Urology pptx - غير معروف

INJURIES TO THE BLADDER

Dr. Mohammed Bassil
4/10/2015
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INJURIES TO THE BLADDER

Bladder injuries occur most often from external force and are often associated with pelvic fractures.
About 15% of all pelvic fractures are associated with concomitant bladder or urethral injuries.
Iatrogenic injury may result from gynecologic and other extensive pelvic procedures as well as from hernia repairs and transurethral operations.

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Pathogenesis & Pathology

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.
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Cont.

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Cont.

When the bladder is filled to near capacity, a direct blow to the lower abdomen may result in bladder disruption.
This type of disruption ordinarily is intraperitoneal.
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.
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Clinical Findings

There is usually a history of lower abdominal trauma.
Blunt injury is the usual cause.
Patients ordinarily are unable to urinate, but when spontaneous voiding occurs, gross hematuria is usually present.
Most patients complain of pelvic or lower abdominal pain.
Pelvic fracture accompanies bladder rupture in 90% of cases.
fracture site will show crepitus and be painful to the touch.

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Cont.

hemorrhagic shock, usually from venous disruption of pelvic vessels.
Evidence of external injury from a gunshot or stab wound in the lower abdomen should make one suspect bladder injury.
tenderness of the suprapubic area and lower abdomen.
An acute abdomen may occur with intraperitoneal bladder rupture.
On rectal examination, landmarks may be indistinct because of a large pelvic hematoma.
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LABORATORY FINDINGS

Urinalysis.
Urine culture.

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X-RAY FINDINGS
Bloody urethral discharge indicates urethral injury, and a urethrogram is necessary before catheterization.
A plain abdominal film generally demonstrates pelvic fractures.
There may be haziness over the lower abdomen from blood and urine extravasation.
A CT scan should be obtained to establish whether kidney and ureteral injuries are present.
Bladder disruption is shown on cystography.
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Complications

Shock and hemorrhage.
pelvic abscess.
peritonitis.
Partial incontinence.

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Treatment

• EMERGENCY MEASURES
• B. SURGICAL MEASURES
• Extraperitoneal bladder rupture:
Extraperitoneal bladder rupture can be successfully managed with urethral catheter drainage only. (Typically 10 days will provide adequate healing time.)
Large blood clots in the bladder or injuries involving the bladder neck should be managed surgically.
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Cont.
2. Intraperitoneal rupture—
Intraperitoneal bladder ruptures should be repaired via a transperitoneal approach after careful transvesical inspection and closure of any other perforations.
3. Pelvic fracture—stable or unstable accordingly.
4. Pelvic hematoma:
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INJURIES TO THE URETHRA

Urethral injuries are uncommon and occur most often in men.
usually associated with pelvic fractures or straddle type falls.
Various parts of the urethra may be lacerated, transected, or contused.

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Cont.

The urethra can be separated into 2 broad anatomic divisions:
posterior urethra, consisting of the prostatic and membranous portions
anterior urethra, consisting of the bulbous and pendulous portions.
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INJURIES TO THE POSTERIOR URETHRA

Etiology
When pelvic fractures occur from blunt trauma, the membranous urethra is sheared from the prostatic apex at the prostatomembranous junction.
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Clinical Findings

• SYMPTOMS:
A history of crushing injury to the pelvis is usually obtained.
lower abdominal pain.
inability to urinate.
B. SIGNS:
Blood at the urethral meatus is the single most important sign of urethral injury.
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Cont.

Suprapubic tenderness.
pelvic fracture are noted on physical examination.
A large developing
pelvic hematoma may be palpated.
A large developing pelvic hematoma may be palpated.
Perineal or suprapubic contusions are often noted.
Rectal examination may reveal a large pelvic hematoma with the prostate displaced superiorly.
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C. X-RAY FINDINGS

Fractures of the bony pelvis are usually present.
A urethrogram.

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D. INSTRUMENTAL EXAMINATION

Catheterization or urethroscopy should not be done, because these procedures pose an increased risk of hematoma, infection, and further damage to partial urethral disruptions.
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Differential Diagnosis

Bladder rupture may be associated with posterior urethral injuries in approximately 20% of cases.
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Complications

Stricture, impotence, and incontinence as complications of prostatomembranous disruption are among the most severe and debilitating mishaps that result from traumato the urinary system.
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Treatment

• EMERGENCY MEASURES:
• B. SURGICAL MEASURES:
• Urethral catheterization should be avoided.
• Immediate management—
Initial management should consist of suprapubic cystostomy to provide urinary drainage.
The suprapubic cystostomyis maintained in place for about 3 months.
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Cont.

2. Delayed urethral reconstruction:
Reconstruction of the urethra after prostatic disruption can be undertaken within 3 months, assuming there is no pelvic abscess or other evidence of persistent pelvic infection.
3. Immediate urethral realignment—
Some surgeons prefer to realign the urethra immediately.
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INJURIES TO THE ANTERIOR URETHRA
Etiology:
The anterior urethra is the portion distal to the urogenital diaphragm.
Straddle injury may cause laceration or contusion of the urethra.
Self-instrumentation or iatrogenic instrumentation may cause partial disruption.

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Pathogenesis & Pathology

• CONTUSION:
Contusion of the urethra is a sign of crush injury without urethral disruption.
Perineal hematoma usually resolves without complications.
B. LACERATION:
A severe straddle injury may result in laceration of part of the urethral wall, allowing extravasation of urine.

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Cont.

If the extravasation is unrecognized, it may extend into the scrotum, along the penile shaft, and up to the abdominal wall.
It is limited only by Colles’ fascia and often results in sepsis, infection, and serious morbidity.

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Clinical Findings

• SYMPTOMS:
There is usually a history of a fall, and in some cases a history of instrumentation.
Bleeding from the urethra is usually present.
There is local pain into the perineum and sometimes massive perineal hematoma.
If voiding has occurred and extravasation is noted, sudden swelling in the area will be present.
If diagnosis has been delayed, sepsis and severe infection may be present.
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Cont.

B. SIGNS:
The perineum is very tender; a mass may be found.
blood at the urethral meatus.
Rectal examination reveals a normal prostate.
The patient usually has a desire to void, but voiding should not be allowed until assessment of the urethra is complete.

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Cont.

When presentation of such injuries is delayed, there is:
massive urinary extravasation and infection in the perineum and the scrotum.
The lower abdominal wall may also be involved.
The skin is usually swollen and discolored.
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X-RAY FINDINGS
A urethrogram, with instillation of 15–20 mL of water-soluble contrast material, demonstrates extravasation and the location of injury .
A contused urethra shows no evidence of extravasation.

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Complications

Heavy bleeding from the corpus spongiosum injury may occur in the perineum as well as through the urethral meatus.
Pressure applied to the perineum over the site of the injury usually controls bleeding.
If hemorrhage cannotbe controlled, immediate operation is required.
sepsis and infection.

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Treatment

• Urethral contusion
If bleeding persists, urethral catheter drainage can be done.
Urethral lacerations—
Instrumentation of the urethra followin urethrography should be avoided.
suprapubic cystostomy tube can be inserted, allowing complete urinary diversion while the urethral laceration heals.

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Urethral laceration with extensive urinary extravasation—

Drainage of these areas is indicated.
Suprapubic cystostomy for urinary diversion is required.
Infection and abscess formation are common and require antibiotic therapy.

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Cont.
Immediate repair—
the incidence of associated stricture is high.

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TREATMENT OF COMPLICATIONS:

Strictures at the site of injury may be extensive and require delayed reconstruction.
Prognosis:
Urethral stricture is a major complication but in most cases does not require surgical reconstruction.

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THANKS A LOT

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