Open injuries and trauma to the bladder

Information on the frequency of open (penetrating wounds) of bladder injuries is quite contradictory. According to various authors, open injuries and trauma to the bladder occur in 0.3-26% of the wounded and injured. During the Great Patriotic War, open injuries (wounds) to the bladder occurred in 6.4% of those wounded in the pelvic area, 24.1% in the abdomen, and 19.3% among soldiers with wounds to the genitourinary organs.

Intraperitoneal wounds accounted for 27.2% of all bladder wounds, of which only 13.8% were isolated. Most often, intraperitoneal wounds were combined with intestinal injuries. Extraperitoneal wounds were recorded in 72.8% of cases, of which 32.8% were isolated.

There are no exact data on the number of combined gunshot wounds to the bladder during combat operations in modern local military conflicts due to the fact that they are mainly taken into account in statistical reports in the group of abdominal wounds and they are often not diagnosed. However, according to some authors, an increase in this indicator is clearly visible as military equipment, weapons and the level of medical evacuation measures develop. Bladder wounds are classified as severe injuries.

Factors determining the severity of combined bladder injuries:

• type of injury (bullet, shrapnel, mine-explosive wound);
• the functional state of the genitourinary organs at the time of injury (for example, the degree of filling of the bladder with urine);
• nature of the injury (intraperitoneal or extraperitoneal);
• the sequence of passage of a wounding projectile through tissues and organs;
• associated injuries and diseases.

By nature, combined bladder injuries can be single or multiple.

Main groups with different types of injuries to the genitourinary organs.

• prostate;
• posterior urethra;
• ureters;
• genitals;
• injuries to other abdominal and pelvic organs (small intestine, rectum)
• organs of other anatomical areas (head, spine, neck, chest, abdomen, limbs).

Gunshot wounds of the rectum and bladder in relation to the peritoneum are divided into intra- and extraperitoneal injuries or a combination of both (mixed).

Types of gunshot wounds to the bladder by severity:

• extremely heavy:
• heavy;
• moderate;
• lungs.

Types of damage depending on the location of the wound channel:

• tangents;
• through;
• blind.

Localization of bladder injuries:

• front wall;
• back wall;
• side wall;
• verzhushka;
• bottom;
• neck of the bladder;
• urinary bladder triangle.

By the presence of complications:

• Complicated:
  • shock;
  • blood loss;
  • peritonitis;
  • urinary infiltration;
  • urinary phlegmon;
  • urosepsis.
• Uncomplicated.

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What causes open bladder injuries and trauma?

Mechanism of injury of open injuries and bladder trauma

In peacetime, stab and cut open injuries are more common, including those resulting from wounds to the bladder from fragments in pelvic bone fractures, and unintentional injuries during surgical interventions (herniotomy, especially with a sliding hernia containing the wall of the bladder, obstetric and gynecological operations, extirpation of the rectum). In wartime, open injuries to the bladder are mostly gunshot - bullet or shrapnel.

When wounded by modern high-speed wounding elements with high kinetic energy, in addition to their direct impact, indirect damage is possible due to the lateral impact of the wounding projectile and the pressure of the temporary pulsating cavity.

Pathological anatomy of open injuries and trauma of the bladder

Pathological changes depend on the caliber, design, mass and speed of the wounding projectile, the nature of energy transfer (direct and indirect action), the degree of filling of the bladder, the distance of tissues from the wound channel and other factors. The wound channel in modern injuries is rarely rectilinear due to the unstable flight of wounding projectiles in tissues: due to tissue displacement, compression of the channel by hematoma, edema, urinary infiltration.

Necrotic and destructive changes predominate in the wound channel area. In the hours immediately following the injury, traumatic edema occurs in the surrounding tissues, worsening microcirculation, contributing, along with urinary infiltration, to the development of secondary necrosis and purulent complications.

Pathological changes in open injuries (as opposed to closed ones) are even more severe due to extensive damage to bones and soft tissues, a combination of wounds to the bladder and rectum or other parts of the intestine, tissue infection from the moment of injury, including anaerobic flora. This leads to the early development of peritonitis, pelvic phlegmon, osteomyelitis with a weak tendency to limit the inflammatory process.

The use of firearms with high-velocity wounding projectiles has led to some peculiarities of injuries. Intraperitoneal and mixed wounds account for 50% of all bladder wounds. The frequency of severe shock and massive blood loss has increased. Multiple extensive destruction of pelvic organs, profuse blood loss in more than 85% of the wounded cause traumatic shock.

The listed features of modern bladder injuries have significantly complicated diagnostics, increased the volume and labor intensity of surgical interventions, made them vital and at the same time delayed the possibility of performing surgery due to the need for resuscitation and anti-shock measures.

Symptoms of open injuries and trauma to the bladder

The main symptoms of open bladder injuries are similar to those of closed injuries. The most reliable symptom characteristic of open injuries of all urinary tracts is the release of urine from the wound. Hematuria is found in almost 95% of cases.

Symptoms of bladder injury in the first hours after injury consist of general signs, symptoms of damage to intra-abdominal organs, pelvic bones and bladder. The most common general signs are collapse and shock. Almost 40% of the injured arrive at the stage of qualified assistance in shock of the third degree or terminal condition.

Symptoms associated with damage to the abdominal organs include pain throughout the abdomen, tension in the muscles of the anterior abdominal wall, sharp pain upon palpation, dullness in sloping areas of the abdomen upon percussion, and overhanging of the anterior wall of the rectum during digital examination.

As peritoneal symptoms develop, tension in the anterior abdominal wall is replaced by bloating, stool and gas retention, and vomiting. Peritonitis in combined intestinal injuries occurs early and is accompanied by pronounced symptoms, which is why bladder injury symptoms are often missed and the injury is diagnosed only during surgery. Combined injury to the bladder and rectum is indicated by the release of gas and feces with urine.

Symptoms of bladder injury include urinary retention, frequent, painful urge to urinate with the release of a small amount or a few drops of bloody urine in the absence of percussion-determined bladder contours after a long break between urinations: hematuria with continued urination and urine leakage from the wound. The listed clinical signs of bladder injury in some of the wounded are not detected in the first hours, or they are smoothed out by manifestations of shock and blood loss.

In combined intraperitoneal wounds of the bladder and intestine, pain diffused throughout the abdomen and symptoms of peritoneal irritation are detected in only 65% of the wounded. Peritoneal symptoms are detected with the same frequency in extraperitoneal wounds combined with damage to the pelvic bones, which is why differential diagnostics of extra- and intraperitoneal wounds is practically impossible without special research methods.

Hematuria, urinary dysfunction and urine leakage from the wound are found separately or in various combinations in 75% of the wounded, including almost all with extraperitoneal or mixed wounds, 60% with intraperitoneal wounds and 50% with bladder contusions.

In severe combined injuries, the clinical picture was dominated by signs of traumatic or hemorrhagic shock, symptoms of internal bleeding and damage to the abdominal organs, pelvic bones and other organs, masking the clinical manifestations of damage to the bladder.

Complications of open injuries and trauma to the bladder

After qualified treatment, complications rarely occur. These include urinary tract infections, abscesses, peritonitis. In case of injuries to the neck of the bladder, urinary incontinence is possible.

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Diagnosis of open injuries and trauma of the bladder

Diagnostics for stab and cut wounds of the bladder is not fundamentally different from that for closed injuries. For gunshot wounds, the use of instrumental and radiological diagnostic methods is limited by the conditions of providing surgical care on the battlefield, the severity of the condition and the need to perform surgery quite often for vital indications (internal bleeding, etc.).

In this regard, the main diagnostic method during the Great Patriotic War was catheterization of the bladder, performed in 30.5% of the wounded with intraperitoneal and 43.9% - extraperitoneal bladder wounds. This method is used somewhat more often (in 55% of the victims) in modern local wars. Catheterization is informative in 75% of observations of its use.

If it is not possible to obtain urine through the catheter (when the catheter beak penetrates the abdominal cavity), no attempt should be made to flush the catheter and bladder: the flushing fluid will increase the contamination of the abdominal cavity in combination with intestinal damage, without introducing significant clarity into the diagnosis.

The location of the wound, the course of the wound channel, the nature of the wound discharge and macrohematuria allow us to suspect damage to the bladder during the initial examination. Intravenous administration of indigo carmine, which colors the urine blue, allows us to confirm the release of urine from the wound.

The diagnostic methods used for open bladder injuries are not fundamentally different from the methods used to diagnose closed bladder injuries.

The leading role belongs to the methods of radiation diagnostics, allowing to verify the damage of the bladder and to determine its nature. The main method allowing to confirm the damage of the bladder is ascending (retrograde) cystography. Indications for its implementation and the technique of its implementation are described in the section devoted to closed injuries of the bladder.

Another accessible and highly reliable method for diagnosing abdominal organ injuries, including intraperitoneal bladder wounds, is ultrasound and laparocentesis with examination of the evacuated fluid for blood, urine, bile and intestinal contents. Diagnosis of bladder injuries is facilitated by introducing a solution of methylene blue or indigo carmine into its cavity and staining the fluid evacuated during laparocentesis with them.

Laparocentesis in a significant number of cases allows avoiding erroneous laparotomies, which in 12% of cases lead to fatal outcomes in military field conditions during the Great Patriotic War. Retrograde cystography, if performed correctly, allows in most cases to identify a bladder injury, assess its location and size, determine the relationship of the wound to the abdominal cavity and the direction of urinary leakage. At the same time, cystography for bladder injuries is used only in 10-16% of victims. Excretory urography is used even less often due to its low information content in shock. This method, like cystoscopy, is used mainly at the stage of specialized urological care for the diagnosis of complications, while at the stage of qualified surgical care more than 50% of bladder injuries are diagnosed during laparotomy.

Timely recognition of urinary infiltration of pelvic tissue presents significant difficulties due to the fact that a local reaction cannot always be detected, and a general reaction is absent or weakly expressed.

It is especially difficult to diagnose urinary leaks in victims with shock and blood loss, which is why pelvic phlegmons develop more often and are more severe.

Typical symptoms of shock: decreased body temperature, rapid pulse, low blood pressure, indifference to one's own condition and those around one - combined with symptoms of urinary infiltration. Patients are restless, sometimes euphoric, complain of pain and a feeling of heaviness in the depths of the pelvis, thirst. Further deterioration of the condition, occurring 3-5 days after the injury, is manifested by signs of a septic condition and is caused by the development of urinary phlegmon - the main complication of extraperitoneal damage to the bladder. The skin is pale, ashen or icteric; appetite is absent; the tongue is dry, coated with a brown coating, with cracks.

Pastosity of tissues appears in the groin area, perineum, on the inner thigh; the skin of these areas subsequently acquires a blue-purple or yellowish color. A targeted examination reveals an infiltrate or purulent streaks. The edges of the wound are dry, granulation is flaccid, the bottom of the wound is covered with a gray coating. The pulse is frequent, weak. The body temperature is high, with chills and profuse sweating, subsequently decreasing to normal as sepsis develops due to the body's unresponsiveness. The occurrence of purulent complications is accompanied by high neutrophilic leukocytosis with a shift to the left and toxic granularity, high ESR, increasing hypochromic anemia and hypoproteinemia.

Pelvic abscesses and osteomyelitis of the pelvic bones are characterized by a gradual deterioration in the general condition, weakness, periodic increases in temperature, signs of intoxication, progressive weight loss and atrophy of skeletal muscles and dystrophic changes in internal organs.

The diagnosis of open bladder injuries is often completed during its intraoperative revision.

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Treatment of open injuries and trauma to the bladder

Treatment of bladder injuries is surgical. The amount of care depends on the type and location of the injury, complications and the capabilities of the stage of medical care.

The standard approach to the treatment of open bladder injuries is an emergency operation - revision and restoration of the integrity of the bladder. Cystostomy, drainage of the perivesical tissue and pelvic tissue spaces. Indications and contraindications for surgery, its basic principles do not differ from those for closed penetrating bladder injuries.

If bladder perforation is suspected during surgery, intraoperative cystography is performed. Small leaks of contrast medium are of little clinical significance: patients are cured only by inserting a catheter into the bladder via the urethra. Significant extraperitoneal perforations may require drainage. Intraperitoneal perforations are more amenable to treatment and restoration of bladder integrity, especially if they are significant.

The peculiarity of the treatment tactics for most open injuries of the urinary bladder is that these injuries are rarely isolated. In this regard, if there is a suspicion of combined damage to the abdominal organs, the main surgical approach is lower midline laparotomy.

After revision of the abdominal organs and completion of the abdominal stage of the operation, revision of the urinary bladder is started. The latter is opened through a midline incision of the anterior abdominal wall, the condition of its walls and distal ureters is assessed. Evaluation of the integrity of the distal ureters is an important part of the operation in penetrating trauma of the urinary bladder. For this purpose, intravenous administration of indigo carmine or methylene blue, retrograde catheterization of the ureter or intraoperative retrograde pyelography can be used.

Next, gentle treatment of the non-viable muscle wall at the site of injury and multi-layer suturing using absorbable threads are performed. If the ureteral orifices or intramural sections of the ureters are affected, the possibility of their reimplantation is considered.

In severe combined injuries, it is possible to apply the concept of general traumatology, the so-called damage control, which allows postponing reconstructive surgery for injuries that do not pose a threat to the life of a patient whose condition is unstable.

The main goal of the initial operation is to stop bleeding, remove urine and prevent infectious and inflammatory complications.

In severe cases, temporary pelvic tamponade is performed to stop bleeding and an epicystostomy is performed. After vital functions are restored, a final reconstructive operation is performed on the bladder.

Modern methods of endoscopy provide the possibility of immediate laparoscopic restoration of the integrity of the bladder in iatrogenic injuries.

The basic principles of surgical treatment of wounded of this category, developed during the Great Patriotic War, have not lost their significance even today.

Basic principles of surgical treatment of open injuries and trauma to the urinary bladder.

• Dissection of the wound channel to create a good outflow of the wound contents, urine and pus; excision of dead tissue, removal of foreign bodies and bone fragments. Foreign bodies located near the urinary bladder must be removed due to the fact that they support its chronic inflammation and often migrate into the bladder with the formation of stones.
• Access to the bladder is lower-midline, regardless of the location of the wound channel. Revision of the bladder cavity and removal of wounding projectiles, bone fragments, and other foreign bodies is mandatory.
• An intraperitoneal wound is sutured with catgut or other absorbable material in two rows from the side of the abdominal cavity, which is dried and sutured tightly, leaving a thin polyvinyl chloride tube for the introduction of antibiotics. In case of gross changes in the peritoneum, a polyvinyl chloride tube with a large number of holes with a diameter of 1-2 mm is additionally inserted into the pelvic cavity for fractional dialysis in the treatment of peritonitis. In case of combined injury of the abdominal organs, appropriate interventions are performed on them first of all according to the same principles as in the absence of damage to the bladder.
• Accessible extraperitoneal wounds of the bladder are sutured from the outside with a double-row suture using absorbable threads. Wounds located in the area of the fundus, bladder triangle or bladder neck are sutured from the mucous membrane side using absorbable material. If it is impossible to suture a wound of such localization, its edges are brought together and drainage is supplied from the outside.
• Urine is drained from the bladder through an epicystostomy, which is placed near the apex and sutured to the muscles and aponeurosis with catgut threads. In case of large wounds and difficulties in suturing them, the epicystostomy is supplemented with active aspiration of urine.
• Drainage of the pelvic tissue, given its infection from the moment of injury and the high frequency of combined intestinal injuries, is performed in most cases using a wound channel, suprapubic access, the Buyalsky-McWhorter or Kupriyanov method. In case of combined injury to the rectum, the most effective way to prevent pelvic uroflegmon is to impose an artificial anus on the sigmoid colon.
• In combined gunshot wounds of the bladder, great importance is attached to the sequence of performing certain surgical interventions (stopping bleeding, surgical interventions on abdominal organs, sanitation of the pelvic cavity, surgical treatment and suturing of bladder wounds, cystostomy). Failure to comply with this principle complicates surgical treatment and is one of the serious risk factors for the development of wound infectious complications.

Treatment of victims with bladder wounds on the battlefield and during medical evacuation is organized as follows. First aid:

• application of an aseptic dressing to the wound;
• immobilization in case of pelvic bone fractures and extensive damage to soft tissues;
• administration of painkillers from a syringe tube;
• use of a broad-spectrum antibiotic;
• Primary evacuation in a prone position.

First aid:

• control and correction of dressings;
• temporary stopping of bleeding by tight tamponade of the wound or application
• clamping of the bleeding vessel; o introduction of antibiotics into the tissue around the wound and intramuscularly;
• administration of antitetanus serum and tetanus toxoid;
• conducting anti-shock and infusion-transfusion therapy in order to prepare for evacuation.

In modern military conflicts, all wounded with combined injuries to the bladder and pelvic bones are required to undergo intrapelvic novocaine blockade according to Shkolnikov and Selivanov.

Qualified surgical care includes surgical treatment of the wound, final stopping of bleeding, surgery on the bladder and other organs, taking into account the principles listed above.

Modern multicomponent general anesthesia allows performing operations for vital indications (ongoing bleeding, damage to internal organs, including bladder injuries, etc.) on wounded patients in a state of shock while simultaneously administering anti-shock therapy.

The wounded are admitted to the specialized care stage for further treatment and correction of complications: long-term non-healing fistulas, urinary leaks, acute and chronic phlegmon of the pelvic tissue and osteomyelitis of the pelvic bones.

Treatment of complications of bladder injuries requires the choice of individual access for surgical treatment of purulent wounds and drainage of abscesses: careful excision of scar tissue and mobilization of the bladder wall, in a number of cases - the use of muscle flaps on a vascular pedicle to close non-healing fistulas.

In the treatment of purulent-septic complications, antibiotics, immunostimulants, transfusions of protein solutions, blood components, and various physiotherapeutic methods are widely used.

The outcome of bladder injuries is determined by the timeliness of surgical intervention. Early removal of urine, drainage of leaks, correct and timely treatment of bone tissue and rectal wounds can significantly reduce mortality in this severe category of wounded.