31 LOWER URINARY TRACT INJURY AND PELVIC TRAUMA
Fernando J. Kim M.D., Siam Oottamasathien M.D.

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.

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

1. Diagnose with CT cystography and retrograde cystourethrography.
2. Extraperitoneal injuries are more common and may be managed conservatively with a Foley catheter for 10 days.
3. 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

References
WEB SITES

1. http://www.east.org/tpg/GUmgmt.pdf
2. http://www.acssurgery.com/abstracts/acs/acs0510.htm

BIBLIOGRAPHY
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