Monday, November 22, 2010

- Bladder Injury.

Bladder Injury
Aetiology:-
  1. Blunt trauma : 10% of pelvic fractures.
  2. Penetrating trauma :gunshots or stap wounds.
  3. Iatrogenic:-
    • Obestetric :- 0.3% with caeserean section.
    • Gynaecological e.g.during a vaginal or abdominal hysterectomy.
    • Urological e.g during cystescopy.
    • Orthopaedic e.g. pins and screws can commonly perforate the urinary bladder, particularly during internal fixation of pelvic fractures.
  4. Idiopathic:- due to presence of a previous scar.
Classification(Pathophysiology):-
  1. Extraperitoneal rupture bladder:
  2. Usually due to fracture pelvis,and Extravasation occur at the perivesical space and may extend up to the anterior abdominal wall,If the urogenital membrane is injuried.
  3. Intraperitoneal rupture bladder:(The most dangerous)
  4. Usually due to direct trauma when the bladder is full,associated with electrolyte disturbance and may passed unnoticed for along time.
Diagnosis:-
  1. History of trauma or Operation.
  2. Clinical Picture:-
    1. Symptoms:-
      •   Gross haematuria.
      •   Suprapubic pain.
      •   Difficulty to void.
    2. Signs:-  Abdominal tenderness,bruises and rigidity.
  3. Investigations: (Radiological):-  Ascending cystogram and CT scan are the diagnostic tools.
(Intraperitoneal rupture bladder by Ascending cystogram : source)

(extraperitoneal rupture bladder by CT cystogram obtained after retrograde filling of the bladder shows an intravesicle air-contrast level (black arrow) and contrast material in the perivesicle extraperitoneal space (white arrows) : source)
Complications:-
  1. Haemorrhage
  2. Pelvic infection
  3. Peritonitis
  4. Some degree of urge incontinence, if the lesion extend to bladder neck.
Managment:-
  1. Emergency treatment of shock.
  2. Bladder injury:-
    • Extraperitoneal rupture bladder: just fixation of a urethral catheter for 7 to 10 days but Surgical intervention must be done if :there is associated organ injuries,large vesical haematoma and injury to the bladder neck.
    • Intraperitoneal rupture bladder: Surgical repair is the first choice in most of cases.
  3. Treatment of fracture pelvis if present.
FOLLOW- UP:-
  1. The urethral catheter must be left 10 to 14 days
  2. Ascending cystogram must be done before removal of the catheter
  3. Leave the suprapubic tube till the patient void successfully.
  4. The patient could return to work 4 to 6 weeks later.

Dr Ibrahim

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