Bladder injury is a violation of the integrity of the organ wall caused by mechanical trauma, exposure to chemicals, rarely by urine pressure in some diseases. It is manifested by abdominal pain, swelling and cyanosis of the skin above the womb, frequent false urge to urinate, a decrease or absence of diuresis, macrohematuria, leakage of urine from the wound opening, an increase in the symptoms of traumatic shock. It is diagnosed by retrograde cystography, catheterization, ultrasound, CT, MRI of the bladder, urinalysis, laparoscopy. In mild cases, conservative management with the installation of a catheter is possible, with intraperitoneal and large extraperitoneal ruptures, reconstructive organ plastic surgery is performed.
ICD 10
S37.2 Bladder injury
Meaning
In the structure of general injuries, mechanical damage to the bladder ranges from 0.4 to 15% (in the USA — from 1 to 7%). In recent years, there has been a more frequent injury to the organ, which is associated with increased intensity of transport links, the deterioration of the fleet, an increase in the number of severe man-made disasters and local military conflicts.
The peak of traumatization is observed at the age of 21-50, about 75% of the victims are men. The peculiarity of injuries is mainly the combined nature of the lesion (in 100% of open wounds and in 85% of blunt injuries, in addition to the bladder, pelvic bones, spine, and other organs are damaged). The urgency of timely diagnosis and emergency medical measures is due to an unfavorable prognosis – according to the evaluation scales, 31.4% of the victims belong to the category of severe, 49.2% — extremely severe patients, the mortality rate exceeds 25%.
Causes
In most patients, bladder injury is associated with the impact of external mechanical factors of various origins on its wall. In rare cases, the injury is caused by the influence of aggressive chemicals installed in the bladder, or the presence of diseases that prevent urination. The causes of injuries are:
- Traffic accidents. In more than a quarter of cases, the bladder is injured during an accident. Damage occurs when a direct blow to the projection of an organ, strong compression in a vehicle, injury by fragments of pelvic bones, structural elements of the car, environmental objects.
- Iatrogenic factors. 22-23% of patients are injured during medical manipulations. The organ wall can be damaged during its catheterization, urethral augmentation, transurethral interventions, cesarean section, uterine extirpation, myomectomy, adenomectomy, colon resection, etc.
- Household and industrial injuries. In 10% of cases, damage occurs due to falling from a height on a solid object. In the presence of prerequisites (overflow of urine, scarring, etc.), an organ rupture is possible due to a sharp concussion of the body during a jump. In 4.2% of the victims, the injury occurs under the influence of production factors.
- Violent actions. The integrity of the bladder can be violated by blunt blows to the stomach, wounds with a knife or other sharp objects in fights, during criminal abortions. In wartime, the number of gunshot injuries and open wounds of the organ by fragments of explosive ammunition increases 3-4 times.
- Urological diseases. Extremely rarely, spontaneous rupture of the bladder is noted in patients who suffer from diseases that disrupt urination — adenoma and prostate cancer, stenosis of the vesical neck, urethral strictures. More often, urological pathology plays the role of a predisposing factor, increasing the stretching of the organ.
The risk of the most severe injuries — partial or complete ruptures — depends not only on the strength of the traumatic impact, but also on the place of its application, direction, suddenness. The probability of injury increases significantly with alcohol intoxication, which contributes to the overflow of the bladder due to the dulling of the urge to urinate and provokes traumatic behavior. Presumptive factors are also tumor lesions, fibrous changes in the organ wall after surgery, radiation therapy, inflammatory diseases.
Pathogenesis
The mechanism of bladder injury depends on the type of factors that caused the damage. With a blunt blow to the suprapubic region, an impact on the sacrum, compression, intravesical pressure sharply increases, the load on the urogenital wall increases. The occurrence of a hydrodynamic effect contributes to the intraperitoneal rupture of the organ in the area of the least developed musculature (usually along the back wall of the bladder near its tip).
The wound is usually torn, with uneven edges. With a lower force of mechanical impact, the impact causes closed damage (bruises, hemorrhages in the wall). A similar pathogenesis is characteristic in the presence of urological diseases with impaired passage of urine. A significant displacement of the bladder during mechanical injuries leads to a sharp tension of the supporting lateral and vesicostatic ligaments with an extraperitoneal rupture of the soft-elastic wall of the organ. A strong blow can cause a rupture of ligaments, urogenital blood vessels, and a rupture of the neck.
With closed and open damage to the vesical membranes by sharp objects, tools, bone fragments, a superficial, deep incision or through dissection of the wall occurs. The wound is usually linear. The combination with hydrodynamic shock in case of gunshot and comminuted wounds leads to additional radial tears of the round wound hole.
Classification
Criteria for systematization of traumatic injuries are the severity, possible communication with the environment, the location of the rupture in relation to the peritoneum, combination with injuries of other organs. This approach makes it possible to predict the course of the pathological process and possible complications, and to choose the optimal patient management tactics. Depending on the severity of the damage to the bladder wall, injuries can be deaf (bruise, superficial wound of the outer shell, tear of the mucous membrane) or through (complete rupture, separation of the neck). In turn, through damage is divided into three groups:
- Intraperitoneal ruptures. Observed in more than 60% of victims. Usually caused by direct blows to an overflowing bladder. Due to the leakage of urine into the abdominal cavity, peritonitis is quickly complicated.
- Extraperitoneal ruptures. Occur in 28% of cases. They are more often provoked by excessive tension of the supporting ligamentous apparatus. The injured bladder does not communicate with the abdominal cavity, urine flows into the pelvis.
- Combined breaks. Observed in 10% of victims. Multiple damage to the organ wall is usually combined with fractures of the pelvic bones. Communication between the bladder, abdominal and pelvic cavities causes a special severity of pathology.
Up to 90% of peacetime injuries are closed, due to the preservation of the integrity of the skin, the damaged bladder does not communicate with the external environment. During the war period, during violent actions with the use of cold and firearms, the frequency of open injuries increases, in which the integrity of the skin is violated, there is a message between the shells or cavity of the organ and the environment. According to the observations of specialists in the fields of traumatology and clinical urology, combined injuries prevail over isolated ones. In 40-42% of patients, fractures of the pelvic bones are detected, in 4-10% — ruptures of the intestine, in 8-10% — injuries of other internal organs.
Symptoms
An important clinical feature of this injury is the frequent predominance of general symptoms over local ones. Due to the pronounced pain syndrome and bleeding, the signs of hemodynamic disorders increase in the victims, traumatic shock is observed in 20.3%: the blood pressure level decreases, the heart rate accelerates, the skin turns pale, becomes covered with sticky cold sweat, weakness, dizziness, deafness, confusion, and then loss of consciousness.
Due to irritation of the peritoneum with urine, patients with intraperitoneal ruptures feel intense pain in the supraplonic region, in the lower part of the abdominal cavity, which subsequently spreads to the entire abdomen, accompanied by nausea, vomiting, gas and stool retention, abdominal muscle tension. Specific symptoms of injury to the urogenital wall are pain and local changes in the area of injury, dysuria. With open wounds on the front wall of the abdomen, less often — in the perineal area, a gaping wound is revealed, from which urine can flow.
Closed extraperitoneal injuries are characterized by the formation of painful swelling above the pubis, in the groin, the bluish color of the skin due to their impregnation with blood. Victims experience frequent false urge to urinate with a significant decrease or complete absence of diuresis, the release of blood drops from the urethra. While maintaining urination in patients with mucosal tears, urine is stained with blood.
Complications
Mortality in traumatic injuries of the bladder, especially open and combined, reaches 25% or more. The causes of death are usually advanced forms of peritonitis, pain, infectious-toxic, hemorrhagic shock, sepsis. End-to-end injuries of the bladder wall are quickly complicated by the involvement of other organs in the process. Anatomical features of the paravesical, retroperitoneal tissue, fascial spaces contribute to urinary infiltration, the spread of congestion, the formation of urohematomas.
With an intraperitoneal rupture, uroascitis occurs. Secondary infection leads to the formation of abscesses, phlegmon. 28.3% of patients develop urinary peritonitis, 8.1% — urosepsis. The upward spread of infection provokes the onset of acute pyelonephritis. In 30% of cases, when a bladder injury is combined with damage to other organs, DIC syndrome is observed. In the long-term period, urinary fistulas sometimes form in patients, urinary incontinence is observed.
Diagnostics
Taking into account the severity of the prognosis, all patients with suspected bladder injury are prescribed a comprehensive examination that allows them to identify ruptures of the bladder wall, determine their features and number, and detect possible damage to adjacent organs. The recommended methods of laboratory and instrumental diagnostics are:
- Urinalysis. The study can be carried out only with preserved urination. The volume of a single serving is often reduced. In the analysis, red blood cells are present in large numbers, confirming the presence of bleeding.
- Bladder ultrasound. According to the echography of the bladder, the organ is usually reduced in volume, blood accumulations are detected next to it. The study is complemented by ultrasound of the kidneys, during which signs of postrenal violation of urine outflow are detected, and ultrasound of the abdominal cavity to detect free fluid.
- X-ray. Retrograde cystography is considered the “gold standard” for the diagnosis of this type of injury. Ruptures of the organ are manifested by leaks of radiopaque substance into the vesico-rectal fossa, peritoneal tissue, the area of the wings of the ilium, the peritoneal cavity.
- Bladder CT. With the help of CT, it is possible to obtain a three-dimensional image of the damaged organ, during MRI it is studied in layers. The results of tomography make it possible to accurately assess the damage, the volume of urohematomas, and identify combined injuries.
- Diagnostic laparoscopy. Examination of the bladder through a laparoscope makes it possible to determine the features of the injured wall, detect urine and blood leaks. When performing laparoscopy, damage to neighboring organs is visualized.
Catheterization of the bladder, supplemented by infusion of fluid into it (Zeldovich’s test), plays a great diagnostic value. The presence of ruptures is indicated by the absence of urination through a catheter or the receipt of a small amount of urine with blood. The fluid injected into the injured organ is released back in a weak stream and not in full. With intraperitoneal ruptures, it is possible to discharge 2-3 times more fluid, which is due to the penetration of the catheter into the abdominal cavity and the release of urine that had previously entered it.
Intravenous urography is prescribed with caution, so as not to provoke the development of contrast-induced nephropathy against the background of shock changes in hemodynamics. Cystoscopy is usually not performed due to the risk of infection. In a general blood test, signs of anemia are determined — erythropenia, a decrease in hemoglobin levels, moderate leukocytosis and an increase in ESR are possible.
Differential diagnosis is carried out with damage to the posterior urethra, injuries to the liver, spleen, various parts of the intestine, ruptures of mesentery vessels. In addition to the urologist, the patient is examined by a traumatologist, surgeon, anesthesiologist, resuscitator, therapist, according to indications – proctologist, gynecologist, cardiologist, gastroenterologist, neurologist, neurosurgeon.
Treatment
The victim is urgently hospitalized in a traumatology or urological department, transferred to strict bed rest. Conservative management in the form of catheterization (usually for 3-5 days before the termination of macrohematuria) is possible only with contusion of the bladder, tears of the mucosa during rough medical manipulations, small extraperitoneal ruptures with a preserved vesical neck. The rest of the victims are shown emergency reconstructive surgery with drainage of the abdominal or pelvic cavities.
At the stage of preoperative preparation, hemostatic, antibacterial, anti-inflammatory, analgesic drugs, means for stabilizing hemodynamics are prescribed. The scope of the operation depends on the characteristics of the damage. In case of intraperitoneal ruptures, the bladder is extraperitonized before suturing the wound to stop the leakage of urine and conduct a full-fledged revision, after reconstruction of the damaged organ, the abdominal cavity is necessarily sanitized.
Extraperitoneal lesions are sutured without extraperitonization. Regardless of the type of injury, after restoring the integrity of the wall, an epicystostomy is applied to men, and a urethral catheter is installed for women. The abdominal or pelvic cavity is drained. After the operation, the administration of antibiotics, analgesics, and antishock infusion therapy is continued.
Prognosis and prevention
Violations of the integrity of the walls of the bladder are reasonably considered severe, prognostically unfavorable injuries. Compliance with the algorithm of surgical treatment of patients provides a reliable reduction in the frequency of complications, even with severe injuries. Prevention is aimed at creating safe working conditions, compliance with traffic rules, compliance with safety requirements when engaging in traumatic hobbies and sports, refusal from alcohol abuse. To reduce the prerequisites for injury, patients with diagnosed diseases of the prostate, urethra, and bladder are recommended to be regularly monitored and treated by a urologist.