Bladder injuries and trauma

Bladder injuries and trauma are considered severe abdominal and pelvic trauma and require immediate medical attention.

ICD 10 code

S37.2. Injury of bladder.

Epidemiology of bladder trauma

Among abdominal injuries requiring surgical treatment, bladder injuries account for about 2%: closed (blunt) injuries - 67-88%. open (penetrating) injuries - 12-33%. In 86-90% of cases, closed bladder injuries are caused by road traffic accidents.

In closed (blunt) injuries, intraperitoneal ruptures of the bladder occur in 36-39%, extraperitoneal - 55-57%, combined extra- and intraperitoneal injuries - 6% of cases. In the general population, extraperitoneal ruptures occur in 57.5-62%, intraperitoneal - 25-35.5%, combined extra- and intraperitoneal injuries - 7-12% of cases. In closed (blunt) injuries, the dome of the bladder is damaged in 35%, in open (penetrating) injuries - the lateral walls in 42%.

Combined injuries are common - 62% of cases of open (penetrating) injuries and 93% of cases of closed or blunt injuries. Pelvic bone fractures are found in 70-97% of patients. In turn, with pelvic bone fractures, bladder damage of varying degrees is found in 5-30% of cases.

Combined injuries to the bladder and posterior wall of the urethra are encountered in 29% of cases. Severe combined injuries occur in 85% of patients with pelvic fractures, which causes high mortality rates - 22-44%.

The severity of the victims' condition and the treatment outcomes are determined not so much by the damage to the bladder as by its combination with damage to other organs and severe complications arising from urine leakage into the surrounding tissues and abdominal cavity. A common cause of death is severe combined damage to the bladder and other organs.

In case of isolated injury of the urinary bladder in the second period of the Great Patriotic War the mortality rate was 4.4%, while in case of combined injury of the urinary bladder and pelvic bones - 20.7%, in case of injury of the rectum - 40-50%. The results of treatment of combined closed and open injuries of the urinary bladder in peacetime remain unsatisfactory. In comparison with the data of the Great Patriotic War in modern local wars and armed conflicts the share of multiple and combined injuries has increased significantly; rapid delivery of the wounded to the stages of medical evacuation contributed to the fact that some of the wounded did not have time to die on the battlefield, but were admitted with extremely severe injuries, sometimes incompatible with life, which made it possible to expand the possibilities of providing them with surgical care at an earlier stage.

Combined gunshot wounds are observed in 74.4% of cases, the mortality rate for combined gunshot wounds of the pelvic organs is 12-30%. And the dismissal from the army exceeded 60%. Modern diagnostic methods, the sequence of surgical care with combined gunshot wounds allow to return to duty 21.0% of the wounded and reduce the mortality rate to 4.8%.

Iatrogenic injuries of the urinary bladder during gynecological operations occur in 0.23-0.28% of cases (of which obstetric operations - 85%. Gynecological 15%). According to literary data, iatrogenic injuries make up to 30% of all cases of urinary bladder injuries. At the same time, concomitant ureter injuries occur in 20% of cases. Intraoperative diagnostics of urinary bladder injuries, in contrast to ureter injuries, is high - about 90%.

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Causes of Bladder Injury

Bladder injuries may result from blunt or penetrating trauma. In both cases, the bladder may rupture; blunt trauma may result in simple contusion (damage to the bladder wall without urine leakage). Bladder ruptures may be intraperitoneal, extraperitoneal, or combined. Intraperitoneal ruptures usually occur in the apex of the bladder, and most often occur when the bladder is overfilled at the time of injury, which is especially common in children, since their bladder is located in the abdominal cavity. Extraperitoneal ruptures are more typical in adults and occur as a result of pelvic fractures or penetrating injuries.

Bladder injuries may be complicated by infection, urinary incontinence, and bladder instability. Associated injuries to the abdominal organs and pelvic bones are common, as significant traumatic force is required to damage the anatomically well-protected bladder.

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Mechanisms of bladder injury

The vast majority of bladder injuries are the result of trauma. The bladder is a hollow muscular organ located deep in the pelvic cavity, protecting it from external influences. A full bladder can be easily damaged by applying relatively little force, whereas an empty bladder requires a devastating blow or penetrating injury to be damaged.

Typically, damage to the bladder occurs as a result of a sharp blow to the lower abdomen, with a full bladder and relaxed muscles of the anterior abdominal wall, which is typical for a person in a state of alcoholic intoxication. In this situation, an intraperitoneal rupture of the bladder often occurs.

In case of a fracture of the pelvic bones, direct damage to the bladder by bone fragments or rupture of its walls due to their traction by ligaments when bone fragments are displaced is possible.

There are also various iatrogenic causes (for example, damage to the bladder during catheterization, cystoscopy, endoscopic manipulations).

The most common causes of closed bladder injuries are:

• road traffic accidents, especially if the injured elderly pedestrian is intoxicated with a full bladder:
• falling from a height (catatrauma);
• industrial injuries:
• street and sports injuries.

The risk of bladder injury increases with severe trauma to the pelvic and abdominal organs.

It should also be noted that intraperitoneal ruptures of the urinary bladder in 25% of cases are not accompanied by fractures of the thalamus. This fact indicates that intraperitoneal ruptures of the urinary bladder are of a compression nature and develop as a result of increased intravesical pressure, leading to a rupture in the most pliable place, the segment of the dome of the urinary bladder covered by the peritoneum.

The main cause of extraperitoneal rupture is direct pressure from the pelvic bones or their fragments, which is why the sites of pelvic fracture and bladder rupture usually coincide.

Bladder injuries correlate with symphysis diastasis, semi-sacral diastasis, fractures of the branches of the sacral, ilium, pubic bones and are not associated with a fracture of the fossa acetabulum.

In childhood, intraperitoneal ruptures of the bladder most often occur due to the fact that in children, most of the bladder is located in the abdominal cavity and, for this reason, is more vulnerable to external trauma.

In case of a fall from a height or a mine blast injury, the bladder may be torn off from the urethra.

Iatrogenic damage to the bladder occurs during gynecological and surgical operations on the pelvic organs, herniotomy and transurethral interventions.

Usually, perforation of the bladder wall is performed with a rectoscope loop during resection of the organ wall when the bladder is overfilled or when the loop movement does not coincide with the surface of the bladder wall. Electrical stimulation of the obturator nerve during resection of the bladder for tumors located on the lower lateral walls increases the likelihood of intra- and extraperitoneal perforations.

Pathological anatomy of bladder trauma

A distinction is made between contusions (concussions) and ruptures of the bladder walls. When the wall is contused, submucous or intramural hemorrhages form, which most often resolve without a trace.

Incomplete ruptures can be internal, when only the mucous membrane and submucous layer are damaged, or external, when the outer (muscular) layers of the wall are damaged (usually by bone fragments). In the first case, bleeding occurs into the bladder cavity, the intensity of which depends on the nature of the damaged vessels: venous bleeding stops quickly, arterial bleeding often leads to tamponade of the bladder with blood clots. With external ruptures, blood flows into the perivesical space, causing deformation and displacement of the bladder wall.

In case of a complete rupture, the integrity of the bladder wall is disrupted along its entire thickness. A distinction is made between intraperitoneal and extraperitoneal ruptures. Complete intraperitoneal ruptures are located on the upper or upper posterior wall along the midline or near it; most often single, smooth, but can be multiple and irregular in shape; have a sagittal direction. Bleeding from these ruptures is minor due to the absence of large vessels in this area and the contraction of damaged vessels along with the emptying of the bladder into the abdominal cavity. The spilled urine is partially absorbed (leading to an early increase in the concentration of urea and other protein metabolism products in the blood), causing chemical irritation of the peritoneum, followed by aseptic and then purulent peritonitis. In case of isolated intraperitoneal ruptures, peritoneal symptoms increase slowly, over several hours. By this time, a significant amount of fluid accumulates in the abdominal cavity due to urine and exudate.

Extraperitoneal ruptures, which usually occur with pelvic fractures, are usually localized on the anterior or anterolateral surface of the bladder, are small in size, have a regular shape, and are often solitary. Sometimes a bone fragment injures the opposite wall from the bladder cavity or simultaneously damages the wall of the rectum. Quite rarely, usually with pelvic bone fractures caused by a fall from a height and mine-explosive trauma, the neck of the bladder is torn from the urethra. In this case, the bladder is displaced upward along with the internal sphincter, due to which partial retention of urine in the bladder and its periodic emptying into the pelvic cavity are possible. This further separates the bladder and urethra.

Extraperitoneal ruptures are usually accompanied by significant bleeding into the paravesical tissue from the venous plexus and pelvic bone fractures, into the bladder cavity from the vascular network of the neck and the vesical triangle. Simultaneously with bleeding, urine enters the paravesical tissues, leading to their infiltration.

As a result, a urohematoma is formed, which deforms and displaces the urinary bladder. Impregnation of the pelvic tissue with urine, purulent-necrotic changes in the wall of the urinary bladder and surrounding tissues, absorption of urine and decay products lead to increasing intoxication of the body, weakening of local and general protective mechanisms. Granulation shaft is usually not formed

The joining infection leads to the rapid melting of the fascial partitions: alkaline decomposition of urine begins, salts fall out and become encrusted with them infiltrated and necrotic tissues, urinary phlegmon of the pelvic, and then retroperitoneal tissue develops.

The inflammatory process from the area of the bladder wound spreads to its entire wall, purulent-necrotic cystitis and osteomyelitis develop with combined fractures of the pelvic bones. The pelvic vessels are immediately or after a few days involved in the inflammatory process, thrombo- and periphlebitis develop. The detachment of thrombi sometimes leads to pulmonary embolism with the development of pulmonary infarction and infarction pneumonia. If surgical care is untimely, the process takes on a septic character: toxic nephritis, purulent pyelonephritis develop, liver and kidney failure appears and rapidly increases. Only with limited ruptures and the entry of small portions of urine into the surrounding tissues does the development of purulent-inflammatory complications occur later. In these cases, individual abscesses form in the pelvic tissue.

In addition to bladder ruptures, there are so-called bladder concussions, which are not accompanied by pathological deviations during radiological diagnostics. Bladder concussion is the result of damage to the mucous membrane or muscles of the bladder without disruption of the integrity of the bladder walls, characterized by the formation of hematomas in the mucous and submucous layers of the walls.

Such injuries do not have serious clinical significance and pass without any intervention. Often, against the background of other injuries, such injuries are ignored and in many studies are not even mentioned.

According to Cass, the true prevalence of bladder concussions out of the total number of all injuries is 67%. Another type of bladder injury is incomplete or interstitial injury: during contrast examination, only submucosal spread of contrast agent is determined, without extravasation. According to some authors, such injuries occur in 2% of cases.

Symptoms and diagnosis of bladder injury

Symptoms may include suprapubic pain and difficulty urinating, with signs including suprapubic tenderness, abdominal distension, and, in the case of intraperitoneal rupture, peritoneal signs and absence of peristaltic sounds. Diagnosis is based on history, clinical examination, and the presence of hematuria in the general urine analysis.

The diagnosis is confirmed by retrograde cystography, standard radiography, or CT; radiography is accurate enough, but CT can identify associated injuries (eg, pelvic fractures).

Classification of bladder trauma

As can be seen from the above, damage to the bladder can be very diverse both in the mechanism of occurrence and in the extent of damage.

Classification of bladder injuries is very important for determining the clinical significance of bladder injuries.

Currently, the classification of bladder injuries according to I.P. Shevtsov (1972) is quite widespread.

• Causes of Bladder Damage
  • Injuries.
  • Closed injuries.
• Localization of bladder damage
  • The top.
  • Body (front, back, side wall).
  • Bottom.
  • Neck.
• Type of bladder injury
  • Closed damage:
    • injury;
    • incomplete break:
    • complete rupture;
    • separation of the bladder from the urethra.
  • Open injury:
    • injury;
    • the injury is incomplete;
    • complete wound (through and through, blind);
    • separation of the bladder from the urethra.
• Bladder injuries in relation to the abdominal cavity
  • Extraperitoneal.
  • Intraperitoneal.

The classification of bladder injuries proposed by Academician N.A. Lopatkin and published in the “Handbook of Urology” (1998) has received wide practical application.

Type of damage

• Closed (with the skin intact):
  • injury;
  • incomplete rupture (external and internal);
  • complete rupture;
  • two-stage bladder rupture:
  • separation of the bladder from the urethra.
• Open (wounds):
  • injury;
  • incomplete wound (tangential):
  • complete wound (through and through, blind);
  • separation of the bladder from the urethra.

Types of wounding projectiles in bladder trauma

• Firearms (bullet, fragmentation).
• Non-firearms (stabbed, cut, etc.).
• As a result of a mine blast injury.

Traumas to the abdominal cavity

• Intra-abdominal.
• Extraperitoneal.
• Mixed.

By localization

• Front and side walls.
• The top.
• Bottom.
• Neck.
• Urinary triangle.

By the presence of damage to other organs

• Isolated.
• Combined:
  • pelvic bone damage;
  • damage to abdominal organs (hollow, parenchymal);
  • damage to extraperitoneal organs of the abdomen and pelvis;
  • damage to other organs and areas of the body.

By the presence of complications

• Uncomplicated.
• Complicated:
  • shock;
  • blood loss;
  • peritonitis,
  • urinary infiltration;
  • urinary phlegmon;
  • osteomyelitis.
  • urosepsis;
  • other diseases.

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Treatment of bladder injury

All penetrating wounds and intraperitoneal ruptures with blunt trauma require surgical treatment. Surgical treatment is not indicated for bladder contusions, but bladder catheterization is necessary in case of urinary retention due to significant hemorrhage or displacement of the bladder neck by an intrapelvic hematoma. Treatment of extraperitoneal ruptures may consist of bladder catheterization alone if urine flows freely and the bladder neck is intact; otherwise, surgical intervention is indicated.

Mortality is about 20% and is usually associated with severe associated injuries.