Tutorial bladder trauma

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Tutorial bladder trauma

  1. 1. BLADDERTRAUMA<br />NOOR HAFIZAH BINTI HASSAN<br />2007287236<br />
  2. 2. REFERENCES:<br />SMITH’S GENERAL UROLOGY 17th ED<br />GUIDELINES ON UROLOGICAL TRAUMA,<br /> EUROPEAN ASSOCIATION OF UROLOGY,<br /> FEBRUARY 2003<br />
  3. 3. INCIDENCE<br /><ul><li>10% of trauma: involve GU system
  4. 4. Bladder trauma: 60-80% are due to BLUNT TRAUMA
  5. 5. Highly associated with pelvic # (70-97%)
  6. 6. Most common complication of bladder trauma -> BLADDER RUPTURE (90%)</li></li></ul><li>CAUSES OF BLADDER TRAUMA<br />BLUNT TRAUMA (67-86%)<br /><ul><li>MVA
  7. 7. DECELERATING INJURY</li></ul>PENETRATING INJURY (14-33%)<br /><ul><li>HIGH VELOCITY GUNSHOT
  8. 8. STAB WOUND</li></ul> IATROGENIC<br /><ul><li>MEDICAL PROCEDURE</li></li></ul><li>CLASSIFICATION OF BLADDER INJURY<br />BASED ON FINDINGS ON CT CYSTOGRAPHY:<br />
  9. 9. Grade II:<br />Subtle intraperitoneal contrast material between small bowel loops<br />Grade III:<br />Focal lenticular thickening of the bladder wall due to interstitial hematoma and likely muscular disruption<br />
  10. 10. Grade IVa:<br />Extravasated contrast material into confined to the perivesical space within extraperitoneal pelvis<br />Grade IVb:<br />Complex extraperitoneal spread-> extension into rectus abdominis muscle as well as subcutaneous fascia<br />
  11. 11. 2) BASED ON TYPES OF INJURY:<br />
  12. 12. PERITONEAL EXTRAVASATION<br />BELOW PERITONEAL REFLECTION (EMPTY BLADDER): <br /><ul><li>EXTRAPERITONEAL SPREAD</li></ul>ABOVE PERITONEAL REFLECTION (FULL BLADDER):<br /><ul><li>INTRAPERITONEAL SPREAD</li></li></ul><li>
  13. 13. EXTRAPERITONEAL BLADDERRUPTURE (80 %)<br />Associated with pelvic fracture (80-100%)<br />Direct laceration of the bladder by the bony fragments<br />> severe fracture, degree of bladder injury ↑<br />Cystographic finding: contrast extravasation around base of bladder confined to perivesical space<br />
  14. 14. Extravasation seen outside the bladder in the pelvis <br />
  15. 15. INTRAPERITONEAL BLADDERRUPTURE (20 %)<br />Direct blow to a distended bladder<br />Full bladder -> muscle fibers are widely separated -> entire bladder wall is thin -> offer little resistance<br />Injury -> ↑ intravesical pressure -> horizontal tear along intraperitoneal portion of bladder wall<br />Cystographic finding: contrast extravasation into peritoneal cavity, lining loops of bowel<br />
  16. 16. Contrast enters the peritoneal cavity & outlines the bowel loops<br />Sterile<br />urine<br />Infected<br />urine<br />
  17. 17. CLINICAL FEATURES<br />SYMPTOMS:<br /><ul><li>Gross hematuria
  18. 18. Abdominal tenderness
  19. 19. Others: inability to void, bruises over suprapubic region</li></ul>ON EXAMINATION:<br /><ul><li>Abdominal tenderness
  20. 20. Per rectal: to exclude rectal injury</li></ul> : assess prostate position<br />
  21. 21. INVESTIGATION<br />CYSTOGRAPHY<br />Gold standard for dx bladder rupture (85-100%)<br />Dx: injected contrast are out of the bladder<br />Require plain film, filled film and post-drainage film<br />CT CYSTOGRAPHY: bladder is inadequately distended to allow extravasation through perforated bladder<br />
  22. 22. MANAGEMENT<br />IMMEDIATE MEASURES:<br /><ul><li>Treat shock and hemorrhage, if any
  23. 23. Catheterization: if blood noted at urethral meatus, don’t insert Foley’s catheter -> retrograde urethrogram</li></ul>2) DETERMINE EXTENT OF PERITONEAL EXTRAVASATION : RETROGRADE CYSTOGRAPHY<br />
  24. 24. EXTRAPERITONEAL RUPTURE:<br />Catheter drainage only, even in the presence of extensive retroperitoneal or scrotal extravasation<br />Healing takes 10 days -> 3 weeks<br />Surgical intervention?<br /><ul><li>bladder neck involvement
  25. 25. presence of bone fragments in the bladder wall
  26. 26. evacuation of pelvic hematoma/drainage of pelvic abscess</li></li></ul><li>INTRAPERITONEAL RUPTURE:<br />Always managed surgically:<br />Transperitoneal approach<br />Peritoneum closed carefully over the area of injury<br />All extravasated fluid should be removed<br />Bladder is closed in separate layer<br />

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