Trauma Buli

Bob Andinata

Bladder is well protected by the bony pelvis and thus injury is rare

Dome has no bony support- weakest point is adjacent to the peritoneum

>300cm H20 to rupture the normal bladder >85% bladder rupture have serious associated

injuries mortality rate of 22-44%

Blunt trauma - Deceleration injuries. - 60-85% have bladder injuries - The most common mechanisms are motor vehicle accidents , falls and assaults - 10-12% patients with pelvic fractures bladder injuries

Penetrating trauma- 15-40% are from a penetrating injury. - gunshot wounds (85%) and stabbings (15%). - concomitant abdominal and/or pelvic organ injuries

Obstetric trauma- prolonged labor or a difficult forceps delivery- direct laceration is reported in 0.3% cesarean delivery

Gynecologic traumaoccur during a vaginal or abdominal hysterectomy

Urologic trauma

- perforation of the bladder during a bladder biopsy, cystolitholapaxy, TURP and TURBT.

Orthopedic trauma- orthopedic pins and screws during internal fixation of pelvic fractures. - Thermal injuries to the bladder wall may occur during the setting of cement substances used to seat arthroplasty prosthetics

Spontaneous or idiopathic bladder trauma- reported <1%- intraperitoneal. - result from a combination of bladder overdistention and minor external trauma.

50-71 % of all bladder ruptures (80%) laterally or at the base

Traumatic extraperitoneal ruptures usually are associated with pelvic fractures (89-100%) or an avulsion tear at fixation points of puboprostatic ligaments

associated with fractures of the anterior pubic arch, and may occur from a direct laceration of the bladder by the bony fragments. The degree of bladder injury is directly related to the severity of the fracture.

complex injury, contrast material thigh, penis, perineum, or into the anterior abdominal wall.

The classic cystographic finding :

contrast extravasation around the base of the bladder confined to the perivesical space.

The bladder may assume : - a teardrop shape from compression by a pelvic

hematoma - Starburst, flame-shape, and featherlike patterns

10-20% of all major bladder injuries dome primarily

Blunt trauma intraperitoneal rupture in children > adults

Classic intraperitoneal bladder ruptures large horizontal tears in the dome of the bladder

The mechanism of injury is a sudden large increase in intravesical pressure in a full bladder.

Common among patients diagnosed with alcoholism or those sustaining a seatbelt or steering wheel injury.

Intraperitoneal ruptures demonstrate contrast extravasation into the peritoneal cavity, often outlining loops of bowel, filling paracolic gutters, and pooling under the diaphragm

more common in children because of the

relative intra-abdominal position of the bladder. The bladder descends into the pelvis usually by the age of 20 years

5-12% of bladder ruptures.

combined ruptures resulting from a combination of penetrating and blunt trauma

Cystogram reveals contrast outlining the abdominal viscera and perivesical space.

Often, the cystogram is bypassed, and the diagnosis is made during an exploratory laparotomy.

Type I: Bladder contusion Most common form Incomplete tear of bladder mucosa & cystography is normal

  Type II: Intraperitoneal rupture

  Type III: Interstitial injury-rare

Caused by a tear of the serosal surface Mural defect without extravasation 

Type IV: Extraperitoneal Almost always associated with pelvic fractures Subdivided into

Simple : extravasation limited to perivesical space Complex : extending to thigh, scrotum or perineum

  Type V: Combined extra- and intraperitoneal rupture

A triad of symptoms is often present gross hematuria suprapubic pain or tenderness difficulty or inability to void

98% of bladder ruptures gross hematuria, and 10% microscopic hematuria

conversely, 10% have normal urinalyses.

…presentation

An abdominal examination may reveal distention, guarding, or rebound tenderness urinary ascites, electrolyte disturbances and absent bowel sounds

Intraperitoneal bladder rupture

bilateral palpation of the bony pelvis abnormal motion indicating an open-book fracture or a disruption of the pelvic girdle.

Cystogram

- 100% accuracy w/ significant bladder injury

- 15% only visible on post-evacuation films

A properly performed cystogram consists of

- an initial kidney-ureter-bladder (KUB)

- AP and oblique views filled with contrast - AP film obtained after drainage

Using a diluted contrast medium, slowly fill the bladder by

to a volume of 300-400 cc. In children : Bladder capacity = 60 cc + (30 cc X age in y)

CT ~60% accuracy

CT cystogram approaches 100% accuracy

Extraperitoneal rupture can be more difficult to visualize

While extraperitoneal bladder rupture can be treated conservatively, intraperitoneal bladder rupture requires surgical repair

Small extraperitoneal- Catheter drainage for 7-10 days - Approximately 85% of the time, the laceration is

sealed.

Large extraperitoneal +/- bony fragments-Exploration-Cystostomy-Debridement-Pelvic reduction and fixation

Bladders with extensive extraperitoneal extravasation often are repaired surgically. Early surgical intervention decreases the length of hospitalization and potential complications, while promoting early recovery

Intraperitoneal Laparotomy Intraperitoneal irrigation and repair of bladder Cystostomy tube

Abscess (retroperitoneal, intraperitoneal, pelvic)

Fistula (vesicoperitoneal, enteric, retroperitoneal cutaneous)

Incontinence secondary to bladder neck injury and/or pelvic fx

Bladder outlet obstruction / neck contracture

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