Gynecology

Closed bladder injuries and injuries

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Bladder rupture is a serious injury, characterized by the violation of the integrity of the organ.

Fortunately, this pathological phenomenon is quite rare, is only 2% of the total number of surgical interventions on the bladder.

The bladder is an intramuscular sac, the purpose of which is to accumulate and retain urine. Its walls are quite elastic, so they can easily stretch.

In most cases, rupture of the bladder is impossible, because nature has taken care of its reliable protection, placing in the pelvic region, surrounded by bones.

But, nevertheless, rupture of the walls of the bladder can still occur and provoke serious consequences. When enough urine is collected, the person has the urge to urinate.

Well, if emptying occurs immediately.

However, in reality, episodes occur when it is impossible to complete the urinary process immediately after the appearance of the urge, therefore the person has to endure.

At this point, new portions of urine continue to flow into the bladder, as a result of which there is a strong stretching of the walls of the organ, while they are experiencing an incredible pressure. It is at this point that the bladder ruptures.

Doctors recommend that when the urge arises, immediately empty the bladder, not to allow overvoltage.

Damage to the bladder is divided into intraperitoneal and extraperitoneal ruptures.

Extraperitoneal rupture is characterized by a breach of integrity, when the urinary organ is either completely empty, or slightly filled.

With such a break, the urinary fluid does not penetrate into the abdominal cavity, but goes into the soft tissue near the bladder.

Due to overflow of the bladder, intraperitoneal damage also occurs, which is particularly dangerous.

The organ filled with urine rests against the upper part of the abdominal cavity, and since the thinnest walls are in this place, the damage occurs almost immediately.

Urine is poured into the abdominal cavity, which contributes to the occurrence of inflammatory processes.

Also, the causes of violation of the integrity of the body are injury to the abdomen, fractures, severe bruises, gunshot or knife wounds.

Virtually any bladder rupture is characterized by the occurrence of hematuria.

In the area of ​​the navel and pubis, the patient begins to feel pain symptoms that manifest themselves with varying degrees of intensity.

Signs of rupture differ depending on the nature of the damage. When extraperitoneal rupture pain manifests itself above the pubis, as well as accompany the urinary process.

Pain can be observed in the intestine and perineum. Such patients have serious problems with urination, as the amount of excreted urine decreases, in which blood impurities are clearly visible.

When intraperitoneal rupture of the bladder pain is localized initially in the pubic area, and then spreads to the entire abdomen.

Pain symptoms are characterized by paroxysmal manifestations. The urge to urinate a person feels, and can not empty. In the area of ​​the pubis, groin, crotch visible swelling.

Due to the fact that during an intraperitoneal rupture, urine is poured into the peritoneum, even external signs appear, since the patient's stomach is very swollen.

When the rupture is accompanied by a serious injury or fracture of the bones, the patient has a rapid heartbeat, a sharp drop in blood pressure.

External signs are also noticeable, since perspiration appears, and the skin becomes excessively pale.

When the patient turns to a medical institution, doctors, by external signs and the indicated symptoms, preliminarily establish a rupture of the urinary organ.

But in order to avoid an erroneous diagnosis, laboratory and instrumental studies are required.

Preference is given to conducting cystoscopic and cystographic studies.

Cystography is a diagnostic study, which is characterized by the introduction of a special contrast agent followed by an X-ray.

After conducting diagnostic and laboratory tests, the doctor receives complete information about the nature of the damage, about the location of the gap. Based on the data obtained, he develops a treatment regimen.

If the gap is quite small and belongs to the extraperitoneal variety, the operation is not performed. The organ itself can heal itself by restoring the integrity of its walls.

In order to provide him with such an opportunity, a catheter must be installed, which should remove urine instantly, not allowing it to concentrate in the damaged bladder.

However, if this approach does not heal the walls, it is necessary to resort to surgery.

In cases of severe bladder injury, catheterization is also used, providing rapid urination.

When intraperitoneal violation of the integrity of the walls of the body to avoid surgery is simply impossible, because the urine is completely poured into the abdominal cavity, filling the liver, spleen and intestines.

In a little less than half of all episodes (40%), doctors determine intraperitoneal damage in patients.

During the operation, the peritoneum is cut, the walls of the bladder are sutured, a catheter is installed, to ensure the rest of the damaged organ for the entire postoperative period.

Sometimes doctors determine mixed ruptures when intraperitoneal and extraperitoneal injuries of the bladder are observed simultaneously.

If a patient has suffered damage due to a penetrating gunshot or knife wound, the operation is necessary, since very often other organs are damaged.

Symptoms can manifest as loss of consciousness, slow breathing, tachycardia.

Due to the fact that the rupture provokes the most dangerous complications that can provoke a lethal outcome, medical assistance is provided instantly, without delay.

What causes closed bladder injuries and injuries?

Spontaneous ruptures of the bladder and its damage during instrumental examinations are described: cystolithotripsy, TUR and hydraulic stretching in order to increase the capacity.

In the mechanism of rupture, the nature and strength of the traumatic effect, the degree of filling of the bladder with urine matters. A sudden increase in intravesical pressure is transmitted with equal force to all the walls of the bladder containing urine. At the same time, its side walls, surrounded by bones, and the base of the bladder, adjacent to the pelvic diaphragm, counteract the increased intravesical pressure, while the least protected and most thinned part of the bladder, breaking to the abdominal cavity, is broken. The intraperitoneal ruptures of the bladder wall arising by this mechanism spread from the inside to the outside: first the mucous membrane, then the submucosal and muscular layer, the last one is the peritoneum.

In a number of cases, the peritoneum remained intact, leading to subperitoneal proliferation of bladder contents. A similar hydrodynamic rupture can be caused by compression of an overflowed bladder by overlapping fragments of the pelvic ring during fractures without direct fracture of the gallbladder wall with bone fragments.

An additional factor affecting the tension of the pubic-cystic ligaments in case of discrepancy between the fragments of the pubic bones and the pubic articulation. The extraperitoneal part of the bladder is more often exposed to this gap. Finally, damage to the bladder near its cervix is ​​caused by displaced fragments of the pubic and sciatic bones, although during surgery they are rarely found in the wound of the bladder.

This fact explains the elasticity of the pelvic ring, as a result of which bone fragments, wounding the bladder at the time of the injury, may subsequently exit the wound canal. Far from all fractures of the pelvic bones, even with a discontinuity in the pelvic ring, are accompanied by bladder ruptures. Apparently, in order to damage it, it is necessary to have enough urine in it, which contributes to the proximity of the walls to the bones of the pelvis and less displaceability of the bladder at the time of injury.

There are bruises, incomplete ruptures of the bladder wall (urine does not pour out beyond its limits) and complete ruptures with urine flow into the surrounding tissues or abdominal cavity. Incomplete rupture turns into complete as a result of inflammatory and necrotic changes in the wound, overflow of the bladder with urine, and an increase in intravesical pressure at the time of urination. Such a mechanism leads to a two-stage break.

Symptoms of closed injuries and bladder injuries

Closed bladder injuries are characterized by a combination of symptoms of damage to the bladder itself, signs of damage to other organs and pelvic bones, and manifestations of early and late complications of injury. Hematuria, disorders of urination, pain in the lower abdomen of the abdomen of the suprapubic area, during the initial examination of a patient with a history of trauma, allow us to suspect bladder damage.

With isolated injuries, pain in the suprapubic area occurs. urination disorders and hematuria. Disorders of urination when the bladder is damaged are different. The nature of the disorder is related to the degree of bladder emptying through the wound hole into the surrounding tissue or into the abdominal cavity. With bruises and incomplete ruptures of the bladder, frequent, painful urination occurs, and acute urinary retention is possible.

Sometimes with light lesions, urination remains normal. Complete breaks are characterized by the lack of independent urination with frequent and painful urging, however, in contrast to the delay in urination, they determine tympanitis above the pubis. In case of extraperitoneal damage, it is soon replaced by accruing dulling, which has no clear boundaries, with intraperitoneal ruptures, tympanitis is combined with the presence of free fluid in the abdominal cavity. When the bladder ruptures against the background of infertile urination to urinate, it is sometimes possible to excrete a few drops of blood, a prolonged absence of urination and the urge to it.

An important symptom of bladder injury is hematuria, the intensity of which depends on the amount of damage and its location. With bruises, external and internal incomplete, intraperitoneal ruptures, gross hematuria is short-term or even absent, whereas with significant ruptures in the region of the cervix and urinary triangle is pronounced. However, isolated bladder ruptures are extremely rarely accompanied by significant blood loss and shock.

When intraperitoneal ruptures of the bladder, peritoneal symptoms develop slowly, gradually increase (within 2-3 days), are mild and unstable, which is often the cause of late diagnosis of urinary peritonitis.

Initially localized pains in the suprapubic area become diffuse, intestinal paresis, abdominal distention, delayed stools and gas, nausea, and vomiting join. After a cleansing enema, there is a stool and gases go off. The abdomen is involved in breathing, muscle tension in the abdominal wall and pain on palpation of the abdomen are mild or moderate. Peritoneal symptoms are mild, and intestinal motility is heard for a long time.

After a day, the patient's condition worsens, signs of intoxication join, leukocytosis, azotemia develop. The ingestion of infected urine into the abdominal cavity leads to an earlier appearance of a picture of diffuse peritonitis, however, the clinic of dynamic intestinal obstruction, accompanied by a sharp swelling of the intestine, comes to the fore. In the absence of anamnestic information about the injury, such a clinical picture is regarded as food poisoning.

With extraperitoneal damage a few hours after the injury, the intensity of hematuria decreases, but the frequency and soreness of the urge to urinate increases. In the suprapubic and inguinal areas, edema of the skin and subcutaneous tissue appears in the form of testes. The condition of the victim gradually deteriorates due to increasing urinary intoxication and the development of pelvic cellulitis or abscesses, as evidenced by high body temperature, in laboratory tests - neutrophilic leukocytosis with a shift to the left, hypochromic anemia, increased residual nitrogen, urea and serum creatinine.

In 50-80% of cases, victims with combined injuries of the bladder are in a state of collapse and shock, which significantly change the nature of the clinical manifestations and make it difficult to diagnose. Isolated fractures of the pelvic bones with perinubular hematoma can also manifest as pain, dysuria, tension and tenderness in palpation of the anterior abdominal wall, delayed gas, stool and urine. These symptoms are probably associated with irritation of the parietal peritoneum with hematoma, compression of the bladder neck.

Suspicion of bladder damage is an indication for special studies to confirm the fact of damage to the bladder, determine its appearance and plan treatment tactics.

Complications of closed injuries and bladder injuries

Complications of bladder injuries are most often caused by late diagnosis of damage or delayed treatment.

Complications of bladder damage:

  • increasing urohematoma:
  • phlegmon of the pelvis,
  • localized abscesses,
  • urinary peritonitis,
  • adhesive intestinal obstruction,
  • sepsis.

In case of damage to the bladder neck, vagina, rectum, urinary incontinence, urinary fistulas, strictures develop without timely elimination. In the future may require plastic surgery.

Extensive trauma to the sacrum, sacral roots or pelvic nerves leads to dennervation of the bladder and impaired urination. If the cause of bladder dysfunction is innervation, then catheterization may be required for some time. With some severe damage to the sacral plexus, urinary disturbances can be sustained due to a reduction in the bladder muscle tone and its neurogenic dysfunction.

Complications of bruises and incomplete ruptures of the bladder are rare: hematuria, urinary tract infection, reduction of the volume of the bladder, less often the formation of bladder pseudodiverticules.

Diagnosis of closed injuries and bladder injuries

Diagnosis of closed bladder damage is based on an analysis of the circumstances and mechanism of injury, data from physical research, laboratory and radiological methods of diagnosis.

At the prehospital stage, the diagnosis of damage to the bladder is difficult: only 20-25% of victims are sent to hospitals with a correctly established diagnosis, where the recognition of extraperitoneal ruptures does not cause any particular difficulties. The high frequency of combinations of damage to the bladder with fractures of the pelvic bones alarms the doctors, and if there are relevant complaints, urination disorders, blood in the urine, there is a need for additional ultrasound and X-ray studies that allow early diagnosis and proper treatment in the first hours after hospitalization .

Quite different is the case with the diagnosis of intraperitoneal ruptures. A typical picture of intraperitoneal damage occurs in about 50% of victims, and therefore the observation of patients is delayed. Clinical signs of trauma (severe general condition, rapid pulse, abdominal distension, free fluid in the abdominal cavity, symptoms of peritoneal irritation, impaired urination, and other signs) are absent or weakly expressed due to shock and blood loss.

Abrasions, bruises and other signs of injury in the abdomen and pelvis, clarification of the mechanism of damage, assessment of the patient's condition and the degree of filling of the bladder help to suspect his damage. Palpation through the rectum determines the presence of its damage, hematoma, and urinary flow of bone fractures, the overhang of the vesical-rectal fold.

On examination, the patient must pay attention to abrasions and subcutaneous hematomas of the anterior abdominal wall, hematomas on the perineum and the inner surface of the thighs. It is necessary to visually assess the color of urine.

The most characteristic symptoms of bladder damage are gross hematuria (82%) and abdominal tenderness on palpation (62%). Other symptoms of bladder injury include microhematuria, inability to urinate, hematoma in the suprapubic area, muscle tension of the anterior abdominal wall, hypotension, decreased urine output.

Если пациент находится в состоянии алкогольного опьянения, вышеперечисленные симптомы проявляются не сразу. При неповреждённой мочеполовой диафрагме затёки мочи ограничены областью таза. В случае разрыва верхней фасции мочеполовой диафрагмы моча инфильтрирует мошонку, промежность и брюшную стенку. When the lower fascia of the pelvic diaphragm ruptures, urine infiltrates the penis and / or thigh.

The most simple, affordable, and not requiring high qualifications and special equipment for diagnosing bladder injuries is a diagnostic catheterization, performed carefully, with a soft catheter, in the absence of signs of damage to the urethra.

Signs indicating damage to the bladder:

  • the absence or small amount of urine in the bladder of a patient who has not urinated for a long time:
  • a large amount of urine, significantly exceeding the physiological capacity of the bladder,
  • admixture of blood to urine (it is necessary to exclude the renal origin of hematuria),
  • discrepancy between the volumes of fluid injected and discharged through the catheter (Zeldovich positive symptom),
  • The released fluid (a mixture of urine and exudate) contains up to 70-80 g / l of protein.

In recent years, ultrasound, laparoscopy, and laparocentesis (diagnostic puncture of the anterior abdominal wall) have been widely used to identify free blood and urine in the abdominal cavity. The catheter inserted into the abdominal cavity is alternately guided under the hypochondria, into the iliac regions and the pelvic cavity, removing the contents of the abdominal cavity with a syringe. Upon receipt of blood, fluid mixed with bile, intestinal contents, or urine, damage to internal organs is diagnosed and an emergency laparotomy is performed. In the case when the fluid does not enter the abdominal cavity, 400-500 ml of physiological sodium chloride solution is injected into the abdominal cavity, then sucked off and examined for blood, diastase and urine. Negative laparocentesis allows you to refrain from laparotomy.

To detect a small amount of urine in the wound discharge and intraperitoneal fluid obtained during laparocentesis or during the operation, determine the presence of substances that are selectively concentrated in the urine and are its indicators. The most suitable endogenous substance is ammonia, whose concentration in the urine is thousands of times higher than in blood and other biological fluids.

The method of determining urine in the test liquid To 5 ml of the test liquid add 5 ml of 10% solution of trichloroacetic acid (to precipitate the protein), mix and filter through a paper filter. In a clear and colorless filtrate for alkalization pour 3-5 ml of 10% potassium hydroxide solution (KOH) and 0.5 ml of Nessler's reagent. If the test liquid contains more than 0.5-1% urine, it becomes orange, it becomes cloudy and a brown precipitate appears, which is regarded as damage to the urinary organs. In the absence of urine in the test fluid, it remains a transparent slightly yellow color.

Ultrasound, bladder catheterization and puncture of the abdominal cavity are the most acceptable methods for diagnosing bladder damage in the practice of emergency care.

The same methods are the main diagnostic techniques at the stage of providing skilled surgical care, which does not have X-ray equipment.

The diagnostic value of cystoscopy for bladder ruptures is limited by the complexity of placing the patient in the urological chair (shock, fractures of the pelvis), the inability to fill the bladder during ruptures, and intense hematuria, which prevents examination due to poor visibility. In this regard, to seek to perform cystoscopy in case of suspected damage to the bladder should not be. It can be used at the final stage if the clinical and radiological data do not confirm, but do not exclude, with sufficient reliability, the presence of damage, and the patient’s condition allows for cystoscopy.

Be sure to conduct a laboratory study of blood to assess the severity of blood loss (hemoglobin, hematocrit and red blood cells) and urine. A high level of serum electrolytes, creatinine and urea causes suspicion of intraperitoneal rupture of the bladder (urine enters the abdominal cavity, urinary ascites and is absorbed by the peritoneum).

Gross hematuria

Gross hematuria is a permanent and most important, but not unambiguous symptom that accompanies all types of damage to the bladder. Numerous studies show that gross hematuria at a hip fracture is strictly correlated with the presence of a rupture of the bladder. During the rupture of the bladder, gross hematuria occurs in 97-100%, and a fracture of the hip - 85-93% of observations. The simultaneous presence of these two states is a strict indication for cystography.

Isolated hematuria without any information about the injury of the lower urinary tract is not an indication for cystography. Additional factors to suspect bladder damage are arterial hypotension, a decrease in hematocrit, the patient's general serious condition, and fluid accumulation in the pelvic cavity. If the injury to the pelvic bones is not accompanied by gross hematuria, the probability of serious damage to the bladder is reduced.

In case of urethrorrhagia, prior to cystography, retro hail urethrography must be performed to identify possible damage to the urethra.

Microhematuria

The combination of pelvic ring fracture and microhematuria indicates damage to the urinary tract, however, if there is less than 25 red blood cells in the field of view with a high magnification of the microscope, then the probability of a bladder rupture is small. All patients with a rupture of the bladder reveal hematuria - more than 50 erythrocytes in the field of view with a high magnification.

Carrying out cystography is advisable if, according to a urine study, with a large increase, the number of red blood cells exceeds 35-50 and even 200 in sight.

Caution should be taken when dealing with childhood injuries, since according to the research done, when 20 red blood cells are detected in the field of view at high magnification without a cystography, up to 25% of bladder ruptures can be missed.

Survey radiography reveals bone fractures, free fluid and gas in the abdominal cavity.

Excretory urography with a descending cystography in most bladder injuries, especially those complicated by shock, is uninformative due to that. that the concentration of the contrast agent is insufficient to detect urine streaks. The use of excretory urography in case of damage to the bladder and urethra in 64-84% of observations gives a false-negative result, as a result of which its use for diagnosis is inappropriate. The usual cystographic phase during standard excretory urography does not preclude bladder damage.

Cystography

Retrograde cystography is the “gold standard” for diagnosing bladder injuries, which makes it possible to detect a violation of the integrity of the bladder. conduct a differential diagnosis between intra-and extraperitoneal ruptures, establish the presence and localization of streaks. In addition to being highly informative, the method is safe, does not make the victim's condition worse, and does not cause complications from the penetration of a contrast agent into the abdominal cavity or perineal cellulose — if a rupture is detected, cystography should be followed by surgical intervention with draining the abdominal cavity or draining drains. It is advisable to combine retrograde cystography with Ya.B. Zeldovich.

In order to ensure high information content of the research on the catheter, at least 300 ml of a 10-15% solution of a water-soluble contrast agent are slowly injected into the bladder in a 1-2% solution of novocaine with a broad-spectrum antibiotic. Perform a series of x-rays of the bladder in the frontal (anteroposterior) and sagittal (oblique) projections. Be sure to take a picture after emptying the bladder to clarify the localization and nature of the spread of leakage in the paravesical and retroperitoneal tissue, which increases the efficiency of the study by 13%.

The main radiological sign of damage to the bladder - the presence (flowed) of a contrast agent outside, indirect - the deformation and shift it up or to the side. Indirect signs are more often observed with extraperitoneal rupture and near-vesicular hematomas.

The characteristic direct radiological signs of an intraperitoneal rupture are clear lateral boundaries, a concave and uneven upper contour of the bladder due to the overlapping of the bubble shadow by efflorescent contrast. At intraperitoneal ruptures, intestinal loops are contrasted: rectal-vesicular (rectal-uterine) recess. The shadows of the contrasting substance poured into the abdominal cavity are well delineated because of their location between the loops of the swollen bowel.

Symptoms of extraperitoneal rupture fuzzy bladder contour, vagueness: flow of radiopaque substance into the paravesical cellulose in the form of individual bands (flames, divergent rays) with a small cloudy shade - medium, solid blackout without clear contours - large rupture.

All streaks, as a rule, lie below the top edge / ossa acetabulum.

If the rules noted above are not observed, there is a possibility of getting a false result. Based on cystography data, the classification of bladder damage according to the European Association of Urology Protocol (2006) is based.

Ultrasound procedure

The use of ultrasound to diagnose damage to the bladder is not recommended as a routine method of research due to the fact that its role in detecting damage to the bladder is small.

Ultrasound can detect free fluid in the abdominal cavity, fluid formation (urothematoma) in the tissue of the pelvis, blood clots in the bladder cavity or the lack of visualization of the bladder when it is filled through the catheter. The use of ultrasound is currently limited due to the fact that CT patients are more likely to undergo CT, a more informative diagnostic method.

CT scan

Although CT is the method of choice for examining blunt and penetrating injuries of the abdomen and thigh, nevertheless, its routine use even with a full bladder is impractical, since it is not possible to differentiate urine from transudate. For this reason, in order to diagnose damage to the bladder, CT scan is performed in combination with retrograde contrasting of the bladder - CT cystography.

CT cystography makes it possible to diagnose bladder injuries with an accuracy of 95% and a specificity of 100%. In 82% of observations, the CT data completely coincide with the data obtained during the operation. In the diagnosis of intraperitoneal damage to the bladder, CT cystography is sensitive in 78% and specific in 99%. During CT scan, performing additional scans after bladder emptying does not increase the sensitivity of the method.

Thus, CT with contrasting bladder and retrograde cystography from the point of view of diagnosis of bladder damage have the same information, but the use of CT provides the ability to diagnose also combined injuries of the abdominal cavity, which undoubtedly increases the diagnostic value of this research method.

Magnetic resonance imaging

MRI in the diagnosis of injuries of the bladder is used mainly to diagnose the combined damage to the urethra.

With clinical signs of damage to the organs of the abdominal cavity, often the final diagnosis of the type of damage to the bladder is carried out during its revision during the operation. After revision of all organs of the abdominal cavity, the integrity of the bladder is checked. Through the wound of the bladder with its sufficient size carry out an audit of all the walls to exclude also extraperitoneal ruptures.

Treatment of closed injuries and bladder injuries

Suspected bladder damage - indication for emergency hospitalization of the patient.

Therapeutic tactics depend on the nature of the damage to the bladder and the combined injuries of other organs. With shock before surgery, anti-shock measures are performed. In case of bruise and incomplete rupture of the bladder, treatment is conservative: bed rest, hemostatic, analgesic, antibacterial and anti-inflammatory drugs are prescribed.

To prevent a two-stage rupture, a permanent urinary catheter is inserted into the bladder. The duration of bladder drainage is individual and depends on the severity of the injury, the patient's condition, the nature of the injury, the duration of hematuria, the duration of pelvic hematoma resorption (average of 7-10 days). Before removing the urethral catheter, it is necessary to perform a cystography and make sure that there are no streaks of contrast material.

Treatment of complete closed injuries is always prompt. The best results are observed at early terms of an operative measure. Before surgery, oriental injuries of the bladder primary task is to stabilize the patient's general condition.

In many patients with a closed extraperitoneal rupture of the bladder, its catheterization is effective, even if there is extravasation of urine behind the peritoneum or into the ravine of the external genital organs.

According to Corriere and Sandlera, 39 patients with bladder rupture were cured solely due to its drainage and a good result was observed in all cases. Cass, having cured 18 patients with extraperitoneal bladder rupture with only one drainage, observed complications only in 4 cases.

According to some authors, preferably transurethral drainage of the bladder, leading to a lower level of complications. Urethral catheter, left for a period of 10 days to 3 weeks. removed after cystography.

For small extraperitoneal injuries of the bladder arising from endourological operations, conservative treatment is possible against the background of bladder drainage for 10 days. By this time, 85% of cases of bladder damage will heal on their own.

Indications for surgical treatment of non-peritoneal blunt trauma:

  • bladder neck damage,
  • fragments of bones in the thickness of the bladder and pinching of the bladder wall between the bone fragments,
  • the impossibility of adequate drainage of the bladder by a urethral catheter (clot formation, continued bleeding),
  • concomitant damage to the vagina or rectum.

Practice shows that the sooner surgery is performed for such intra-and extraperitoneal bladder injuries, the better the results.

The purpose of the operation is a revision of the bladder, suturing of its defects with a single-row suture using absorbable suture material, urination of the urine by imposition of an epicystostomy and drainage of paravesical urinary streaks and urohematoma of small pelvis tissue.

When intraperitoneal damage produces a median laparotomy. The abdominal cavity is thoroughly drained. The bladder wound is sutured with single or double row sutures of catgut or synthetic absorbable sutures. After suturing the bladder wall defect, check the seam tightness. In the abdominal cavity leave thin PVC drainage.

For the introduction of antibiotics and the abdominal cavity is sutured to the place of the delivered drainage. If it is difficult to detect a defect in the cystic wall during the operation and to check the tightness of the seam at the end of the bladder operation, use the introduction of a 1% methylene blue solution or a 0.4% indigo carmine solution into the bladder through the catheter, following the location of the ink in the abdominal cavity. If the closure of the bladder wound is difficult, it is extraperitonized.

Extraperitoneal, easily accessible bladder ruptures are sutured with a two- or single-row suture. With the localization of damage in the area of ​​the bottom and neck of the bladder due to their inaccessibility may be the imposition of immersion sutures from the side of his cavity. To the wound hole outside, drainage flows, depending on the localization of the wound through the suprapubic access, are supplied: however, it is preferable through the crotch according to Kupriyanov or the obturator opening in the Buyal-Mac-Worger. Then the catheter is fixed to the hip with a tension for a day and is removed not earlier than after 7 days.

With the separation of the bladder neck from the urethra, the stapling of the dispersed parts is almost impossible due to the technical difficulties of stitching in this area and developed urinary infiltration at the time of surgery. To restore the patency of the urethra and prevent the formation of long strictures after evacuation of the urohematoma into the bladder, a catheter is passed through the urethra.

Then, retreating to 0.5-1.5 cm from the edge of the wound of the bladder neck, apply 1-2 catgut ligatures on the right and left, while bladder detrusor and prostate capsule are pierced near the urethral opening. The ligatures are staggered, they pull together the bladder and eliminate the diastasis between the bladder neck and the proximal end of the urethra. The bladder is fixed in its anatomical bed. Мочевой пузырь и околопузырное пространство дренируют силиконовыми (хлорвиниловыми) трубками.

Уретральный катетер сохраняют до 4-6 сут. If it is impossible to overlap, fixing ligatures, a Foley catheter is used; the balloon is filled with liquid and the neck of the bladder is brought closer to the prostate by a tension, a suture is placed between them in easily accessible places and the catheter is fixed to the thigh. In case of a severe condition of the patient and a prolonged intervention, the comparison of the bladder neck with the urethra is postponed to a later date, and the operation is completed by cystostomy and drainage of the parabubular space.

The bladder is drained for any breaks, using mostly epicystosty, and it is better to install the drainage tube as close as possible to the top of the bubble.

The tube is fixed with catgut to the wall of the bladder, after the suturing of the cystic wound below the tube, the region of the stroma is hemmed to the aponeurosis of the rectus muscles. The high location of the drainage tube prevents the development of osteomyelitis of the pubic bones. Only in some cases, with an isolated slight damage to the bladder in women, the absence of peritonitis and urinary leakage, the tightness of the seam of the gallbladder wound, drainage with a permanent catheter is acceptable for 7-10 days.

In the postoperative period, it is advisable to actively remove urine with the help of siphon drainage, a device for draining the UDR-500, and a vibroaspirator. Stationary vacuum suction. If necessary, a continuous flushing of the bladder with antibacterial solutions is carried out through the intra-drainage irrigator of the double lumen drainage or an additional capillary tube installed through the suprapubic access. Improving the outcome of closed bladder damage is determined by early diagnosis and timely surgical intervention. Mortality in a number of institutions was reduced to 3-14%. Cause of death affected -
multiple severe injuries, shock, blood loss, peritonitis and urosepsis.

If the patient is in extremely severe condition, they perform cystostomy and drain the para-bladder tissue. Reconstructive surgery is performed after stabilization of the patient's condition.

Patients with pelvic fractures need bladder reconstructive surgery before intraosseous fixation of the fragments.

In the postoperative period, broad-spectrum antibiotics, hemostatic drugs, analgesics are prescribed. In the overwhelming majority of cases, when using this method of treating damage, complete healing occurs within a period not exceeding 3 weeks.

The intraperitoneal rupture of the bladder is an absolute indication for emergency surgery, contraindication is only the agonal condition of the patient. If you suspect a combined damage to the abdominal organs, it is advisable to include an abdominal surgeon in the surgical team.

Rapid access - lower median laparotomy. After opening the abdominal cavity, a thorough inspection of the organs is carried out in order to exclude their combined injuries. In the presence of such injuries, the abdominal phase of the operation is first performed.

Bladder rupture is usually observed in the area of ​​the transitional fold of the peritoneum. If it is difficult to locate a bubble rupture, it is advisable to use intravenous injection of a 0.4% solution of indigo carmine or 1% solution of methylene blue, dyeing the urine blue and thereby facilitating the detection of bladder damage.

After damage to the bladder wall is detected, an epicystostomy is performed, and the rupture is sutured with a double-row suture using absorbable material. Sometimes the bladder is additionally drained with a urethral catheter; for 1-2 days, a constant washing of the bladder with antiseptic solutions is established.

In the absence of combined injuries of the abdominal organs, the operation is completed by reorganization and drainage. Drainage tubes set through kontraperturny incisions in the pelvic cavity and on the right and left lateral channels of the abdominal cavity. With diffuse peritonitis, nasogastrointestinal intestinal intubation is performed.

In the postoperative period, antibacterial, hemostatic, anti-inflammatory, infusion therapy, intestinal stimulation and correction of homeostasis disorders are carried out.

The duration of the drainage of the abdominal cavity and bladder is determined individually depending on the characteristics of the postoperative period. At the same time, they focus on the indicators of intoxication, the duration of hematuria, the presence of infectious and inflammatory complications.

Causes of damage

Among the causes of this injury may be external influences or certain human condition:

  • overflow of the body with urine and the inability to empty it,
  • abdominal trauma,
  • injuries to the bladder,
  • very strong bruises,
  • medical intervention
  • trauma during childbirth in women.

Abdominal injuries that can cause bladder integrity problems can be sustained during a car accident, when a pelvic bone fracture occurs, and they damage the walls of the organ with their fragments. In addition, the causes of injury may be a fall, a strong blow, a knife or a gunshot wound. Of course, injuries are mainly characteristic of people in extreme situations, but anything happens in life.

Dangerous situations may be when the bladder is full, but it is not possible for a person to urinate. Despite this, the kidneys continue to work, and more new urine flows into the bladder. This leads to excessive stretching of the walls and the risk of their rupture. The cause of such conditions are some pathologies, for example, narrowing of the urethra, adenoma or prostate cancer. They are typical for men, so damage to this organ is more common in males.

A significant risk factor for injury to the bladder walls is medical manipulation. This may be a catheter setup or cystoscopy. All interventions should be performed only by professionals, if possible it is better to use special techniques that allow to visualize the process. Bladder rupture during labor is very rare. This happens when applying forceps to retrieve a child. The uterus also suffers.

Types of damage

Damage to this organ is divided into extraperitoneal and intraperitoneal rupture of the organ. Damage, called intraperitoneal, is quite dangerous. It occurs when the organ is full. The walls of the bubble in its upper part are the thinnest, namely, it is at risk. The danger is that in this case, urine is poured directly into the abdominal cavity, spreading to the tissues of the spleen, liver, and intestines. All this is fraught with inflammation, which may be complicated by peritonitis.

Extraperitoneal rupture occurs usually in injuries, when bone fragments damage the mucous membrane and muscle layer. Urine in this case penetrates the surrounding tissue. Consequences - flow of urine in the perineal region, pubis, development of phlegmon, hemorrhages in the retina of the eye are possible.

Symptoms and manifestations

Symptoms of bladder rupture occur very quickly. First of all, it is pain, which can be of different intensity. With extraperitoneal damage, pain will accompany urination.

It is often localized above the pubis, in the perineum, and there may be pain in the lower abdomen. A person has difficulty urinating, the amount of urine is less.

In almost all cases of trauma to the bladder, hematuria, that is, blood in the urine, is present, which is caused by rupture of the bladder tissue. Painful symptoms of intra-abdominal rupture manifest paroxysmal. The pain is felt in the perineum, in the pubic area, and soon in the entire abdomen.

External manifestations

  • Puffiness in the pubis and perineum.
  • Increased abdomen.
  • Pallor of the skin.
  • Cold sweat.
  • Slow breathing.
  • Fainting.

If the rupture occurred due to a bone fracture or another serious injury, then the patient's blood pressure drops sharply, and heart palpitations appear. Perhaps the development of a state of life-threatening shock.

Diagnosis and treatment

This diagnosis is pre-made on the basis of the patient's complaints and history taking. To confirm it is necessary to conduct laboratory tests and hardware research. The most informative are cystoscopy and cystography. Cystographic examination is performed using a contrast agent. This allows you to get a complete picture of the problem: the nature of the damage, its size and localization.

Independent scarring is possible only with small extraperitoneal ruptures, in other cases intervention is required.

Treatment methods

  • Catheterization.
  • Operation.

Catheterization is carried out with extraperitoneal injuries. After installing the catheter, the urine freely exits the bladder without accumulating in it. This allows the tissues to not experience stress and allows them to heal. If scarring does not occur, then resort to surgery. It is also necessary if an intraperitoneal rupture of the walls of the bladder occurs.

During the operation, an incision is made in the peritoneum to gain access to the organ. Next, its walls are stitched together. Installing a catheter is required. This is required to give the body peace and opportunity to recover. This is necessary for the entire period of rehabilitation after surgery.

In case of injuries as a result of injuries, the operation is necessary, because the probability of damage to other organs is also high. Since the consequences can be very dangerous, even fatal, it is impossible to delay the adoption of measures. These cases require emergency medical care.

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Symptoms of bladder injury

  • Lower abdominal pain, above the pubis or in the entire abdomen.
  • Blood in the urine.
  • Urinary retention - the patient cannot urinate on his own.
  • Frequent, unsuccessful urination to expel a few drops of blood.
  • The release of urine from the wound - with open injuries of the bladder (in violation of the integrity of the skin).
  • Signs of bleeding (skin pallor, low blood pressure, rapid pulse).
  • Symptoms of peritonitis (inflammation of the walls of the abdominal cavity) - occur during intraperitoneal rupture of the bladder (the cavity of the bladder communicates with the abdominal cavity - the space in which the intestine, stomach, liver, pancreas, spleen):
    • abdominal pain,
    • forced position of the patient: half-sitting (pain in the abdomen is worse when the patient is lying down and weakens in a sitting position),
    • fever,
    • bloating
    • tension of the abdominal muscles
    • stool retention
    • nausea, vomiting.
  • When extraperitoneal rupture of the bladder (there is no message of the cavity of the bladder with the abdominal cavity) can be observed:
    • swelling of the pubis, in the groin,
    • blueness of the skin (due to the accumulation of blood under the skin) above the pubis.

In relation to the abdominal cavity (the space in which the intestines, stomach, liver, pancreas, spleen are) allocate:

  • extraperitoneal gapBladder (occurs most often in fractures of the pelvic bones, the cavity of the bladder is not communicated with the abdominal cavity),
  • intraperitoneal bladder rupture (occurs most often when the bladder was full at the time of injury, in which case the cavity of the bladder communicates with the abdominal cavity),
  • combined bladder rupture (The injury led to a fracture of the pelvic bones, and at this point the bladder was full, the bladder is damaged in several places, and there is a connection with the abdominal cavity and the pelvic cavity (the space in which the rectum, prostate gland is located)).

By type of damage:
  • open bladder damage (in violation of the integrity of the skin, this causes the communication of internal organs with the external environment),
  • closed bladder damage (without compromising the integrity of the skin).

By severityinjuries emit:

  • injury (the integrity of the bladder is not broken),
  • incomplete rupture of the bladder wall,
  • complete rupture of the bladder wall.

By the presence of damage to other organs:
  • isolated bladder injury (only bladder damage occurs)
  • combined bladder injury (in addition to the bladder, abdominal organs are damaged).

  • Drop from a height onto a solid object.
  • Shaking of the body during a jump (against the background of an overflowing bladder).
  • A blow to the abdomen (often due to a traffic accident).
  • Gunshot or knife wound.
  • Medical manipulations:
    • bladder catheterization (insertion of a thin plastic or metal tube into the bladder to remove urine),
    • bougienage of the urethra (expansion of the urethra with metal rods),
    • surgery on the pelvic organs with fractures of his bones.
  • Alcohol intoxication - contributes to the occurrence of bladder injury, as the urge to urinate is dulled.
  • Diseases that cause disruption of urine outflow from the bladder, contribute to the appearance of bladder injury:
    • prostate adenoma (benign prostate tumor),
    • prostate cancer (malignant tumor of the prostate),
    • narrowing of the urethra (urethral stricture).

A urologist will help in the treatment of the disease

Diagnostics

  • Analysis of the history of the disease and complaints - when an injury occurred, when blood appeared in the urine, difficulty in urinating, whether there was a treatment, an examination, whether there were any injuries to the bladder.
  • Analysis of the history of life - what diseases a person suffers, what operations he underwent. Special attention is paid to prostate diseases.
  • Complete blood count - allows you to determine signs of bleeding (decrease in the level of red blood cells (red blood cells that carry oxygen), hemoglobin (iron-containing protein, located in red blood cells, which is involved in the transport of oxygen and carbon dioxide)).
  • Urinalysis - to determine the presence of red blood cells (red blood cells) and to identify the degree of bleeding.
  • Ultrasound examination (ultrasound) of the kidneys, bladder - allows you to assess the size and structure, the presence of blood near the bladder, the presence of blood clots inside the bladder, to identify violation of urine outflow from the kidneys.
  • Ultrasound examination (ultrasound) of the abdominal organs. Allows you to detect the presence of blood in the abdomen, which should not be normal.
  • Retrograde cystography. A substance visible on the X-ray is injected into the cavity of the bladder through the urethra. The method allows to determine the type of damage to the bladder, the state of the pelvic bones.
  • Intravenous urography. An x-ray-positive drug is injected into a patient's vein, which in 3-5 minutes is excreted by the kidneys, while several pictures are taken. The method allows to assess the degree of bladder injury, to identify the place where there is a defect in the bladder.
  • Magnetic resonance imaging (MRI) is a high-precision method for diagnosing bladder injury based on the possibility of studying the organ layer by layer. The method allows to determine the degree of damage to the bladder. Also using this method, you can identify damage to neighboring organs.
  • Computed tomography (CT) is an x-ray study that allows to obtain a spatial (3D) image of an organ. The method allows you to accurately determine the degree of damage to the bladder, as well as the volume of blood, urine, located next to the bladder. Also using this method, you can identify damage to neighboring organs.
  • Laparoscopy is a diagnostic method based on insertion of a video camera and instruments into the abdominal cavity through small skin incisions. The method allows to determine the type of damage to the bladder, the degree of bleeding, to assess damage to internal organs.
  • Surgeon consultation is also possible.

Complications and consequences

  • Excessive bleeding with the onset of shock (lack of consciousness, low blood pressure, rapid pulse, and frequent shallow breathing). The condition can lead to death.
  • Urosepsis - the penetration of microorganisms in the blood and the development of inflammation throughout the body.
  • Suppuration of blood and urine around the bladder.
  • The formation of urinary fistula. Нагноение крови и мочи рядом с мочевым пузырем приводит к нарушению целостности тканей, что в свою очередь приводит к прорыву гнойника наружу через кожу.As a result, a channel is formed through which the external environment communicates with the internal organs.
  • Peritonitis - inflammation of the walls and organs in the abdominal cavity.
  • Osteomyelitis is an inflammation of the pelvic bones.

Bladder injury prevention

  • Timely treatment of diseases of the prostate gland, such as: prostate adenoma (benign tumor), prostate cancer (malignant tumor of the prostate).
  • Exclusion of injury.
  • Avoid excessive drinking.
  • After injury, regular observation at the urologist for at least 3 years.
  • Control of PSA (prostate-specific antigen is a specific protein that is detected in the blood, which rises in prostate diseases, including cancer.)

  • Hadzhibaev AM, The stages of diagnosis and surgical treatment for combined injuries of the bladder, Urology, № 4, 2012, p 13-19.
  • Emergency Urology. Yu.A. Pytel, I.I. Zolotorev. "Medicine", 1985
  • Damage to the urogenital system. I.P. Shevtsov, "Medicine", 1972
  • Urology by Donald Smith. Ed. E. Tanaho, J. McAninch. "Practice" 2005
  • Textbook. Urology. N. A. Lopatkin. “Geotar-Med” 2004

Damage classification

Bladder ruptures can be divided among themselves according to the nature of the lesions and their position:

  1. Injury. It is the most harmless of all types of damage. When bruised the integrity of the body is not broken. Volumetric blood clots are removed using a special catheter.
  2. Extraperitoneal. This type of damage is characteristic of the change in the integrity of the urea, the damage is caused by bone fragments or as a result of knife wounds. Urine is retained in the tissues adjacent to the urea. The abdomen area is not filled.
  3. Intraperitoneal. With a strong pressure inside the bladder, with a large accumulation of urine, the urethra ruptures in the upper, unprotected part of the pelvic bones. Urine enters the abdominal cavity.
  4. Combined. In case of repeated injuries of the bladder, urine can get into the abdominal cavity and at the same time into the pelvic region.

Why do injuries occur?

There are such causes of bladder rupture:

  • errors in medical procedures, such as installing a catheter for outflow of urine, research using a cystoscope,
  • fracture of the pelvic bones, in which debris can pierce the urea,
  • urea diseases that are inflammatory and violate the integrity of its walls,
  • tumors of different nature
  • strong blows in the area of ​​the bubble, injuries inflicted with a cold weapon and a firearm,
  • high pressure on the bubble, for example, a car seat belt,
  • pressure inside the urea due to failures in the process of urine discharge due to urological diseases,
  • tumors of the urinary system, urinary system and surrounding organs,
  • adenoma and prostatitis in men,
  • narrowing of the urethra.

Manifestations of the disease

Symptoms of bladder rupture are rather indirect, on the basis of which one can only assume its presence. The full picture and diagnosis is possible only after the necessary examinations. Symptoms for different types of breaks differ from each other. For extraperitoneal rupture characteristic:

  • increasing pain, pain in the groin,
  • preservation of urination,
  • separation of urine in small portions, contains blood.

For intraperitoneal damage, the following symptoms are observed:

  • sharp attacks of pain, including in the abdomen,
  • lack of urination, although there are urges,
  • abdominal distention due to the accumulation of urine in the peritoneum,
  • swelling in the groin area.

For combined breaks, general malaise may be added to the symptoms:

  • increased heart rate
  • pressure drop
  • reduced reaction
  • increased sweating
  • pallor.

Diagnostic measures

The urologist after the necessary examinations can diagnose ruptures:

  1. Cystography. Conducted by introducing into the bladder a contrast agent. On the images obtained during the examination, the doctor can see the place of the gap and estimate its size.
  2. Cystoscopy. Examination by which the doctor receives information about the condition of the bladder and the integrity of its walls. It is performed by inserting a cystoscope device into the urea.
  3. MRI and CT. Survey data help to get a complete picture of damage, to determine where and in what quantity urine and blood accumulate. It is possible to determine the degree of damage to nearby organs.

Laboratory tests may also be needed to diagnose a rupture of a urea:

  1. General blood analysis. According to it, the doctor will be able to determine the presence of bleeding.
  2. General urine analysis. If possible, will determine the degree of bleeding.

Non-surgical therapy

In rare cases, if there is a minor damage to the urea, but with these injuries the urine is retained and does not flow into the abdominal or pelvic cavity, it is possible to avoid surgery. In this case, a catheter will be installed in the patient to avoid stretching the bladder and urine leakage.

Damage may be delayed by themselves. In this case, in addition to the installation of the catheter, the patient is recommended bed rest, as well as drugs that stop bleeding, painkillers and antibiotics.

Surgery for pathology

For the most part, in case of rupture of the urea, an operation cannot be done. Access to the body occurs by abdominal incision of the anterior abdomen.

If the damage is due to a fracture of the pelvic bones, the operation will be carried out in conjunction with the orthopedic surgeon who will restore the pelvic bones and provide the surgeon with access to the urethra. The gap is sewn.

Before completion of the operation, a catheter is installed in the patient to remove urine from the bladder and eliminate the divergence of stitches. The catheter can be installed for up to ten days. The time it is worn depends on the healing of postoperative sutures. After surgery, antibiotics are prescribed to the patient without fail, in order to exclude the appearance of infections.

Postoperative period

After surgery, you must systematically visit the attending physician to exclude postoperative complications. Also, for the speedy recovery of the body and the healing of sutures, it is necessary to exclude salty, spicy and smoked meats from food. This is necessary to eliminate the increased acidity of urine. Alcohol and smoking are contraindicated.

In the postoperative period, it is necessary to abandon physical activity, which can lead to repeated rupture. It should be dressed warmer to eliminate the inflammatory process of the urea and urinary tract.

For several months, patients may experience involuntary emptying of the bladder, in this case special medicines are prescribed by the doctor to relieve the discomfort.

What can cause the disease?

In case of late assistance or improper treatment, damage to the bladder may have its own complications. The consequences of the gap include:

  • peritonitis when urine enters the abdomen, as well as other organs,
  • a large loss of blood, in the presence of bleeding can lead to death from rupture of the bladder,
  • infectious and inflammatory diseases, blood poisoning,
  • purulent deposits, which, when rupture, form passages to the internal organs, which is dangerous by bacteria and microorganisms.

Injury prevention

Most often, damage to the urea is associated with injuries, for example, after an accident, it is impossible to prevent such injuries, but it is important to treat your life carefully and try not to create dangerous situations and, if possible, avoid various injuries.

Cystoscopy should be performed only by medical staff to eliminate the risk of a bladder puncture.

In cases not related to external injury, there are some recommendations:

  1. Timely treatment of urological diseases.
  2. Observation by a gynecologist after childbirth in women.
  3. Monitoring the state of the prostate in men.
  4. Complete rejection of alcohol or reducing its amount.

Compliance with these recommendations will help reduce the likelihood of developing various pathologies and injuries.

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