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31 LOWER URINARY TRACT
INJURY AND PELVIC TRAUMA |
| Fernando J. Kim M.D., Siam Oottamasathien M.D. |
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| 1. What
are the causes of bladder injury? |
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| Iatrogenic manipulation and penetrating or blunt
trauma. Because of the rich detrusor blood supply, bladder injury is
usually accompanied by hematuria. Other signs may include suprapubic
pain, inability to void, or incomplete recovery of catheter irrigation.
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| 2. What
types of bladder injury may occur with blunt trauma? |
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| Laceration or perforation may be either intra- or
extraperitoneal. Hematuria with a normal cystogram defines bladder
contusion in the absence of upper tract injury. Extraperitoneal
injuries constitute the majority of bladder trauma and tend to
concentrate at the bladder base or parasymphyseal area. These can be
managed conservatively with urinary catheter drainage for at least 10
days. Intraperitoneal (IP) ruptures typically occur when the bladder is
distended at the time of trauma, causing a blowout of the dome of a
bladder. IP vesical rupture should be surgically repaired using a
two-layer closure with absorbable sutures and placement of suprapubic
and urethral catheters. |
| KEY
POINTS: MANAGEMENT OF BLADDER INJURY DUE TO BLUNT TRAUMA |
- Diagnose with CT cystography and retrograde
cystourethrography.
- Extraperitoneal injuries are more common and may be
managed conservatively with a Foley catheter for 10 days.
- Intraperitoneal injuries are more likely if the
bladder is distended at the time of injury; they require surgical
repair with suprapubic and Foley drainage postoperatively.
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| 3. What
is the likelihood of a bladder injury in patients with a fractured
pelvis? |
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| Extraperitoneal bladder injury occurs in 10% of all
pelvic fractures. Conversely, approximately 85% of blunt bladder injury
is associated with pelvic fracture. Bladder injuries occur more often
with parasymphyseal pubic arch fractures and more often with bilateral
than unilateral fractures. Isolated ramus fractures produce bladder
laceration in 10% of cases. |
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| 4. How
is bladder injury evaluated? |
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| Both computed tomography (CT) cystography and
retrograde cystourethrography provide great diagnostic accuracy for
bladder rupture. The bladder should be filled under gravity with a
total of 300-400 mL of a 50% dilution of standard radiocontrast agent
using the Foley catheter. Films should include anteroposterior,
lateral, and oblique views. Finally, a postvoid film should be
obtained. When renal or distal ureteral injury is suspected, upper
tract imaging (intravenous pyelogram [IVP] or CT scan) should precede
the cystogram. |
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| page 150 |
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| 5. What
are the retrograde cystourethrographic patterns of bladder injury? |
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| Extraperitoneal injury allows contrast agent to
escape adjacent to the symphysis, but it is confined to the bladder
base by the intact peritoneum. Intraperitoneal extravasation produces a
"sunburst" appearance from the bladder dome, which may collect in the
paracolic gutters, outline loops of bowel, or pool under the liver or
spleen. It is pivotal to obtain postvoid films. |
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| 6. How
is bladder rupture managed? |
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| Extraperitoneal lacerations can be managed with an
indwelling catheter for 7-10 days, at which time cystogram usually
confirms resolution of extravasation. Intraperitoneal lacerations
require operative repair. Bladder contusion requires catheter drainage
until gross bleeding has subsided. |
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| 7. When
should urethral injury be investigated? |
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| The mechanism of injury (e.g., crushing or
deceleration/impact, straddle injuries) and associated trauma (e.g.,
pelvic fracture), blood at the meatus, penile or scrotal swelling and
ecchymosis, upward prostatic displacement on digital rectal
examination, and inability to void or to pass a urethral catheter (do
not try this) should be investigated. |
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| 8. When
a patient presents with a pelvic fracture, is concomitant urethral
injury a major concern? |
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| Yes. Urethral trauma occurs in 10% of pelvic
fractures; it is more common with anterior disruption of the pelvic
ring, including 20% of unilateral and 50% of bilateral parasymphyseal
fractures. Posterior (prostatomembranous) avulsion is associated with
potentially disabling sequelae and requirements for complex and
challenging operative corrections. In contrast, more distal urethral
injuries avoid impotence and incontinence issues and are more
surgically accessible. |
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| 9. How
is urethral injury best assessed? |
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| Retrograde urethrography must always be performed
before inserting a Foley catheter. Incomplete urethral transection
produces local contrast dye extravasation and bladder opacification.
Total avulsion produces extensive local extravasation, and no contrast
dye gets into the bladder. Incomplete transection is more common with
anterior (50%) than posterior (10%) urethral injuries. |
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| 10. How
is urethral injury managed? |
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| For incomplete transection regardless of site,
either catheter stenting across the defect or diversion by suprapubic
cystostomy permits resolution. With complete urethral transection, the
bladder should be decompressed initially via suprapubic cystostomy.
Early restoration of continuity by placement of a bridging urethral
catheter should be performed endoscopically. A bridging catheter
reduces complex scarring and avoids subsequent surgery in many
patients. |
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| 11. What
are the complications of urethral injury? |
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| Strictures, incontinence, and impotence (associated
with traumatic prostatic displacement). Iatrogenic complications are
associated with retropubic dissection. |
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| 12. What
is the differential diagnosis in blunt scrotal trauma? |
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| Testicular rupture, hematocele, scrotal hematoma,
intratesticular hematoma, and testicular torsion. Ultrasonography helps
sort this out. |
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| 13. What
is the sonographic sign of testicular rupture? |
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| The sign is loss of the normal homogenous echo
texture of the testicle, with areas of irregular hyper- or
hypoechogenicity. |
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| page 151 |
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| 14. How
are patients with acute testicular rupture managed? |
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| Management includes surgical exploration and
debridement of extruded, nonviable tubules and evacuation of the
hematoma. After proper hemostasis is achieved, the tunica albuginea
should be closed with running absorbable suture. |
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| 15. What
is the most common cause of penile fractures? |
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| Penile fracture is a rupture of the corpus
cavernosum, most commonly associated with sexual intercourse,
masturbation, or an abnormally forced bending of the erect penis.
Characteristically the patient hears a popping sound, followed by pain
and detumescence. |
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| 16. What
are the physical examinations findings with a penile fracture? |
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| Injury to the tunica albuginea causes formation of
hematoma and deviation of the shaft to the opposite side of injury. If
Buck's fascia is intact, the hematoma will be confined to the penis;
disruption of Buck's fascia allows spread of the hematoma under Colles'
and Scarpa's fascia onto the perineum and abdominal wall. |
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| 17. How
are penile fractures managed? |
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| Surgically. A retrograde urethrogram should be
performed when urethral injury is suspected. Closure of the defect (or
defects) along the tunica albuginea and evacuation of hematoma are
performed after degloving the penis. |
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| 18. In
penile amputation injuries, how should the amputated portion of the
penis be preserved for transport? |
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| The amputated portion of the penis should be
wrapped in saline-soaked gauze, placed in a plastic bag with ice slush
surrounding the bag. |
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| 19. How
is major scrotal skin loss managed? |
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| If primary repair is not possible, meshed
split-thickness skin grafts may be used to cover the testis. When
delayed repair is necessary, thigh pouches should be created until
permanent reconstruction is feasible. |
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| 20. A
50-year-old woman complains of urine leakage from her vagina after a
hysterectomy. What is the most likely diagnosis? |
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| Unrecognized bladder injury during hysterectomy
with subsequent urine extravasation into the surgical field and
drainage via the vaginal cuff suture line leads to formation of
vesicovaginal fistula. |
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| 21. What
is the best time to repair a vesicovaginal fistula secondary to an
uncomplicated hysterectomy? |
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| Although 3-6 months after injury has been
recommeded in the past, early repair can be successful if there is
minimal inflammation and there are no complicating factors. |
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