Tutorial bladder trauma

Tutorial bladder trauma

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  BLADDERTRAUMANOOR HAFIZAH BINTIHASSAN2007287236
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  REFERENCES:SMITH’S GENERAL UROLOGY17th EDGUIDELINES ON UROLOGICAL TRAUMA, EUROPEAN ASSOCIATION OF UROLOGY, FEBRUARY 2003
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  INCIDENCE10% of trauma:involve GU system
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  Bladder trauma:60-80% are due to BLUNT TRAUMA
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  Highly associatedwith pelvic # (70-97%)
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  Most commoncomplication of bladder trauma -> BLADDER RUPTURE (90%)CAUSES OF BLADDER TRAUMABLUNT TRAUMA (67-86%)MVA
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  DECELERATING INJURYPENETRATING INJURY(14-33%)HIGH VELOCITY GUNSHOT
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  STAB WOUND IATROGENICMEDICALPROCEDURECLASSIFICATION OF BLADDER INJURYBASED ON FINDINGS ON CT CYSTOGRAPHY:
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  Grade II:Subtle intraperitonealcontrast material between small bowel loopsGrade III:Focal lenticular thickening of the bladder wall due to interstitial hematoma and likely muscular disruption
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  Grade IVa:Extravasated contrastmaterial into confined to the perivesical space within extraperitoneal pelvisGrade IVb:Complex extraperitoneal spread-> extension into rectus abdominis muscle as well as subcutaneous fascia
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  2) BASED ON TYPES OF INJURY:
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  PERITONEAL EXTRAVASATIONBELOWPERITONEAL REFLECTION (EMPTY BLADDER): EXTRAPERITONEAL SPREADABOVE PERITONEAL REFLECTION (FULL BLADDER):INTRAPERITONEAL SPREAD
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  EXTRAPERITONEAL BLADDERRUPTURE(80 %)Associated with pelvic fracture (80-100%)Direct laceration of the bladder by the bony fragments> severe fracture, degree of bladder injury ↑Cystographic finding: contrast extravasation around base of bladder confined to perivesical space
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  Extravasation seen outsidethe bladder in the pelvis
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  INTRAPERITONEAL BLADDERRUPTURE (20%)Direct blow to a distended bladderFull bladder -> muscle fibers are widely separated -> entire bladder wall is thin -> offer little resistanceInjury -> ↑ intravesical pressure -> horizontal tear along intraperitoneal portion of bladder wallCystographic finding: contrast extravasation into peritoneal cavity, lining loops of bowel
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  Contrast enters theperitoneal cavity & outlines the bowel loopsSterileurineInfectedurine
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  CLINICAL FEATURESSYMPTOMS:Gross hematuria
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  Abdominal tenderness
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  Others: inability tovoid, bruises over suprapubic regionON EXAMINATION:Abdominal tenderness
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  Per rectal: toexclude rectal injury : assess prostate position
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  INVESTIGATIONCYSTOGRAPHYGold standard fordx bladder rupture (85-100%)Dx: injected contrast are out of the bladderRequire plain film, filled film and post-drainage filmCT CYSTOGRAPHY: bladder is inadequately distended to allow extravasation through perforated bladder
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  MANAGEMENTIMMEDIATE MEASURES:Treatshock and hemorrhage, if any
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  Catheterization: if bloodnoted at urethral meatus, don’t insert Foley’s catheter -> retrograde urethrogram2) DETERMINE EXTENT OF PERITONEAL EXTRAVASATION : RETROGRADE CYSTOGRAPHY
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  EXTRAPERITONEAL RUPTURE:Catheterdrainage only, even in the presence of extensive retroperitoneal or scrotal extravasationHealing takes 10 days -> 3 weeksSurgical intervention?bladder neck involvement
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  presence ofbone fragments in the bladder wall
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  evacuation ofpelvic hematoma/drainage of pelvic abscessINTRAPERITONEAL RUPTURE:Always managed surgically:Transperitoneal approachPeritoneum closed carefully over the area of injuryAll extravasated fluid should be removedBladder is closed in separate layer