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Dx & Mx of urethral and bladder injuries

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Dx & Mx of urethral and bladder injuries

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Dx & Mx of urethral and bladder injuries

  1. 1. Bladder and Urethral Injuries Diagnosis and Management Lakmal Nandadewa
  2. 2. Bladder Injuries  Bladder injuries occur in approximately 1.6% of blunt abdominal trauma victims.  The vast majority of injuries are associated with pelvic fractures.  The bladder rupture can occur into the peritoneal cavity (intraperitoneal bladder rupture) or outside the peritoneal cavity (extraperitoneal rupture
  3. 3. Bladder Injuries contd..  Bladder injuries are extraperitoneal in approximately 60%, intraperitoneal in approximately 30%,  Gross hematuria is the most common sign, present in 77-100% of injuries.19
  4. 4. Urethral injuries Uncommon in females In females, urethral injuries occur almost exclusively as a result of pelvic fracture and should be suspected in patients having labial edema and/or blood in the vaginal vault during pelvic exam Can be partial or complete Injury to male urethra is divided into 1.Injuries to the posterior urethra (at or above membranous urethra)  Almost exclusively associated with pelvic fractures  Occur between 1.5% -10% of pelvic fractures  Concomitant bladder injuries are present in 15% such urethral injuries 2.Injuries to the anterior urethra(penile /bulbar urethra)  May be blunt/penetrating  Straddle injuries where the urethra is crushed between pubic bones and a fixed object
  5. 5. Suspect a urethral rupture in the adult male with a pelvic fracture with blood at the urethral meatus(37-93%) and a high riding prostate ,perineal/genital haematoma and urinary retention These classic signs will not present in all presentations
  6. 6. Diagnosis of urethral and bladder injuries American Urological Association- Urotrauma- AUA guideline-2014 https://www.auanet.org/education/guidelines/u rotrauma.cfm Diagnostic imaging pathways(2013) - http://www.imagingpathways.health.wa.gov.au /index.php/imaging- pathways/musculoskeletal- trauma/trauma/lower-urinary-tract- trauma#pathway
  7. 7. Diagnostic imaging of bladder injuries Retrograde cystography (CT or conventional) is critical as it can determine the presence of an injury and whether it is intraperitoneal or extraperitoneal.
  8. 8. CT Cystographic Findings in Bladder Injury  Type 1: Contusion Bladder contusion is defined as an incomplete or partial tear of the bladder  Type 2: Intraperitoneal Rupture Intraperitoneal bladder rupture occurs in approximately 10%–20% of major bladder injuries. CT cystography demonstrates intraperitoneal contrast material around bowel loops, between mesenteric folds, and in the paracolic gutters
  9. 9. CT Cystographic Findings in Bladder Injury contd..  Type 3: Interstitial Injury Interstitial bladder injury is rare and is defined as an intramural or partial- thickness laceration with intact serosa  Type 4: Extraperitoneal Rupture Extraperitoneal rupture is the most common type of bladder injury (80%– 90% of cases)
  10. 10. Extraperitoneal bladder rupture
  11. 11. Management of bladder injuries Since the 1980s, clinicians manage most extraperitoneal bladder ruptures non-operatively with catheter drainage, while intraperitoneal ruptures are surgically repaired.
  12. 12. Diagnosis and management of urethral injuries  Diagnosis is made by retrograde urethrography.  Immediate surgical closure of urethral injuries is recommended primarily in penetrating injuries of the anterior urethra.  Straddle injuries of the anterior urethra are initially treated with suprapubic (SP) or urethral urinary drainage and are at high risk for delayed stricture formation.  Attempts at immediate sutured repair of posterior urethral injury of posterior urethral injury are associated with unacceptably high rates of erectile dysfunction and urinary incontinence  Traditional management of pelvic fracture urethral injury (PFUI) is placement of a suprapubic tube (SPT) and delayed urethroplasty to reconnect the ruptured urethra
  13. 13. Diagnosis and management ..  As endoscopic equipment and techniques have improved over the past two decades, primary realignment (PR) of posterior urethral ruptures has become more common. Primary realignment refers to advancing a urinary catheter across the ruptured urethra.  The goal of PR is to allow a partial urethral injury to heal while diverting the urine via the catheter, or to align both ends of the disrupted urethra so that they heal in the correct position as the pelvic hematoma is reabsorbed.
  14. 14. Urethra, trauma. Retrograde urethrogram reveals a type III urethral tear at the urogenital diaphragm (solid arrow) and a type IV urethral disruption at the bladder neck (dashed arrow).
  15. 15. Retrograde urethrogram reveals a type I urethral injury with minimal stretching and slight luminal irregularity of the posterior urethra. No extravasation of contrast material is present.
  16. 16. Straddle injury. Retrograde urethrogram shows a type V urethral injury with extravasation of contrast material from the distal bulbous urethra
  17. 17. References  Gomez RG, Ceballos L, Coburn M et al: Consensus statement on bladder injuries. BJU Int 2004; 94: 27.  Brandes S and Borrelli J, Jr.: Pelvic fracture and associated urologic injuries. World J Surg 2001; 25: 1578.  Morey AF, Iverson AJ, Swan A et al: Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma 2001; 51: 683.  Bjurlin MA, Fantus RJ, Mellett MM et al: Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. J Trauma 2009; 67: 1033.  Martinez-Pineiro L, Djakovic N, Plas E et al: EAU Guidelines on Urethral Trauma. Eur Urol 2010; 57: 791.  Koraitim MM: Pelvic fracture urethral injuries: evaluation of various methods of management. J Urol 1996; 156: 1288.  Koraitim MM: Effect of early realignment on length and delayed repair of postpelvic fracture urethral injury. Urology 2012; 79: 912.  Balkan E, Kilic N and Dogruyol H: The effectiveness of early primary realignment in children with posterior urethral injury. Int J Urol 2005; 12: 62.  Jordan G, Chapple C, Heyns C, eds. Urethral Strictures: Société Internationale d'Urologie; 2010.  Leddy L, Voelzke B and Wessells H: Primary realignment of pelvic fracture urethral injuries. Urol Clin North Am 2013; 40: 393.  Brandes SB, Buckman RF, Chelsky MJ et al: External genitalia gunshot wounds: a ten- year experience with fifty-six cases. J Trauma 1995; 39: 266.

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