Damage and trauma to the bladder

Damage and trauma to the bladder refers to a serious injury to the abdomen and pelvis, requiring urgent medical attention.

ICD Code 10

S37.2. Injury of the bladder.

Epidemiology of bladder trauma

Among the abdominal injuries requiring surgical treatment, bladder damage is about 2%: closed (blunt) injuries - 67-88%. Open (penetrating) - 12-33%. In 86-90% of cases, the causes of closed bladder injuries are traffic accidents.

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

Combined damage is often met - in 62% of cases with open (penetrating) injuries and 93% with closed, or dull ones. In 70-97% of patients, fractures of pelvic bones are revealed. In turn, with fractures of pelvic bones, bladder damage of one degree or another is met in 5-30% of cases.

In 29% of cases, there are combined bladder and posterior urethral canal injuries. In 85% of patients with a fracture of the pelvis there are severe combined injuries, which causes high mortality rates - 22-44%.

The severity of the condition of the injured and the outcome of treatment are determined not so much by bladder damage as by their combination with injuries to other organs and severe complications arising from a swallow of urine in the surrounding tissues and abdominal cavity. A common cause of death is severe bladder and other organ damage.

With isolated bladder trauma, the lethality in the second period of the Great Patriotic War was 4.4%, while in combination with injuries of the bladder and pelvic bones - 20.7%, rectal injury - 40-50%. The results of treatment with combined closed and open lesions of the urinary bladder in peacetime remain unsatisfactory. Compared with the data of the Great Patriotic War, the share of multiple and combined injuries in modern local wars and armed conflicts has significantly increased; the 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, and acted with extremely serious injuries, sometimes incompatible with life, which allowed them to expand the possibilities of surgical assistance to them earlier.

Combined gunshot wounds are observed in 74.4% of cases, the lethality with combined gunshot wounds of pelvic organs is 12-30%. And the dismissal from the army exceeded 60%. Modern methods of diagnosis, the succession of surgical care with combined gunshot wounds allow to return to the operation of 21.0% of the wounded and reduce the lethality to 4.8%.

Iatrogenic bladder lesions in gynecological operations occur in 0.23-0.28% of observations (of which obstetric operations are 85%, gynecological 15%). According to the literature, iatrogenic injuries account for up to 30% of all observations of bladder damage. At the same time, concomitant ureteral lesions occur in 20% of cases. Intraoperative diagnosis of bladder damage, in contrast to damage to the ureter, is high - about 90%.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Causes of bladder injury

Damage to the bladder can be the result of a blunt or penetrating injury. In both cases, bladder rupture is possible; closed trauma can lead to a simple concussion (damage to the wall of the bladder without the expiration of urine). Bladder ruptures are intraperitoneal and extraperitoneal, or combined. Intraperitoneal ruptures usually occur in the area of the tip of the bladder, most often occur when the bladder is full at the time of trauma, which is especially common in children, since the bladder is in their abdominal cavity. Extraperitoneal ruptures are more typical in adults and occur due to fractures of pelvic bones or penetrating lesions.

Bladder injuries can be complicated by infection, urinary incontinence and bladder instability. Associated lesions of the abdominal cavity and pelvic bones are often found, since an anatomically well-protected bladder requires a significant traumatic force to damage.

[12], [13]

Mechanisms of damage to the bladder

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 filled bladder can easily be damaged by applying a relatively small force. Whereas to destroy an empty bladder, a destructive blow or penetrating wound is needed.

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

With a fracture of the pelvic bones, it is possible to directly damage the bladder with bone fragments or rupture of its walls due to their traction with ligaments when bone fragments are displaced.

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

The most common causes of closed bladder damage:

• road accidents, especially if the victim is an elderly pedestrian in a state of intoxication with a full bladder:
• firing from height (catatrauma);
• industrial injuries:
• street and sports injuries.

The probability of damage to the bladder increases with severe injuries to the pelvic organs and abdomen.

It should also be noted that intraperitoneal ruptures of the bladder in 25% of cases are not accompanied by fractures of the hoop. This fact indicates that the vivo-peritoneal ruptures of the bladder are of a compression nature and develop as a result of an increase in intravesical pressure, leading to a rupture in the most compliant place, the dome-covered bladder segment covered by the peritoneum.

The main cause of extraperitoneal rupture is direct pressure from the pelvic bones or their fragments, in connection with which the places of pelvic fracture and bladder rupture, as a rule, coincide.

Damage of the bladder correlates with symphysis diastasis, polyciaoshio-sacral diastasis, fractures of sacral, iliac, pubic bone and are not associated with a fossa acetabulum fracture.

In childhood, the bowl develops vitrocranial ruptures of the bladder associated with the fact that in children the majority of the bladder is in the abdominal cavity and, for this reason, is more vulnerable to external trauma.

When falling from a height and a mine-vrynoy injury, bladder can be separated from the urethra.

Iatrogenic bladder lesions occur during gynecological and surgical operations on pelvic organs, hernia repair and transurethral interventions.

Usually perforation of the bladder wall is performed by the rectoscope loop during resection of the organ wall with a full bladder or when the loop does not coincide with the surface of the bladder wall. Electrostimulation of the occlusal nerve during resection of the bladder in tumors located on the lower lateral walls increases the likelihood of intra- and extraperitoneal perforations.

Pathological anatomy of a bladder injury

Distinguish bruises (concussion) and ruptures of the walls of the bladder. With a wall injury, submucosal or intra-wall hemorrhages form, most often they dissolve completely.

Incomplete breaks can be internal if the integrity of the mucous membrane and submucosal layer is violated or external - damage (most often bone fragments) of the external (muscle) layers of the wall. In the first case, bleeding occurs in the bladder cavity, the intensity of which depends on the nature of the damaged vessels: the venous stops quickly arterial - often leads to tamponade of the bladder with blood clots. With external ruptures, blood is poured into the perianous space causing deformation and displacement of the wall of the bladder.

With a complete break, the integrity of the wall of the bladder is compromised throughout the entire thickness. In this case, intraperitoneal and extraperitoneal ruptures are distinguished. Complete intraperitoneal ruptures are located on the upper or upper-posterior wall along the middle line or near it; more often single, even, but may be multiple and irregular in shape; have a sagittal direction. Bleeding at these ruptures is small due to the lack of large vessels in this area and the reduction of damaged vessels along with the emptying of the bladder into the abdominal cavity. Outpoured urine is partially absorbed (leading to an early increase in the concentration of urea and other products of protein metabolism in the blood), causes chemical irritation of the peritoneum, followed by aseptic and then purulent peritonitis. With isolated intraperitoneal ruptures, peritoneal symptoms grow slowly, after a few hours. By this time in the abdominal cavity a significant amount of fluid accumulates due to urine and exudate.

Extraperitoneal ruptures, usually arising from pelvic fractures, are usually located on the anterior or anterolateral surface of the bladder, are small in size, regular in shape, more often solitary. Sometimes a splinter of bone injures and the opposite wall from the side of the bladder cavity or at the same time damages the wall of the rectum. Rarely, usually with fractures of the pelvic bones caused by a fall from the height and a mine-blast injury, the bladder neck is detached from the urethra. In this case, the bladder shifts upward along with the internal sphincter, which is why it is possible to partially retain the urine in the bladder and periodically drain it into the pelvic cavity. This further separates the bladder and urethra.

Extraperitoneal ruptures, as a rule, are accompanied by significant bleeding to the perivascular fiber from the venous plexus and fractures of the pelvic bones, into the bladder cavity from the vasculature of the cervix and the bladder triangle. Simultaneously with bleeding, urine enters the paravezic tissues, leading to their infiltration.

As a result, urogemata is formed, deforming and displacing the bladder. Impregnation of the pelvic cellular tissue with urine, purulent necrotic changes in the wall of the bladder and surrounding tissues, absorption of urine and decomposition products lead to increasing intoxication of the body, weakening of local and general protective mechanisms. Granulation shaft usually does not form

 Attachment infection leads to rapid melting of fascial partitions: alkaline decomposition of urine begins, salts fall out and they infiltrate infiltrated and necrotic tissues, develop urinary phlegmon pelvic, and then retroperitoneal tissue.

Inflammatory process from the area of the wound of the bladder extends to the entire wall, develops purulent-necrotic cystitis and osteomyelitis with combined fractures of the pelvic bones. In the inflammatory process, immediately or after a few days, the pelvic vessels are involved, thrombotic and periphylebites develop. Closure of blood clots sometimes leads to embolism of the pulmonary artery with the development of a myocardial infarction and infarct pneumonia. In case of untimely surgical care, the process takes a septic character: toxic nephritis develops, purulent pyelonephritis, and hepatic-renal failure develops rapidly. Only with limited discontinuities and the intake of small portions of urine into the surrounding tissues, the development of purulent-inflammatory complications occurs later. In these cases, separate abscesses form in the pelvic cellulose.

In addition to ruptures of the bladder, there are so-called shocks of the bladder, which are not accompanied by pathological abnormalities during radiation diagnostics. Concussion of the bladder - the result of damage to the mucous membrane or muscles of the bladder without disrupting the integrity of the walls of the bladder, characterized by the formation of hematomas in the mucous and submucosal wall layer.

Such damage is not of serious clinical significance and goes without any intervention. Often, on the background of other injuries, such traumas are ignored and not even mentioned in many studies.

According to Cass, the true prevalence of bladder concussions from the total number of all injuries is 67%. Another type of bladder injury is incomplete or interstitial trauma: in a contrast study, only the submucosal spread of the contrast medium is defined, without extravasation. According to some authors, such traumas occur in 2% of cases.

Symptoms and Diagnosis of Bladder Trauma

Symptoms may include pain over the pubic and difficulty urinating, among the symptoms distinguish pain during palpation above the pubis, bloating and, with intraperitoneal rupture, peritoneal symptoms and the absence of peristaltic sounds. The diagnosis is based on anamnesis, clinical examination data, hematuria in the data of the general urinalysis.

Confirm the diagnosis with retrograde cystography, standard radiography or CT; the accuracy of radiography is sufficient, but CT can determine the concomitant damage (eg, fractures of the pelvic bones).

Classification of bladder injury

As can be seen from the foregoing, the damage to the bladder can be very diverse both in the mechanism of origin and in the volume of damage.

To determine the clinical significance of damage to the bladder, their classification is very important.

At present, the classification of bladder damage according to IP is rather widespread. Shevtsov (1972).

• Causes of bladder damage
  • Wounds.
  • Closed injuries.
• Localization of bladder damage
  • Top.
  • Body (front, back, side wall).
  • Bottom.
  • Neck.
• Kind of damage to the bladder
  • Closed Damage:
    • injury;
    • incomplete break:
    • complete break;
    • separation of the bladder from the urethra.
  • Open damage:
    • injury;
    • incomplete wound;
    • complete wound (through, blind);
    • separation of the bladder from the urethra.
• Damage of the bladder in relation to the abdominal cavity
  • Extraperitoneal.
  • Intraperitoneal.

Classification of bladder injuries, proposed by academician N.A. Lopatkin and published in the "Guide to Urology" (1998).

Type of damage

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

Types of wounding shells with a trauma of the bladder

• Gunshot (bullet, fragmentation).
• Non-fire (chipped, cut, etc.).
• Due to mine explosion injury.

Injuries to the abdominal cavity

• Intraperitoneal.
• Extraperitoneal.
• Mixed.

By localization

• Front and side walls.
• Top.
• Bottom.
• Neck.
• The colonic triangle.

By the presence of damage to other organs

• Isolated.
• Combined:
  • damage to the pelvic bones;
  • damage to the abdominal cavity (hollow, parenchymal);
  • damage to the 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.

[14], [15], [16]

Treatment of bladder trauma

All penetrating wounds and intraperitoneal ruptures with blunt trauma require surgical treatment. In case of bladder bruising, surgical treatment is not indicated, but bladder catheterization is necessary in case of urinary retention due to a significant bleeding or displacement of the bladder neck by intra-cellular hematoma. Treatment of extraperitoneal ruptures can consist only of catheterization of the bladder, if urine flows freely, and the neck of the bladder is intact, otherwise surgery is indicated.

Mortality is about 20%, and, as a rule, it is associated with a combination of severe injuries.