The document discusses the management of bladder injuries, outlining their causes, clinical presentation, investigations including cystography, complications, and treatment approaches which may involve nonsurgical management for minor injuries or surgical repair for more severe injuries involving the bladder wall or neck. Grading systems are used to classify injury severity to determine the appropriate treatment.

1. MANAGEMENT OF
BLADDER INJURIES
PRESENTER : AROJU S.A
MODERATOR : PROF. MBIBU
UROLOGY UNIT,
SURGERY DEPARTMENT,
ABUTH, ZARIA

2. OUTLINE
Introduction
Surgical Anatomy
Aetiology
Pathophysiology
Clinical Features
Investigations
complications
Treatment
prognosis
Conclusion
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3. INTRODUCTION
• Relatively uncommon
• 2% of abdominal injuries
• Rarity ► protection in bony pelvis
• 83 – 100% are due to blunt injury
• 90% are associated with pelvic #
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4. INTRODUCTION…
Pelvic # associated with bladder
rupture :
• Pubic symphysis diastasis
• Sacroiliac diastasis,
• Sacral, iliac,
• Pubic rami #s
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5. INTRODUCTION…
• Up to 30% of patients with pelvic
fractures will have some degree of
bladder injury.
• 5 – 10% : major bladder injury
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6. INTRODUCTION…
• Previously fatal
• prompt diagnosis & intervention
► excellent outcome
• The probability of bladder injury α
the degree of bladder distention
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7. SURGICAL ANATOMY
• Bladder: hollow muscular organ that
serves as reservoir for urine.
• Empty bladder : protected behind
the pubic symphysis
• Largely a pelvic organ in adults,
abdominal organ in children.
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8. SURGICAL ANATOMY
• The bladder enters the greater
pelvis by 6yrs & it is not entirely
within the lesser pelvis until after
puberty.
• When empty : tetrahedral in shape
& has apex, body, fundus, neck &
uvula.
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9. SURGICAL ANATOMY…
• Separated from the pubic
symphysis by space of retzius.
• The posterior surface & Dome of
bladder is covered with
peritoneum thus related to
bowels.
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10. SURGICAL ANATOMY…
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11. SURGICAL ANATOMY…
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12. SURGICAL ANATOMY…
• Bladder neck in males is contiguous
with the prostate, & attached to the
pubis by puboprostatic ligaments.
• Body of the bladder receives support
from the urogenital diaphragm
inferiorly, & the obturator internus
Laterally.
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13. SURGICAL ANATOMY…
• The superior fascia of the urogenital
diaphragm is continuous and
includes the obturator, and
endopelvic fasciae.
• The inferior fascia of the urogenital
diaphragm fuses with the Colles
fascia.
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14. SURGICAL ANATOMY…
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15. SURGICAL ANATOMY…
• Injury above the peritoneal
reflection ► intraperitoneal
extravasation
• Injury below the peritoneal
reflection ► extraperitoneal
extravasation
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16. SURGICAL ANATOMY…
• Arterial : superior, middle &
inferior vesical arteries, uterine
and vaginal arteries.
• Venous: internal iliac veins.
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17. SURGICAL ANATOMY…
• Lymphatics: vesical, internal iliac,
& common iliac nodes.
• Sympathetic : Thoraco-lumbar;
Parasympathetic : pelvic plexus.
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18. AETIOLOGY
• Penetrating trauma(15 – 40%)
• Blunt trauma(60 – 85%)
• Iatrogenic: from gynecologic, urologic,
and orthopedic operations near the
urinary bladder.
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19. AETIOLOGY…
Gynaecologic Trauma Urological Trauma
• Myomectomy • Cystoscopy +
• TAH biopsy(36%),
• Vag. Hysterectomy • TURP
• Litholapaxy
• Idiopathic:
chronic alcoholics
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20. AETIOLOGY…
Orthopaedic Trauma
• Orthopaedic pins : pelvic & hip #
• Thermal injury : bone cement used
in hip arthroplasty.
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21. PATHOPHYSIOLOGY
EXTRAPERITONEAL
• Blunt or penetrating trauma.
• Associated pelvic # (90-100%)
• commonly anterolateral
• Due to direct burst injury
• Shearing force of the deforming pelvic
ring.
• Direct perforation by a bony fragment.
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22. PATHOPHYSIOLOGY...
EXTRAPERITONEAL
• When the sup. fascia of UD is ruptured,
urine can infiltrate the abdominal wall,
scrotum & perineum.
• When the Inf. fascia of UD is ruptured,
urine can infiltrate the thigh or penis.
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23. PATHOPHYSIOLOGY...
INTRAPERITONEAL
• Sudden large increase in intravesical
pressure in a full bladder.
• Full bladder ► widely separated
muscle fibres ► thin bladder wall
►no resistance to perforation
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24. PATHOPHYSIOLOGY...
INTRAPERITONEAL
• Usually involves the dome &
posterior part of the bladder.
• common in seat-belt & steering
wheel injury and in chronic
alcoholics, following trivial fall.
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25. Intraperitoneal bladder
rupture
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26. PATHOPHYSIOLOGY...
• Continuous urine drainage into
the abdomen ► hyperkalemia,
hypernatremia, uremia & acidosis.
• Such patients may appear anuric,
and have urinary ascites.
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27. CLINICAL FEATURES
relatively
nonspecific
• Triad of symptoms is often present
(1) gross haematuria (90%),
(2) suprapubic pain or tenderness,
(3) difficulty or inability to void.
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28. CLINICAL FEATURES…
• Swelling in perineum, scrotum or
Anterior abdominal wall.
• Evidence of pelvic # (>90%),
symphysial / sacro- iliac diasthesis,
pubic rami #.
• Posterior urethral injuries (10%)
& renal injuries in (~2%)
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29. CLINICAL FEATURES…
• Mortality (~50%) ► severe pelvic #s,
haemorrhage, & MODS
• Late presentations are due mild
intraperitoneal rupture ►
azotemia, hyperchloremia,
hypernatremia hyperkalemia &
metabolic acidosis.
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30. INVESTIGATIONS
Cystography
• Very accurate (>90%)
• By gravity filling of contrast into
bladder.
• At least 3 films must be taken ►
Plain, Filled,& post drainage.
• Severity of injury can be graded
• Distinguishes intraperitoneal from
extraperitoneal rupture.
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31. Cystogram
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32. INVESTIGATIONS…
CT Cystography
• Has approx. 100% sensitivity.
• Has advantage of being able to
correctly assess other visceral
injuries in a polytraumatized pt.
• Expensive
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33. CT cystogram
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34. INVESTIGATIONS…
USS
• Not routinely used
• Show injury to other structures
• Peritoneal fluid + normal viscera
OR failure to visualize bladder
after the transurethral intro of
saline ► highly suggestive of
bladder rupture
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35. INVESTIGATIONS…
• Haematocrit
• E/U/Cr
• RBS
• CXR
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36. STAGING…
• Cystoscopy & cystogram findings
• Adapted by AAST & used by EUA
Stage I :
Hematoma Contusion, intramural
hematoma, Laceration Partial
thickness.
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37. STAGING…
Stage II :
Laceration Extraperitoneal
bladder wall laceration < 2 cm
Stage III :
Laceration Extraperitoneal (2cm)
or intraperitoneal (< 2cm) bladder
wall laceration
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38. STAGING…
Stage IV :
• Laceration Intraperitoneal
bladder wall laceration 2cm
• Stage V :
Laceration Intraperitoneal or
extraperitoneal bladder wall
laceration extending into the
bladder neck or ureteral orifice
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39. COMPLICATIONS
• Urinary extravasation
• Sepsis & MODS
• Haemorrhage
• Pelvic infection
• Small-capacity bladder
• Urinary incontinence
• Obstructive uropathy
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40. MANAGEMENT
• Multidisciplinary approach
Trauma surgeon, Urologist,
anaesthesiologist, Orthopaedic
surgeon
• The first priority: stabilization of
the patient and treatment of
associated life-threatening injuries.
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41. MANAGEMENT…
• High velocity : urgent exploration
• Isolated bladder injury: definitive
treatment depends on grade of
injury.
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42. MANAGEMENT…
Grades 1&2
Nonsurgical management
• Adequate analgesics
• Indwelling catheter is passed
• Observe pt. for Increasing pains or
changes in vital signs.
• Repeat Cystogram at 10-14 days.
• If normal, discharge pt home.
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43. MANAGEMENT…
Grades 1&2
Nonsurgical management
• Obstruction of the catheter by clots or
tissue debris must be prevented.
• 87% of cases heal in 10days and
virtually all heal in 3weeks.
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44. MANAGEMENT…
Grades 3, 4 & 5
Surgical management
• Pre-op analgesic, antibiotics
• Midline approach, bladder & any
bowel injury inspected & severity
assessed.
• Bladder bivalved at dome, & UO
inspected.
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45. MANAGEMENT…
Grades 3, 4 & 5
Surgical management
• Repair in at least two layers,
• Leave SPT in situ via a diff. Stoma
• Leave drain in situ.
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46. MANAGEMENT…
Post-Op
• IV antibiotics & analgesics
• Drain out when it not functioning
• Do x-ray cystogram at 14th day.
• If normal, remove SPC, the
urethral catheter & discharge.
• For those with pelvic #s, invite
orthopaedics
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47. PROGNOSIS
 Appropriate Rx
Excellent outcome
 Bladder neck involvement
Temporary incontinence
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48. CONCLUSION
• Traumatic bladder injuries was
previously fatal, BUT currently
managed quite successfully.
• Adequate evaluation, application
of modern imaging techniques, &
prompt surgical intervention are
conditions for optimal outcome.
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49. Thank you for your patience
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