3. INTRODUCTION
• Relatively uncommon
• 2% of abdominal injuries
• Rarity ► protection in bony pelvis
• 83 – 100% are due to blunt injury
• 90% are associated with pelvic #
05-Jul-12 management of bladder injuries 3
5. INTRODUCTION…
• Up to 30% of patients with pelvic
fractures will have some degree of
bladder injury.
• 5 – 10% : major bladder injury
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6. INTRODUCTION…
• Previously fatal
• prompt diagnosis & intervention
► excellent outcome
• The probability of bladder injury α
the degree of bladder distention
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7. SURGICAL ANATOMY
• Bladder: hollow muscular organ that
serves as reservoir for urine.
• Empty bladder : protected behind
the pubic symphysis
• Largely a pelvic organ in adults,
abdominal organ in children.
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8. SURGICAL ANATOMY
• The bladder enters the greater
pelvis by 6yrs & it is not entirely
within the lesser pelvis until after
puberty.
• When empty : tetrahedral in shape
& has apex, body, fundus, neck &
uvula.
05-Jul-12 management of bladder injuries 8
9. SURGICAL ANATOMY…
• Separated from the pubic
symphysis by space of retzius.
• The posterior surface & Dome of
bladder is covered with
peritoneum thus related to
bowels.
05-Jul-12 management of bladder injuries 9
12. SURGICAL ANATOMY…
• Bladder neck in males is contiguous
with the prostate, & attached to the
pubis by puboprostatic ligaments.
• Body of the bladder receives support
from the urogenital diaphragm
inferiorly, & the obturator internus
Laterally.
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13. SURGICAL ANATOMY…
• The superior fascia of the urogenital
diaphragm is continuous and
includes the obturator, and
endopelvic fasciae.
• The inferior fascia of the urogenital
diaphragm fuses with the Colles
fascia.
05-Jul-12 management of bladder injuries 13
21. PATHOPHYSIOLOGY
EXTRAPERITONEAL
• Blunt or penetrating trauma.
• Associated pelvic # (90-100%)
• commonly anterolateral
• Due to direct burst injury
• Shearing force of the deforming pelvic
ring.
• Direct perforation by a bony fragment.
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22. PATHOPHYSIOLOGY...
EXTRAPERITONEAL
• When the sup. fascia of UD is ruptured,
urine can infiltrate the abdominal wall,
scrotum & perineum.
• When the Inf. fascia of UD is ruptured,
urine can infiltrate the thigh or penis.
05-Jul-12 management of bladder injuries 22
23. PATHOPHYSIOLOGY...
INTRAPERITONEAL
• Sudden large increase in intravesical
pressure in a full bladder.
• Full bladder ► widely separated
muscle fibres ► thin bladder wall
►no resistance to perforation
05-Jul-12 management of bladder injuries 23
24. PATHOPHYSIOLOGY...
INTRAPERITONEAL
• Usually involves the dome &
posterior part of the bladder.
• common in seat-belt & steering
wheel injury and in chronic
alcoholics, following trivial fall.
05-Jul-12 management of bladder injuries 24
26. PATHOPHYSIOLOGY...
• Continuous urine drainage into
the abdomen ► hyperkalemia,
hypernatremia, uremia & acidosis.
• Such patients may appear anuric,
and have urinary ascites.
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27. CLINICAL FEATURES
relatively
nonspecific
• Triad of symptoms is often present
(1) gross haematuria (90%),
(2) suprapubic pain or tenderness,
(3) difficulty or inability to void.
05-Jul-12 management of bladder injuries 27
28. CLINICAL FEATURES…
• Swelling in perineum, scrotum or
Anterior abdominal wall.
• Evidence of pelvic # (>90%),
symphysial / sacro- iliac diasthesis,
pubic rami #.
• Posterior urethral injuries (10%)
& renal injuries in (~2%)
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29. CLINICAL FEATURES…
• Mortality (~50%) ► severe pelvic #s,
haemorrhage, & MODS
• Late presentations are due mild
intraperitoneal rupture ►
azotemia, hyperchloremia,
hypernatremia hyperkalemia &
metabolic acidosis.
05-Jul-12 management of bladder injuries 29
30. INVESTIGATIONS
Cystography
• Very accurate (>90%)
• By gravity filling of contrast into
bladder.
• At least 3 films must be taken ►
Plain, Filled,& post drainage.
• Severity of injury can be graded
• Distinguishes intraperitoneal from
extraperitoneal rupture.
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32. INVESTIGATIONS…
CT Cystography
• Has approx. 100% sensitivity.
• Has advantage of being able to
correctly assess other visceral
injuries in a polytraumatized pt.
• Expensive
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34. INVESTIGATIONS…
USS
• Not routinely used
• Show injury to other structures
• Peritoneal fluid + normal viscera
OR failure to visualize bladder
after the transurethral intro of
saline ► highly suggestive of
bladder rupture
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40. MANAGEMENT
• Multidisciplinary approach
Trauma surgeon, Urologist,
anaesthesiologist, Orthopaedic
surgeon
• The first priority: stabilization of
the patient and treatment of
associated life-threatening injuries.
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41. MANAGEMENT…
• High velocity : urgent exploration
• Isolated bladder injury: definitive
treatment depends on grade of
injury.
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42. MANAGEMENT…
Grades 1&2
Nonsurgical management
• Adequate analgesics
• Indwelling catheter is passed
• Observe pt. for Increasing pains or
changes in vital signs.
• Repeat Cystogram at 10-14 days.
• If normal, discharge pt home.
05-Jul-12 management of bladder injuries 42
43. MANAGEMENT…
Grades 1&2
Nonsurgical management
• Obstruction of the catheter by clots or
tissue debris must be prevented.
• 87% of cases heal in 10days and
virtually all heal in 3weeks.
05-Jul-12 management of bladder injuries 43
45. MANAGEMENT…
Grades 3, 4 & 5
Surgical management
• Repair in at least two layers,
• Leave SPT in situ via a diff. Stoma
• Leave drain in situ.
05-Jul-12 management of bladder injuries 45
46. MANAGEMENT…
Post-Op
• IV antibiotics & analgesics
• Drain out when it not functioning
• Do x-ray cystogram at 14th day.
• If normal, remove SPC, the
urethral catheter & discharge.
• For those with pelvic #s, invite
orthopaedics
05-Jul-12 management of bladder injuries 46
48. CONCLUSION
• Traumatic bladder injuries was
previously fatal, BUT currently
managed quite successfully.
• Adequate evaluation, application
of modern imaging techniques, &
prompt surgical intervention are
conditions for optimal outcome.
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49. Thank you for your patience
05-Jul-12 management of bladder injuries 49
