Management of Urethral & Bladder Injuries

Dr. Amar Ul Ala ButtConsultant Urologist

06 R M 12967MOH 88/458 BCH 7/1

URETHRAL URETHRAL INJURIES INJURIES & &

MANAGEMENTMANAGEMENT

AnatomyAnatomy

1.1. Posterior urethra.Posterior urethra.

• ProstaticProstatic

• MembranousMembranous

22. . Anterior urethra.Anterior urethra.

• BulbousBulbous

• PendolousPendolous

prostatic

membranous

pendulous

bulbar

Posterior urethral injuriesPosterior urethral injuries..

• Posterior urethra injured in 1.6Posterior urethra injured in 1.6-9.9% -9.9% of pelvic fracture.of pelvic fracture.

• Complete: 73%Complete: 73%

• Partial: 27%Partial: 27%

Causes.Causes.

• Shearing force.Shearing force.

• Direct laceration by pelvic bone Direct laceration by pelvic bone fragment.fragment.

• Distraction,caused by pelvic fracture Distraction,caused by pelvic fracture b/w pubic symphysis & pubic rami.b/w pubic symphysis & pubic rami.

Symptoms and SignsSymptoms and Signs

• Blood at the urethral meatus. Do not, Blood at the urethral meatus. Do not, do not, do not try to pass the do not, do not try to pass the catheter if it’s present!!!catheter if it’s present!!!

• Inability to urinateInability to urinate

• Palpapable bladderPalpapable bladder

• Pelvic hematomaPelvic hematoma

• Superiorly dispalced prostateSuperiorly dispalced prostate

DiagnosisDiagnosis

•Immediate retrograde Immediate retrograde urethrogam.urethrogam.

Posterior urethra Posterior urethra lacerationlaceration

Posterior urethra –Posterior urethra –complete tearcomplete tear

TreatmentTreatment

• Suprapubic cystostomy (Initial treatment)Suprapubic cystostomy (Initial treatment)

• If incomplete laceration – spontaneous If incomplete laceration – spontaneous healing in 2-3 weekshealing in 2-3 weeks

• Complete laceration – reconstruction after Complete laceration – reconstruction after 3 months3 months

• Primary repair – not recommended. Surgery Primary repair – not recommended. Surgery is difficult because of hematomas. is difficult because of hematomas.

Complications.Complications.

1.1. Stricture:Stricture:• Primary repair Primary repair →50%→50%• Delayed repair→ 5%Delayed repair→ 5%

2.2. Impotence: Impotence:• Primary repair Primary repair →30-80%→30-80%• Delayed repair →30-35%Delayed repair →30-35%

3.3. Incontinence: Incontinence:• <2% pts<2% pts

• Typically ass:with sacral fracture & S2-S4 nerve Typically ass:with sacral fracture & S2-S4 nerve injury.injury.

Anterior Urethral InjuriesAnterior Urethral Injuries

• Causes.Causes.

• Stradle injuriesStradle injuries→Laceration or →Laceration or ContusionContusion

• Self instrumentation or iatrogenic Self instrumentation or iatrogenic may cause partial disruption.may cause partial disruption.

Symptoms & SignsSymptoms & Signs

• Histry of fallHistry of fall

• Local pain in perineumLocal pain in perineum

• History of instrumentationHistory of instrumentation

• Massive prineal hematomMassive prineal hematom

• Butterfly sign(hematoma)Butterfly sign(hematoma)

TreatmentTreatment

• Contusion:.if no extravasion urethra intact,after Contusion:.if no extravasion urethra intact,after urethrography pt:allowed to void if ok no addional urethrography pt:allowed to void if ok no addional treatment.treatment.

• If bleeding present urethral cathetar can be done.If bleeding present urethral cathetar can be done.• Laceration:.S/P cystostomyLaceration:.S/P cystostomy→14-21 days→14-21 days• Urethral cathhetar avoided bcz it converts Urethral cathhetar avoided bcz it converts

incomplete tear to completeincomplete tear to complete one. one.• Pts: who develops complete oclusion of urethra Pts: who develops complete oclusion of urethra

should have S/P for 3-6 months before definite should have S/P for 3-6 months before definite repairs.repairs.

Bladder TraumaBladder Trauma

• Adult: Extraperitoneal organAdult: Extraperitoneal organ

• Bladder dome = weakest pointBladder dome = weakest point

• Blunt: 60-85%Blunt: 60-85%

• MVA: #1 causeMVA: #1 cause

• Important to recognizeImportant to recognize– Pelvic/abdominal wall abscess/necrosisPelvic/abdominal wall abscess/necrosis– PeritonitisPeritonitis– Intra-abdominal abscessIntra-abdominal abscess– Sepsis / DeathSepsis / Death

Types of ruptureTypes of rupture

• ExtraperitonealExtraperitoneal– Most commonMost common– Pelvic # in 89-100%Pelvic # in 89-100%– Bladder rupture in 5-10% of all pelvic #Bladder rupture in 5-10% of all pelvic #

• IntraperitonealIntraperitoneal– Extravasation of urine in abdomenExtravasation of urine in abdomen– Sudden force to full bladderSudden force to full bladder– Associated injuries +++ Mortality Associated injuries +++ Mortality

(20%)(20%)

Clinical PresentationClinical Presentation

• 98% : Gross hematuria98% : Gross hematuria

• 2%: Microscopic hematuria + Pelvic #2%: Microscopic hematuria + Pelvic #

• 100%: Gross hematuria100%: Gross hematuria

• 85% Pelvic #85% Pelvic #

•McConnel et al. Rupture of the bladder. Urol Clin North Am. 1982.•Carroll et al. Major bladder trauma: Mechanisms of injury and a unified method of diagnosis and repair. Journal of Urology. 1984.

•Morey AF et al. Bladder rupture after blunt trauma : guidelines for diagnostic imaging. Journal of Trauma-Injury Infections & Critical Care. 51(4): 683-6, 2001 Oct.

InvestigationInvestigation

• Cystography: Gold standardCystography: Gold standard• CT Cystography : New trendCT Cystography : New trend• Peng et al. Peng et al. AJRAJR 1999. 1999.

– Prospective studyProspective study– 55 patients. 5 bladder rupture55 patients. 5 bladder rupture– Cystography VS. CT Cystography VS. CT

cystographycystography– Ruptures confirmed by SurgeryRuptures confirmed by Surgery– 100% sensitive and specific100% sensitive and specific

Peng et al. CT cystography versus conventional cystography in evaluation of bladder injury. AJR 1999; 173:1269-1272.

Investigation…Investigation…Deck et al. Deck et al. Journal of UrologyJournal of Urology, 2000., 2000.

– Retrospective studyRetrospective study– 316 patients with CT Cystography316 patients with CT Cystography– Sensitivity/Specificity = 95% and Sensitivity/Specificity = 95% and

100%100%– But 78% and 99% for intraperitoneal But 78% and 99% for intraperitoneal

rupturerupture– Comparable to Cystography aloneComparable to Cystography alone– Identifies other injuriesIdentifies other injuries

Deck AJ et al. CT Cystography for the diagnosis of traumatic bladder rupture. J Urol, Jul. 2000; 164(1); 43-6.

Standard Helical CTStandard Helical CT

• Pao et al. Pao et al. Acad RadiolAcad Radiol 2000. 2000.– With IV contrastWith IV contrast– Misses bladder ruptureMisses bladder rupture– 100% sensitive if “free fluid” criteria 100% sensitive if “free fluid” criteria

used.used.– Can R/O bladder injury if NO free Can R/O bladder injury if NO free

fluid.fluid.– Not specific.Not specific.– Not accepted as diagnostic tool.Not accepted as diagnostic tool.Pao et al. Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol 2000; 7:317-324.

TreatmentTreatment

• Penetrating injuries: ORPenetrating injuries: OR

• BluntBlunt– Intraperitoneal: Almost all ORIntraperitoneal: Almost all OR– Extraperitoneal: Urethral cath. drainage Extraperitoneal: Urethral cath. drainage

x 7-10 days.x 7-10 days.

ConclusionConclusion

• No Foley if you suspect urethral No Foley if you suspect urethral traumatrauma

• Pelvic # + Microhematuria GU Pelvic # + Microhematuria GU investigationinvestigation

• Don’t remove Foley if you suspect a Don’t remove Foley if you suspect a partial tear of urethra afterwards.partial tear of urethra afterwards.

THANKSTHANKS