Bladder Trauma.pptx

Bladder injuries may result from blunt,Penetrating and Iatrogenic trauma.
Full bladder is more susceptible to injury than empty bladder.
Management varies from conservative to surgical aiming to directly repair the injury.

1. Bladder Trauma Dr Abdul Qayyum Khan PGR

2. LEARNING OBJECTIVES Introduction Anatomy of bladder Mechanism of injury Types of trauma Evaluation Management Complication Follow up

3. INTRODUCTION Bladder injuries may result from blunt,Penetrating and Iatrogenic trauma. Full bladder is more susceptible to injury than empty bladder. Management varies from conservative to surgical aiming to directly repair the injury.

4. Anatomy In adults,bladder is located in the anterior pelvis and envelop by the connective tissue and extra peritoneal fat. It is separated from pubic symphysis by anterior prevesical space called space of retzius. The dome is covered by peritonium. The neck of bladder is held in position by puboprostatic and pubovesical ligament.

5. Trauma Trauma is defined as physical injury or a wound to living tissue cause by an extrinsic agent. 6th leading cause of death worldwide. 5 million deaths worldwide and diasability to millions more. Mangement of trauma based on ATLS guidlines.

6. Mechanism of injury The bony pelvis protects the urinary bladder very well. When the pelvis is fractured by blunt trauma, fragments from the fracture site may perforate the bladder. These perforations usually result in extraperitoneal rupture. If the urine is infected, extraperitoneal bladder perforations may result in deep pelvic abscess and severe pelvic inflammation.

7. When the bladder is filled to near capacity, a direct blow to the lower abdomen may result in bladder disruption. This type of disruption is ordinarily intraperitoneal. Since the reflection of the pelvic peritoneum covers the dome of the bladder, a linear laceration will allow urine to flow into the abdominal cavity. If the diagnosis is not established immediately and if the urine is sterile, no symptoms may be noted for several days. If the urine is infected, immediate peritonitis and acute abdomen will develop.

8. Risk factors Pre existing Neuropathic Diasease Prior urological procedure Malignancy

9. Clinical Presentation • Associated with other non urological life threatening injuries. • Patients may present with 1 . Haematuria ..... Most common 2 . Suprapubic pain or abdominal distension due to urinary ascites. 3 . Inability to void or reduced urine output 4 . Uremia and raised creatinine due to intraperitoneal absorption. 5 . Entry or exit wound at lower abdomen, perineum or buttocks in penetrating injuries.

10. Diagnosis History Examination Investigation

11. Diagnosis Clinical indicators of Bladder trauma 1 . Suprapubic pain or tenderness. 2 . Abdominal distention or ileus. 3 . Inability to void or low urine output. 4 . Haematuria associated with pelvic fracture. 5 . Enlarged scrotum with ecchymosis. 6 . Free intraperitoneal fluid on USG or CT scan.

12. AAST CLASSIFICATION

13. Investigation Cystogram CT Cystogram Cystoscopy Ultrasound

14. Investigation Cystography: • Preferred modality for non iatrogenic and suspected IBT in post op setting. • Both plain and CT urography have comparable sensitivity ( 90-95%) and specificity (100%). • Absolute indication : gross haematuria associated with pelvic fracture (29% of patients have bladder trauma)

15. Investigation • Relative indications after blunt trauma are gross haematuria without pelvic fracture and microhaematuria with pelvic fracture. • Penetrating injuries of the buttock, pelvis or lower abdomen with any degree of haematuria warrant cystography.

16. Investigations • Retrograde cystography is nearly 100% accurate if performed precisely. • In cooperative and conscious patient bladder should be filled upto sense of discomfort and otherwise upto 350 ml.

17. Investigations Plain film technique : • Three images must be obtained i. Control. ii. Full bladder AP film. iii. Drainage film. ( Posterior extravasation of contrast can be missed without this film)

18. CT Urogram : • Superior in identification of bony fragments in the bladder and bladder neck injuries as well as concomitant abdomen injuries. • Bladder must be filled in retrograde manner with contrast material diluted upto 2-4% to avoid scatter artifact.

19. Cystoscopy : Preferred method for detection of intraoperative injuries. Localize the lesion in relation to the position of trigone and ureteral orifices. Lack of bladder distension suggest a large perforation.

20. Ultrasonography : • Alone is insufficient. • Can be used to visualise intraperitoneal fluid or extraperitoneal collection of fluid.

21. Conservative Managment : Clinical observation. Continuous bladder drainage. Antibiotic prophylaxis.

22. Conservative Managment Standard treatment of uncomplicated extraperitoneal and intraperitoneal injury i-e in the absence of peritonitis and ileus. If lesion is larger intraperitoneal drain may be placed. In these situations ,when conditions are ideal, urethral catheter management alone suffices.

23. Large bore 22 Fr catheter should be used to promote adequate drainage. Cystography is necessary to verify complete healing before catheter removal 14 days after injury. In case of extravasation continue with bladder drainage until radiograhic confirmation of healing. Antibiotics should be continued for 7 days to avoid infection.

24. Surgical Managment INDICATIONS FOR IMMEDIATE REPAIR OF BLADDER INJURY Intraperitoneal injury from external trauma Penetrating or iatrogenic nonurologic injury Inadequate bladder drainage or clots in urine Bladder neck injury Rectal or vaginal injury Open pelvic fracture Pelvic fracture requiring open reduction and intemal! ixation ; Selected stable patients undergoing laparotomy tor reasons Bone fragments projecting into the bladder

25. Surgical Managment PENETRATING OR INTRAPERITONEAL INJURIES should be managed by immediate operative repair. These injuries are often larger than suggested on cystography and are unlikely to heal spotaneously. Prolonged leak of urine may cause chemical peritonitis or abscess.

26. WHEN OPERATING WITHOUT PRIOR IMAGING : The ureteric orifices should be inspected for clear efflux of urine. Ureteral integrity may be confirmed by retrograde passage of ureteric catheter or IV administration of methylene blue or indigo carmine.

27. INJURIES INVOLVING URETERIC ORIFICES OR INTRAMURAL URETERS: • Warrants primary closure with stented reimplantation of the ureter and a perivesical drain. • In repaired bladder cystogram can be obtained after 7-10 days.

28. Technique of bladder repair : • Removal of devitalized tissue. • Removal of intravesical clots. Repair of bladder in two layers : • Running 3-0 vicryl suture for mucosa. • Running 2-0 vicryl sutures for muscularis.

29. Unrecognized bladder injuries may manifest as • Azotemia • Acidosis • Fever and sepsis • Low urine output • Peritonitis • Ileus • Urinary ascites Complications

30. Follow up • Conservatively treated bladder injuries are followed up by cystograhy to rule out extravasation and ensure bladder healing. • 1st cystography is planned ten days after surgery. • If ongoing leak, cystoscopy done to rule out bony fragments in the bladder and then cystography 7 days later