34. Injury to the bladder Flashcards
what are the common IATROGENIC causes of injury to the bladder
(IGEE’s bad bladder)
- Inguinal and femoral hernia repairs
- Gynaecological operations such as hysterectomy and
caessarian section.
- Extended abdominal operations for colerectal carcinoma
- Endoscopic urological procedures with diagnostic and therapeutic purposes
- dg procedures= retrograde dg endoscopic precedures
- Cystoscopy, Cystoscopy + biopsy
- therapeutic procedures
- Cystolitholapaxy (for stones)
- Transureteral resection of prostate gland
- ransureteral resection of bladder tumour
what is the Classification of traumas to the urinary bladder
OPEN trauma
CLOSED trauma
- Contusion
-
Rupture
- Extraperitoneal rupture of urinary bladder
- Intraperitioneal rupture of urinary bladder
- Mixed rupture of the urinary bladder
COMBINED trauma- rupture of urinary bladder + pelvic fracture. ???
give an example of
Closed trauma of urinary bladder-
Extraperitoneal rupture
- what is the integrity of the bladder
- what complication can form
Perforation of the UB by a Fracture of the pelvis
- indirect mechanism
- Extravasation of urine spreads into the pelvic space and retroperitoneal space
- *urohematoma adjacent to the bladder
- anterior and lateral bladder and peritoneum still intact
what are hte 2 Mechanisms of bladder trauma
- Direct mechanism: direct blunt blow over the lower abdomen in a full bladder leads to intraperitoneal UB rupture,
- equals rupture of the posterior wall of UB (which is covered by peritoneum).
- the centre of the UB has poorer vascularisation and is also thinner than the other part, when UB is full, a blunt blow over the lower abdomen here can cause the intraperitoneal rupture of UB.
- In IP rupture of UB, urine escapes into the peritoneal cavity.
- Indirect mechanism: during a p_elvic fracture, ruptured bone may injure the UB._
- It can cause extraperitoneal bladder rupture.
- Extravasation means urohematoma - (means blood plus urine)
- located to adjacent to UB, lateral wall, left and right and in front of the anterior wall of the bladder.
- Also can be described as beneath the pubic symphysis.
Mechanisms of bladder trauma
- Direct mechanism:
- direct blunt blow over the lower abdomen in a full bladder
- leads to intraperitoneal UB rupture,
- it means the rupture of the posterior wall of UB. as Posterior wall of UB is covered by peritoneum
- the centre of the UB has poorer vascularisation and is also thinner
- when UB is full, a blunt blow over the lower abdomen here can cause the intraperitoneal rupture of UB.
- In IP rupture of UB,
- Indirect mechanism:
- In case of pelvic fracture, ruptured bone may injure the UB.
- It can cause extraperitoneal bladder rupture.
- Extravasation means urohematoma - (means blood plus urine)
- It is located to adjacent to UB,
- lateral wall, left and right and in front of the anterior wall
- Also can be described as beneath the pubic symphysis.
- It is located to adjacent to UB,
clinical features of Closed rupture of uriniary bladder
intraperitoneal UB rupture:
Cardinal sx is empty urinary bladder -> bloody anuria.
- Urine accumulates in the peritoneal cavity. (and empty bladdder found on physical examination)
- can lead to PERITONITIS.
extraperitoneal UB rupture:
four symptoms are sx:
1.Suprapubic pain 2.Haematuria, 3.Difficulty urinating 4.Urinary retention
-
Blood & Urine escapes/extravasates into the retroperitoneal space and pelvis
- =>perivesucular cyst can form and develop into => pelvic abscess which is one of the typical examples of PUS FOCUS IN true PELVIS
dx betw/ the 2 types of closed rupture of UB
for UB biophysical examination the main differential sign for intra and extraperitoneal bladder traum is
- empty UB - Is equal to intraperitoneal bladder trauma.
- Urinary retention means extraperitoneal bladder rupture.
Imaging investigations for trauma to UB
which dg imaging is best to determine the type of trauma
what is the lecturers fav method for imaging of bladder trauma
the best imaging to define the type of trauma to UB is retrograde cystography,
imaging for INTRAperitoneal trauma, on retrograde cystography
- shows the leakage/extravasation of urine in peritoneal cavity, by the means of a cloud shadow
imaging for EXTRAperitoneal trauma, on retrograde cystography
- shows the leakage/extravasation of urine adjacent to UB, by the means of a flame shadow adjacent to UB.
Plain abdominal radiography/ x-ray (lecturers favourite method) - (KUB is the abbreviation) - may show pelvis fracture
- For closed renal traumas - fracture of ribs and transverse processed of vertebrae •
- Other imaging investigations are ultrasound and CT, but the best method to define the type of rupture is retrograde cystography
which investigation is used to visualise pelvic fractures
KUB/ plain abdominal xray
Treatment of bladder injuries
when is surgery indicated
NB** immediate surgery, regardless of the type of trauma, after diagnosis need immediate surgical approach.
- In case of rupture conservative rx is CONTRAINDICATED
which type of UB trauma can lead to pelvic abscess
what is it exactly causes a pelvic abscess/ phlegmon to arise
-
paravesicle urohematoma+2 infection may lead to forming of pelvic abscess or pelvic phlegmona.
* It is a great example for pus focus in the true pelvis.
2 Possible cases for this to occur
- Extraperitoneal bladder rupture.
- Pathological form of acute pyelonephritis
how do you treat extraperitoneal rupture of the UB
- drain with catheter
- retroperitionial approach and evacuation if?
- urohematoma present
- unstable pt
treatment of intraperitoneal rupture of the UB
-
emergency laparotomy to remove urine and blood d/2 high risk of peritonitis
- clean cavity using lavage to remove bloody urine
- hemostasis
- find and suture laceration
- leave cystostomy in for a month
treatment in complete avulsion of the bladder
why wait 3-6 mo (2 reasons)
Suprapubic drainage→Reconstruction anastomosis via urethra and bladder neck
wait 3-6 months as immidiate surgery has a high risk of bleeding and post operative dehiscence
