lower urinary tract injuries

LOWER URINARY LOWER URINARY TRACT INJURIESTRACT INJURIES

Dr.Pankaj Bharadva

INTRODUCTIONINTRODUCTIONIncludes injuries to urinary

bladder and urethra.

Most common etiological factors are vehicular accident and iatrogenic injuries.

INJURIES TO URINARY INJURIES TO URINARY BLADDERBLADDER

Constitutes <2% of abdominal injuries requiring surgery.

Etiology:1) Blunt injuries: usually associated with

pelvic fractures.2) Penetrating injuries:3) Iatrogenic injuries: may result from

gynecologic and other extensive pelvic procedures; laparoscopic surgery, transurethral operations and hernia repair.

INJURIES TO URINARY INJURIES TO URINARY BLADDERBLADDER

Classification of bladder injuries:

Extra peritoneal rupture 80%Intra peritoneal rupture 20%

INJURIES TO URINARY INJURIES TO URINARY BLADDERBLADDERExtraperitoneal rupture:

Introduction:o Bony pelvis protects urinary bladder.o When the pelvis is fractured by blunt

trauma, fragments from the fracture site may perforate the bladder. These perforations usually result in extraperitoneal rupture and leads to extraperitoneal extravasation of urine.

o If the urine is infected, extraperitoneal bladder perforation may result in deep pelvic abscess and severe pelvic inflammation.

Extraperitoneal Extraperitoneal rupturerupture

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDERExtraperitoneal rupture:

Clinical features:o Usually associated with fracture pelvis, which

is ascertained by pelvic compression test.

o Symptoms: H/O lower abdominal trauma; inability to urinate or when urinate- gross hematuria and pelvic & lower abdominal pain.

o Signs: - heavy bleeding associated with hemorrhagic shock. - evidence of lower abd. Trauma. - marked tenderness of suprapubic area and lower abdomen.

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDERIntraperitoneal rupture:

Etiology: may be secondary to blow, kick or fall on fully distended bladder and it is more common the male than in the female, usually following beer drinking.

Pathogenesis & Pathology:- injury usually near dome of bladder and

urine will 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.

Intraperitoneal Intraperitoneal rupturerupture

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDERIntraperitoneal rupture:

Clinical features:- history of lower abdominal injury.- Sudden agonizing pain in hypogastrium,

often accompanied by syncope. - Not passed urine since injury and no desire.- Suprapubic tenderness present but no

dullness.- Varying degree of abdominal rigidity and

distension and sometimes shifting dullness.

- P/R examination: bulging of rectovesical pouch.

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDER Investigations:

i. Plain X- ray abdomen:• demonstrates pelvic fractures.• Haziness or ground glass appearance in lower

abdomen due to extravasated blood and urine.i. Retrograde cystography or MCUG:• if no signs of fracture then it may be done.• drainage film (of contrast) will demonstrate • areas of extraperitoneal extravasation of blood

and urine that may not appear in filling film.• with intraperitoneal rupture, free contrast

material will be visualized in the abdomen highlighting bowel loops.

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDER Investigations:

iii. IVP: - may confirm leak from bladder.

v. Computed tomography- cystography:- highly sensitive and specific.-also reveals intraabdominal injuries and pelvic fracture.

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDER Complications:

i. Pelvic abscess: from extraperitoneal bladder rupture.

ii. Delayed peritonitis: from intraperitoneal rupture.

iii. Partial incontinence: if laceration extends into bladder neck and not properly repaired.

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDER Treatment:

I. Emergency treatment of shock and hemorrhage.

II. Surgical treatment:A. Extraperitoneal rupture:

-most cases managed with catheter drainage only.-contraindications to conservative management: Bone fragments projecting into the bladder Open pelvic fracture. Rectal perforation. Patients undergoing laparotomy for other

reasons. - All above mentioned cases rupture should be

repaired intravesically.

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDERTreatment:II.Surgical treatment: (Contd.)

B. Intraperitoneal Rupture:-Repaired via transperitoneal approach

suctioning of urine from peritoneal cavity; -closure of perforation in two layers.-Suprapubic and per urethral catheter.

C. Surgical measures for pelvic fracture and pelvic hematoma:

- stabilization and packing.

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDERInjury to bladder during surgery:

Open surgery: Prevention by catheterization before surgery.

If injury recognized at time of surgery, bladder should be sutured in two layers and catheter drainage for 7 days.

Perforation is usually extraperitoneal- bladder drained by large catheter and antibiotics. If however, mass of extraperitoneal fluid is palpable per abdomen it is best to place a small drain into extraperitoneal prevesical space.

For intraperitoneal perforation- laparotomy required.

URETHRAL INJURIESURETHRAL INJURIESIntroduction:

◦ Most often in men, rare in women.◦ Usually associated with pelvic fractures or

straddle type falls.◦ Separated in 2 broad anatomic

divisions. Posterior urethra:

consists of prostatic and membranous urethra.

Anterior urethra:consists of bulbous and penile portions.

URETHRAL INJURIESURETHRAL INJURIES Injuries of membranous urethra:

Etiology:I. Pelvic fracture:

10-15% have associated urethral injury. Sudden force to one lower limb( e.g. car

accident) causes pubic and ischial rami fracture —>disruption of sacroiliac joint—> traction force on prostate—> torn ends of urethra may be widely displaced.

Front to back compression of pelvis by direct blow from front—>butterfly fracture—> ends of torn urethra are close to each other.

II. Shear injury: Rare. Due to sudden explosive rostral migration of

prostate and bladder.

Injuries of membranous Injuries of membranous urethraurethra

URETHRAL INJURIESURETHRAL INJURIESInjuries of membranous urethra:

Clinical findings: H/o lower abdominal pain and inability to

urinate and H/o injury. Blood at external urinary meatus. Suprapubic tenderness and presence of

pelvic fracture. Rectal examination: displacement of

prostate; pelvic hematoma.

URETHRAL INJURIESURETHRAL INJURIESInvestigation and management:Investigation and management:in polytrauma check for other injuries and manage in polytrauma check for other injuries and manage according to priority after initial management of according to priority after initial management of shock an hemorrhage.shock an hemorrhage.

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URETHRAL INJURIESURETHRAL INJURIESUrethral catheterization ???

Never tried before ICUG. partial tear can be converted into complete. Some advocate gentle attempt by a

urologist.Types of rupture:

Complete- dye does not go into bladder. Partial- dye enters bladder; do well with

catheter drainage.

URETHRAL INJURIESURETHRAL INJURIESA. Immediate management:

◦ Suprapubic cystostomy: Maintain for about 3 months. Incomplete laceration of post.

Urethra will heal spontaneously and SPC can be removed within 2-3 weeks ( after voiding cystourethrography show no extravasation) .

URETHRAL INJURIESURETHRAL INJURIESPrimary realignment:

Open repair (direct method):-difficult and bloody-methods are cystostomy & rail roading, antegrade

flexible cystoscopy and placement of catheter through guide wire.

Endoscopic method: (indirect method)-stenting of distraction with urethral catheter

without pelvic dissection.-ideal for incomplete tear.-Least morbidity and mortality.

URETHRAL INJURIESURETHRAL INJURIES

Post operative ( open repair ):

Leave urethral catheter for 6 weeks. Get MCUG + ICUG. If no leak—> Remove. High chances of developing urethral

stricture.

URETHRAL INJURIESURETHRAL INJURIESC. Delayed urethral reconstruction:

Under taken within 3 months ( if there is no pelvic abscess and persistent pelvic infection.)

MCUG + ICUG should be done to determine exact length of resulting urethral stricture.

URETHRAL INJURIESURETHRAL INJURIESInjuries to the anterior urethra:

Most often isolated. Etiology;

Blow to perineum, due to fall astride a projecting object, cycling accidents, manhole covers, gymnasium accidents.

Penetrating or gunshot injury to perineum. Self instrumentation/ iatrogenic

instrumentation. Pathogenesis & pathology:

Contusion: crush injury without urethral disruption.

Laceration: allowing extravasation of urine.

URETHRAL INJURIESURETHRAL INJURIESClinical features:

Triad of - retention of urine. - perineal haematoma - bleeding from external urinary meatus

If patient try to void then signs of superficial extravasation .

P/R reveals normal prostate. If neglected and delayed cases with

massive extravasation leads to infection in scrotum, lower abdomen.

URETHRAL INJURIESURETHRAL INJURIESInjuries to the anterior urethra:

Primary assessment and treatment:

- not allowed to urinate.- Urgent ICUG.- Percutaneous SPC.- Analgesics and prophylactic antibiotics.

URETHRAL INJURIESURETHRAL INJURIES Injuries to anterior urethra:

Specific measures:

A. Urethral contusion:-urethra intact.-after urethrography pt. Is allowed to void.-if voiding occurs normally without pain or

bleeding no additional treatment required.

-if bleeding persists—> urethral catheter drainage.

URETHRAL INJURIESURETHRAL INJURIES

V O ID IN G S T U D Y W IT H IN 7 D A Y S

S P C

M IN O R E X T R A V A S A T IO N

V O ID IN G S T U D Y A F T E R 2 -3 W E E K S

S P C

E X T E N S IV E IN JU RY

IC U G

Specific measures:B. Urethral laceration;

Strictly no instrumentation.

If no extravasation—> SPC may be removed. Healing at site results in stricture and do not

require surgical reconstruction.


Complications;i. Bleeding.ii. Sepsis and infection from

extravasation.iii. Urethral stricture.

Ascending Ascending Urethrogram(ICUG)Urethrogram(ICUG) Investigation of choice for stricture urethra.Catheter is passed into the external meatus.Water soluble iodine dye is injected through

the catheter.Oblique x-ray films are taken to visualise the

urethra.Site,size,extent of stricture and

extravasation can be found out in urethrogram.


C. Urethral laceration with extensive urinary extravasation:- extravasation involves perineum,

scrotum, lower abdomen.- Drainage of these areas.- SPC.- Antibiotics.


D. Immediate repair:- difficult.- High chances of bleeding, infection,

stricture.E. Delayed reconstruction:

- surgical: urethroplasty; single stage or multistaged.

- Endoscopic: optical urethrotomy followed by clean intermittent self catheterization.

lower urinary tract injuries

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