Lower urinary tract injuries

LOWER URINARY TRACTLOWER URINARY TRACT
INJURIESINJURIES
Dr.Pankaj Bharadva

INTRODUCTIONINTRODUCTION
Includes injuries to urinary bladder and
urethra.
Most common etiological factors are
vehicular accident and iatrogenic injuries.

INJURIES TO URINARYINJURIES TO URINARY
BLADDERBLADDER
 Constitutes <2% of abdominal injuries
requiring surgery.
 Etiology:
1) Blunt injuries: usually associated with pelvic
fractures.
2) Penetrating injuries:
3) Iatrogenic injuries: may result from gynecologic
and other extensive pelvic procedures;
laparoscopic surgery, transurethral operations
and hernia repair.

BLADDERBLADDER
Classification of bladder injuries:
Extra peritoneal rupture 80%
Intra peritoneal rupture 20%

BLADDERBLADDER
Extraperitoneal rupture:
 Introduction:
o Bony pelvis protects urinary bladder.
o When the pelvis is fractured by blunt trauma,
fragments from the fracture site may perforate the
bladder. These perforations usually result in
extraperitoneal rupture and leads to extraperitoneal
extravasation of urine.
o If the urine is infected, extraperitoneal bladder
perforation may result in deep pelvic abscess and
severe pelvic inflammation.

Extraperitoneal ruptureExtraperitoneal rupture

INJURIES TO URINARY BLADDERINJURIES TO URINARY BLADDER
Extraperitoneal rupture:
 Clinical features:
o Usually associated with fracture pelvis, which is
ascertained by pelvic compression test.
o Symptoms: H/O lower abdominal trauma; inability to
urinate or when urinate- gross hematuria and pelvic &
lower abdominal pain.
o Signs: - heavy bleeding associated with hemorrhagic
shock.
- evidence of lower abd. Trauma.
- marked tenderness of suprapubic area and
lower abdomen.

Intraperitoneal rupture:
 Etiology: may be secondary to blow, kick or fall on
fully distended bladder and it is more common the
male than in the female, usually following beer
drinking.
 Pathogenesis & Pathology:
- injury usually near dome of bladder and urine will
flow into the abdominal cavity.
- 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.

Intraperitoneal ruptureIntraperitoneal rupture

Intraperitoneal rupture:
 Clinical features:
- history of lower abdominal injury.
- Sudden agonizing pain in hypogastrium, often
accompanied by syncope.
- Not passed urine since injury and no desire.
- Suprapubic tenderness present but no dullness.
- Varying degree of abdominal rigidity and distension
and sometimes shifting dullness.
- P/R examination: bulging of rectovesical pouch.

 Investigations:
i. Plain X- ray abdomen:
• demonstrates pelvic fractures.
• Haziness or ground glass appearance in lower
abdomen due to extravasated blood and urine.
i. Retrograde cystography or MCUG:
• if no signs of fracture then it may be done.
• drainage film (of contrast) will demonstrate
• areas of extraperitoneal extravasation of blood and
urine that may not appear in filling film.
• with intraperitoneal rupture, free contrast material
will be visualized in the abdomen highlighting
bowel loops.

 Investigations:
iii. IVP:
- may confirm leak from bladder.
v. Computed tomography- cystography:
- highly sensitive and specific.
-also reveals intraabdominal injuries and pelvic
fracture.

 Complications:
i. Pelvic abscess:
from
extraperitoneal bladder rupture.
ii. Delayed peritonitis:
from
intraperitoneal rupture.
iii. Partial incontinence:
if laceration extends into bladder neck
and not properly repaired.

 Treatment:
I. Emergency treatment of shock and hemorrhage.
II. Surgical treatment:
A. Extraperitoneal rupture:
-most cases managed with catheter drainage only.
-contraindications to conservative management:
 Bone fragments projecting into the bladder
 Open pelvic fracture.
 Rectal perforation.
 Patients undergoing laparotomy for other reasons.
- All above mentioned cases rupture should be repaired
intravesically.

Treatment:
II.Surgical treatment: (Contd.)
B. Intraperitoneal Rupture:
-Repaired via transperitoneal approach
suctioning of urine from peritoneal cavity;
-closure of perforation in two layers.
-Suprapubic and per urethral catheter.
C. Surgical measures for pelvic fracture and pelvic
hematoma:
- stabilization and packing.

Injury to bladder during surgery:
Open surgery:
 Prevention by catheterization before surgery.
 If injury recognized at time of surgery, bladder should be
sutured in two layers and catheter drainage for 7 days.
 Perforation is usually extraperitoneal- bladder drained by
large catheter and antibiotics. If however, mass of
extraperitoneal fluid is palpable per abdomen it is best to
place a small drain into extraperitoneal prevesical space.
 For intraperitoneal perforation- laparotomy required.

URETHRAL INJURIESURETHRAL INJURIES
Introduction:
◦ Most often in men, rare in women.
◦ Usually associated with pelvic fractures or
straddle type falls.
◦ Separated in 2 broad anatomic divisions.
 Posterior urethra:
consists of prostatic and membranous
urethra.
 Anterior urethra:
consists of bulbous and penile portions.

 Injuries of membranous urethra:
 Etiology:
I. Pelvic fracture:
 10-15% have associated urethral injury.
 Sudden force to one lower limb( e.g. car accident)
causes pubic and ischial rami fracture —>disruption
of sacroiliac joint—> traction force on prostate—>
torn ends of urethra may be widely displaced.
 Front to back compression of pelvis by direct blow
from front—>butterfly fracture—> ends of torn
urethra are close to each other.
II. Shear injury:
 Rare.
 Due to sudden explosive rostral migration of
prostate and bladder.

Injuries of membranous urethraInjuries of membranous urethra

Injuries of membranous urethra:
Clinical findings:
 H/o lower abdominal pain and inability to urinate and
H/o injury.
 Blood at external urinary meatus.
 Suprapubic tenderness and presence of pelvic fracture.
 Rectal examination: displacement of prostate;
pelvic hematoma.

Investigation and management:Investigation and management:
in polytrauma check for other injuries and manage according toin polytrauma check for other injuries and manage according to
priority after initial management of shock an hemorrhage.priority after initial management of shock an hemorrhage.
s u s p e c ts o th e r c a u s e
e a s ily p a s s e d n o t p a s s e d
u r in a r y c a th e te r
n o rm a l
o p e n :if b la d d e r in ju ry is s u s p e c te d p e rc u ta n e o u s
s u p r a p u b ic c y s to to m y
u re th ra l in ju ry
im m e d ia te IC U G / re tro g r a d e u re th r o g r a p h y
b lo o d a t e x te r n a l u rin a ry m e a tu s

Urethral catheterization ???
 Never tried before ICUG.
 partial tear can be converted into complete.
 Some advocate gentle attempt by a urologist.
Types of rupture:
 Complete- dye does not go into bladder.
 Partial- dye enters bladder; do well with catheter
drainage.

A. Immediate management:
◦ Suprapubic cystostomy:
 Maintain for about 3 months.
 Incomplete laceration of post. Urethra will
heal spontaneously and SPC can be
removed within 2-3 weeks ( after voiding
cystourethrography show no
extravasation) .

Primary realignment:
 Open repair (direct method):
-difficult and bloody
-methods are cystostomy & rail roading, antegrade flexible
cystoscopy and placement of catheter through guide wire.
 Endoscopic method: (indirect method)
-stenting of distraction with urethral catheter without pelvic
dissection.
-ideal for incomplete tear.
-Least morbidity and mortality.

Post operative ( open repair ):
 Leave urethral catheter for 6 weeks.
 Get MCUG + ICUG.
 If no leak—> Remove.
 High chances of developing urethral stricture.

C. Delayed urethral reconstruction:
 Under taken within 3 months ( if there is no
pelvic abscess and persistent pelvic infection.)
 MCUG + ICUG should be done to
determine exact length of resulting urethral
stricture.

Injuries to the anterior urethra:
 Most often isolated.
 Etiology;
 Blow to perineum, due to fall astride a projecting object,
cycling accidents, manhole covers, gymnasium accidents.
 Penetrating or gunshot injury to perineum.
 Self instrumentation/ iatrogenic instrumentation.
 Pathogenesis & pathology:
 Contusion: crush injury without urethral disruption.
 Laceration: allowing extravasation of urine.

Clinical features:
 Triad of - retention of urine.
- perineal haematoma
- bleeding from external urinary
meatus
 If patient try to void then signs of superficial
extravasation .
 P/R reveals normal prostate.
 If neglected and delayed cases with massive
extravasation leads to infection in scrotum, lower
abdomen.

Injuries to the anterior urethra:
 Primary assessment and treatment:
- not allowed to urinate.
- Urgent ICUG.
- Percutaneous SPC.
- Analgesics and prophylactic antibiotics.

 Injuries to anterior urethra:
 Specific measures:
A. Urethral contusion:
-urethra intact.
-after urethrography pt. Is allowed to void.
-if voiding occurs normally without pain or
bleeding no additional treatment required.
-if bleeding persists—> urethral catheter
drainage.

V O I D IN G S T U D Y W I T H I N 7 D A Y S
S P C
M I N O R E X T R A V A S A T I O N
V O I D I N G S T U D Y A F T E R 2 - 3 W E E K S
S P C
E X T E N S I V E I N J U R Y
I C U G
 Specific measures:
B. Urethral laceration;
 Strictly no instrumentation.
 If no extravasation—> SPC may be removed.
 Healing at site results in stricture and do not require
surgical reconstruction.

 Complications;
i. Bleeding.
ii. Sepsis and infection from extravasation.
iii. Urethral stricture.

Ascending Urethrogram(ICUG)Ascending Urethrogram(ICUG)
 Investigation of choice for stricture urethra.
 Catheter is passed into the external meatus.
 Water soluble iodine dye is injected through the
catheter.
 Oblique x-ray films are taken to visualise the urethra.
 Site,size,extent of stricture and extravasation can be
found out in urethrogram.

C. Urethral laceration with extensive urinary
extravasation:
- extravasation involves perineum, scrotum, lower
abdomen.
- Drainage of these areas.
- SPC.
- Antibiotics.

D. Immediate repair:
- difficult.
- High chances of bleeding, infection, stricture.
E. Delayed reconstruction:
- surgical: urethroplasty; single stage or multistaged.
- Endoscopic: optical urethrotomy followed by clean
intermittent self catheterization.

Lower urinary tract injuries

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