catheter-
associated infection requires further
treatment.
INJURIES TO THE URETHRA
• Urethral injuries are uncommon and occur most
often in men, usually associated with pelvic
fractures or straddletype falls. They are rare in
women.
• The urethra can be separated into 2 broad
anatomic divisions:
the posterior urethra
:consisting of the prostatic
and membranous portions, and:
the anterior urethra
:consisting of the bulbous and
pendulous portions.
INJURIES TO THE POSTERIOR
URETHRA
• Etiology:
The membranous urethra is the
portion of the posterior urethra most likely to
be injured.
• When pelvic fractures occur from blunt
trauma, the membranous urethra is sheared
from the prostatic apex at the
prostatomembranous junction.
Clinical Findings
• SYMPTOMS:
Patients usually complain of lower
abdominal pain and inability to urinate.
• SINGS:
Blood at the urethral meatus is the single most
important sign of urethral injury.
• pass a urethral catheter may result in infection
of the periprostatic and perivesical hematoma
and conversion of an incomplete laceration to a
complete one.
• The presence of blood at the external urethral
meatus indicates that immediate urethrography
is necessary to establish the diagnosis.
• Suprapubic tenderness and the presence of
pelvic fracture are noted on physical
examination.
• Perineal or suprapubic contusions are often
noted.
• Rectal examination may reveal a large pelvic
hematoma with the prostate displaced
superiorly.
• Superior displacement of the prostate does
not occur if the puboprostatic ligaments
remain intact.
• Partial disruption of the membranous urethra
(currently 10% of cases) is not accompanied
by prostatic displacement.
X-RAY FINDINGS
• Fractures of the bony pelvis are usually present.
• A urethrogram (using 20–30 mL of water-soluble
contrast material) shows the site of extravasation
at the prostatomembranous junction.
• INSTRUMENTAL EXAMINATION: Catheterization
or urethroscopy should not be done, because
these procedures pose an increased risk of
hematoma, infection, and further damage to
partial urethral disruptions.
Differential Diagnosis
• Bladder rupture may be associated with
posterior urethral injuries in approximately
20% of cases.
• Cystography cannot be done preoperatively,
since a urethral catheter should not be
passed.
Complications
• Stricture, impotence, and incontinence as
complications of prostatomembranous
disruption.
• These complications will decrease if
suprapubic drainage with delayed urethral
reconstruction are done.
Treatment
• A. EMERGENCY MEASURES:
Shock and
hemorrhage should be treated.
• B. SURGICAL MEASURES:
Urethral
catheterization should be avoided.
1. Immediate management:
consist of
suprapubic cystostomy to provide urinary
drainage. A midline lower abdominal incision
should be made, with care being taken to
avoid the large pelvic hematoma.
• 2. Delayed urethral reconstruction:
• Reconstruction of the urethra after prostatic
disruption can be undertaken within 3
months.
• The preferred approach is a single-stage
reconstruction of the urethral rupture defect
with direct excision of the strictured area and
anastomosis of the bulbous urethra directly to
the apex of the prostate.
• TREATMENT OF COMPLICATIONS:
• Approximately 1 month after the delayed
reconstruction, the urethral catheter can be
removed and avoiding cystogram obtained
through the suprapubic cystostomy tube.
• Prognosis:
If complications can be avoided, the
prognosis is excellent. Urinary infections
ultimately resolve with appropriate
management.
INJURIES TO THE ANTERIOR URETHRA
• Etiology:Self-instrumentation or iatrogenic
instrumentation may cause partial disruption.
• Pathogenesis & Pathology:
• A. CONTUSION:Contusion of the urethra is a
sign of crush injury without urethral
disruption. Perineal hematoma usually
resolves without complications.
• B. LACERATION:If the extravasation is
unrecognized, it may extend into the scrotum,
along the penile shaft, and up to the
abdominal wall. It is limited only by Colles’
fascia and often results in sepsis, infection,
and serious morbidity.
• Clinical Findings:
• A. SYMPTOMS:Bleeding from the urethra is
usually present.
• There is local pain into the perineum and
sometimes massive perineal hematoma. If
voiding has occurred and extravasation is
noted.
• B. SIGNS:The perineum is very tender; a mass
may be found, as may blood at the urethral
meatus. Rectal examination reveals a normal
prostate.
• When presentation of such injuries is delayed,
there is massive urinary extravasation and
infection in the perineum and the scrotum.
• The lower abdominal wall may also be involved.
The skin is usually swollen and discolored.
LABORATORY FINDINGS
• Blood loss is not usually excessive, particularly if
secondary injury has occurred. The white count
may be elevated with infection.
X-RAY FINDINGS
• A urethrogram, with instillation of 15–20 mL of
water-soluble contrast material, demonstrates
extravasation and the location of injury.
• A contused urethra shows no evidence of
extravasation.
• Complications:Heavy bleeding from the
corpus spongiosum.
• Pressure applied to the perineum over the site
of the injury usually controls bleeding.
• If hemorrhage cannot be controlled,
immediate operation is required.
• The complications of urinary extravasation are
chiefly sepsis and infection.
Treatment
• A. GENERAL MEASURES:If heavy bleeding does
occur, local pressure for control, followed by
resuscitation, is required.
• B. SPECIFIC MEASURES:
• 1. Urethral contusion:intact. After urethrography,
the patient is allowed to void; and if the voiding
occurs normally, without pain or bleeding, no
additional treatment is necessary. If bleeding
persists, urethral catheter drainage can be done.
• 2. Urethral lacerations:Instrumentation of the
urethra following urethrography should be
avoided.
• Percutaneous cystostomy may also be used in
such injuries.
• 3. Urethral laceration with extensive urinary
extravasation:Suprapubic cystostomy for urinary
diversion is required. Infection and abscess
formation are common and require antibiotic
therapy
• C. TREATMENT OF COMPLICATIONS:Strictures
at the site of injury may be extensive and
require delayed reconstruction.