Open injuries and bladder trauma

Information on the frequency of open (penetrating injuries) damage to the bladder is quite contradictory. According to various authors, open injuries and traumas of the bladder are met in 0.3-26% of the wounded and injured. During the Great Patriotic War, open injuries (injuries) of the bladder occurred in 6.4% of the wounded in the pelvic region, 24.1% in the abdomen and 19.3% among the fighters with injuries of the urogenital organs.

Intraperitoneal wounds accounted for 27.2% of all bladder wounds, and among them only 13.8% were isolated. Most often intraperitoneal wounds were combined with damage to the intestine. Extraperitoneal wounds were recorded in 72.8% of cases, of which 32.8% were isolated.

Accurate data on the number of gunshot combined bladder wounds during the conduct of hostilities in modern local military conflicts are not due to the fact that they are mainly taken into account in statistical reports in the group of wounds in the abdomen and they are often not diagnosed. However, according to some authors, there is a clear increase in this indicator as the development of military equipment, armaments and the level of medical evacuation measures. Wounds of the bladder are classified as severe injuries.

Factors determining the severity of bladder wounds combined:

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

By nature, the combined wounds of the bladder are single or multiple.

The main groups with various variants of wounds of the genito-urinary organs.

• prostate;
• posterior part of urethra;
• ureters;
• genital organs;
• injuries to other organs of the abdomen and pelvis (thin, sung rectum)
• organs of other anatomical regions (head, spine, neck, chest, abdomen, limbs).

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

Types of gunshot wounds of the bladder in terms of severity:

• extremely heavy:
• heavy;
• middle-aged;
• lungs.

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

• tangential;
• cross-cutting;
• the blind.

Localization of bladder wounds:

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

By the presence of complications:

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

[1], [2], [3]

What causes open injuries and bladder trauma?

The mechanism of trauma of open injuries and bladder injuries

In peacetime, chipped and cut open lesions are more common, including as a result of injuring the bladder with splinters in fractures of pelvic bones, and unintentional injuries during surgical interventions (hernia repair, especially with a sliding hernia containing the wall of the bladder, obstetric and gynecological operations, extirpation of the rectum). In wartime, open bladder lesions in most cases are gunshot - bullet or fragmentation.

When injured by modern high-speed wounding elements possessing great kinetic energy, in addition to their direct action, indirect damage due to the side impact of a wounding projectile and the pressure of a temporary pulsating cavity are possible.

Pathological anatomy of open injuries and bladder trauma

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

Necrotic and destructive changes predominate in the area of the wound channel. In the next few hours after trauma, a traumatic edema appears in the surrounding tissues, worsening microcirculation, contributing to the development of secondary necrosis and suppurative complications along with urinary infiltration.

Pathological changes in open lesions (in contrast to closed ones) are manifested even more severely due to extensive damage to bones and soft tissues, a combination of injuries of the bladder and rectum or other parts of the intestine, infection of tissues from the moment of injury, including anaerobic flora. This leads to early development of peritonitis, pelvic phlegmon, osteomyelitis with a poorly expressed tendency to distinguish the inflammatory process.

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

The listed features of modern bladder wounds significantly complicated the diagnosis, increased the volume and laboriousness of surgical interventions, made them vital and at the same time removed the possibility of performing surgery in connection with the need for resuscitation and anti-shock measures.

Symptoms of open injuries and bladder injuries

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

Symptoms of a bladder injury in the first hours after an injury consists of signs of a general nature, symptoms of damage to the intra-peritoneal organs, pelvic bones and the bladder. The most frequent signs of a general nature are collapse and shock. Almost 40% of the wounded go to the stage of qualified assistance in shock III degree or terminal state.

Symptoms associated with damage to the abdominal organs include pain throughout the abdomen, muscle tension in the anterior abdominal wall, sharp tenderness in palpation, dullness in the loins of the abdomen with percussion, and overhanging the anterior wall of the rectum when it is fingered.

With the development of peritoneal symptoms, the tension of the anterior wall of the abdomen is replaced by swelling of the intestine, stool and gas retention, and vomiting. Peritonitis with associated injuries of the intestine occurs early and proceeds with severe symptoms, which is why the symptoms of a bladder injury are often missed and the damage is diagnosed only during surgical intervention. On the combined damage of the bladder and rectum indicates the release of gas and feces with urine.

Symptoms of bladder damage are urinary retention, frequent, painful urination, with a small amount or a few drops of bloody urine in the absence of percussion-determined bladder contours after a long intermission between urination: hematuria with remaining urination and urinary outflow from the wound. The listed clinical signs of a bladder injury in a part of the wounded in the first hours do not reveal, or they are smoothened by manifestations of shock and blood loss.

When combined intraperitoneal injuries of the bladder and intestine, the pain spread throughout the abdomen and the symptoms of irritation of the peritoneum are revealed only in 65% of the wounded. With the same frequency, peritoneal symptoms also occur with extraperitoneal injuries associated with damage to the pelvic bones, and therefore differential diagnosis of extra- and intraperitoneal wounds is virtually impossible without special methods of investigation.

Hematuria, violation of the act of urination and urinary excretion from the wound are met separately or in various combinations in 75% of the wounded, including almost all with extraperitoneal or mixed wounds, 60% - intraperitoneal and 50% - bruises of the bladder.

In severe combined injuries in the clinical picture, signs of traumatic or hemorrhagic shock, symptoms of internal bleeding and injuries of the abdominal organs, pelvic bones and other organs that mask the clinical manifestations of bladder damage predominated.

Complications of open injuries and bladder injuries

After a qualified treatment, complications are rare. These include urinary tract infections, abscess, peritonitis. In cases of bladder neck trauma, urinary incontinence is possible.

[4], [5]

Diagnosis of open injuries and injuries of the bladder

Diagnosis with stabbed and incised wounds of the bladder is not fundamentally different from that with closed injuries. In the case of gunshot wounds, the use of instrumental and radiographic diagnostic methods is limited by the conditions of providing surgical care on the warrior, the severity of the condition, and the need to perform surgery for vital signs quite frequently (internal bleeding, etc.).

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

If the catheter fails to receive urine (when the catheter's beak penetrates into the abdominal cavity), do not attempt to rinse the catheter and bladder: the wash fluid will increase the colonization of the abdominal cavity by combining damage to the intestine, without significantly clarifying the diagnosis.

The localization of the wound, the course of the wound channel, the nature of the wound detachable and the macrohematuria make it possible, at a primary examination, to suspect bladder damage. Intravenous introduction of indigo carmine, coloring the urine in blue, allows to confirm the excretion of urine from the wound.

Diagnostic methods used in cases of open bladder damage do not fundamentally differ from the methods used to diagnose their closed lesions.

The leading role belongs to the methods of radiation diagnosis, which allows verifying the damage of the bladder and determining its character. The main method to confirm damage to the bladder is ascending (retrograde) cystography. Indications for its conduct and methodology for implementation are described in the section on closed bladder injuries.

Another available and highly reliable method for diagnosing abdominal injuries, including intraperitoneal wounds of the bladder, is ultrasound and laparocentesis, with the evacuated fluid being examined for impurities of blood, urine, bile and intestinal contents. It facilitates the diagnosis of bladder injuries by the introduction of a solution of methylene blue or indigo carmine into the cavity of the bladder and staining them with liquids evacuated during laparocentesis.

Laparocentesis in a significant number of observations allows to avoid erroneous laparotomy, in 12% leading to lethal blood outflow in military field conditions during the Great Patriotic War. Retrograde cystography, if carried out correctly, allows in most cases to identify the wound of the bladder, to assess its localization and size, to determine the ratio of the wound to the abdominal cavity and directed urinary streams. However, cystography for bladder injuries is used only in 10-16% of the victims. Even more rarely use excretory urography because of its low information in shock. This method, like cystoscopy, is used primarily at the stage of specialized urological care to diagnose complications, whereas at the stage of qualified surgical care more than 50% of bladder wounds are diagnosed with laparotomy.

Timely recognition of urinary infiltration of pelvic fiber presents significant difficulties due to the fact. That the local reaction is not always possible to detect, and the general reaction is absent or weakly expressed.

It is especially difficult to diagnose urinary swabs in the affected with shock and blood loss, in connection with which the pelvic phlegmons develop more often and are more severe.

Typical for shock symptoms: lowering body temperature, frequent pulse low blood pressure, indifference to one's condition and others - are combined with symptoms of urinary infiltration. Patients are restless, sometimes euphoric complain of pain and a feeling of heaviness in the depth of the pelvis, thirst. Further deterioration of the condition, occurring 3-5 days after injury, manifests itself as signs of a septic condition and is due to the development of urinary phlegmon, a major complication of extraperitoneal bladder damage. Skin covers are pale, ashy or icteric; appetite is absent; tongue dry, coated with a brown coating, with cracks.

There appears pastosity of the tissues in the inguinal region, perineum, on the inner surface of the thigh; the skin of these areas subsequently acquires a blue-purple or yellowish color. With a purposeful study, infiltrate or purulent feces are found. The edges of the wound are dry, the granulations are sluggish, the bottom of the wound is covered with a gray coating. Pulse is frequent, weak filling. The body temperature is high, with chills and puffy sweats, in the future as sepsis develops, it decreases to normal due to the organism's non-reactivity. The occurrence of suppurative complications is accompanied by high neutrophilic leukocytosis with a leftward shift and toxic granularity, high ESR, increasing hypochromic anemia and hypoproteinemia.

Pelvic ulcers and pelvic osteomyelitis characterize the gradual deterioration of the general condition, weakness, periodic temperature rises, signs of intoxication, progressive weight loss and atrophy of skeletal muscles and dystrophic changes in internal organs.

Diagnosis of open bladder damage is often completed with its intraoperative revision.

[6], [7],

Treatment of open injuries and injuries of the bladder

Treatment of bladder wounds operative. The amount of assistance depends on the type and location of damage, complications and opportunities for 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 peri-bubble tissue and cellular spaces of the pelvis. Indications and contraindications to the operation, its basic principles do not differ from those with closed penetrating damage to the bladder.

If suspicion of perforation of the bladder occurs during surgery, intraoperative cystography is performed. Small contusions of contrast material are not of great clinical significance: patients are cured only by inserting a catheter into the bladder through the urethra. Significant extraperitoneal perforations may require the installation of drains. Intraperitoneal perforations are better suited for treatment and restoration of the integrity of the bladder, especially if they are significant.

The peculiarity of therapeutic tactics in most open bladder lesions is that. That these lesions are rarely isolated. In this regard, if there is a suspected combination of damage to the abdominal organs, the main operative access is the lower-median laparotomy.

After the revision of the abdominal organs and the implementation of the abdominal stage, the operations begin to revise the bladder. The latter is opened through the median incision of the anterior abdominal wall, the condition of its walls and distal ureteral divisions is evaluated. Evaluation of the integrity of the distal ureter is an important part of the operation with penetrating trauma to the bladder. For this purpose, it is possible to use intravenous indigo carmine or methylene blue, retrograde catheterization of the ureter, or intraoperative retrograde pyelofafia.

Further, gentle treatment of the non-viable muscle wall at the injury site and a multilayered seam using absorbable filaments are carried out. If ureteral estuates or intramural sections of the ureters are affected, they consider the possibility of their reimplantation.

In severe co-traumatic injuries, it is possible to use the concept of general traumatology, the so-called damage control, which allows you to postpone a recovery operation for damage that does not pose a threat to the life of a patient whose condition is unstable.

The main task of the initial operation is the stopping of bleeding, excretion of urine and the prevention of infectious and inflammatory complications.

When the patient is in a serious condition, a temporary tamponization of the pelvis is performed in order to stop the bleeding and impose an epicystostomy. After restoration of vital functions, the final reconstructive operation on the bladder is performed.

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

The main provisions of the operational treatment of the wounded in this category, worked out during the Great Patriotic War, have not lost their significance even now.

The main provisions of the surgical treatment of open injuries and bladder injuries.

• Dissection of the wound channel to create a good outflow of the contents of the wound, urine and pus; excision of necrotic tissue, removal of foreign bodies and bone fragments. Mandatory removal is subject to foreign bodies located near the bladder due to the fact that they support its chronic inflammation and often migrate inside the bladder to form stones.
• Access to the bladder is inferior, regardless of the location of the wound channel. Mandatory examination of the cavity of the bladder and the removal of wounding shells, bone fragments, other foreign bodies.
• The intraperitoneal wound is sutured with catgut or other absorbable material in two rows from the side of the abdominal cavity, which is drained and sutured tightly, leaving a thin polyvinylchloride tube for administration of antibiotics. With gross changes in the peritoneum for fractional dialysis in the treatment of peritonitis, a polyvinylchloride tube with a large number of holes 1-2 mm in diameter is additionally introduced into the pelvic cavity. When combined injuries of the abdominal cavity organs, they are primarily performed by appropriate interventions according to the same principles as in the absence of damage to the bladder.
• Available extraperitoneal wounds of the bladder are sutured from the outside with a double-suture resorbable thread. Wounds located in the region of the bottom, the urinary bladder or the neck of the bladder, are sutured from the mucosal side by absorbable material. If it is impossible to cover the wound with such a localization, its edges are brought together and drains are brought from the outside.
• The urine from the bladder is removed through an epicystostome, which is placed near the top and sutured to the muscles and aponeurosis with catgut threads. With large wounds and difficulties in their suturing epicystostomy is supplemented with active aspiration of urine.
• Drainage of the pelvic fat tissue, taking into account its infection from the moment of injury and the high incidence of associated intestinal injuries, in most cases perform the suprapubic access, the method of Buyalsky-McWarter or Kupriyanov, using the wound channel. When combined rectal damage for the prevention of urinary esophageal phlegmon, the most effective is the application of an unnatural anus to the sigmoid colon.
• When gunshot combined bladder wounds, great importance is attached to the sequence of performing certain surgical interventions (stopping bleeding, surgical interventions on the abdominal cavity, sanation of the pelvic cavity, surgical treatment and suturing of the bladder wounds, cystostomy). Failure to comply with this principle complicates surgical treatment and is one of the major risk factors for wound infection.

Treatment of victims with bladder injuries on the battlefield and the stages of medical evacuation is organized as follows. First pre-medical care:

• application of an aseptic wound dressing;
• immobilization in fractures of pelvic bones and extensive damage to soft tissues;
• administration of anesthetics from a syringe-tube;
• use of a broad-spectrum antibiotic;
• prime evacuation in the lying position.

First medical aid:

• control and correction of dressings;
• temporary stop of bleeding with a tight wound tamponade or overlap
• clamping on a bleeding vessel: o administration of antibiotics into tissues around the wound and intramuscularly;
• administration of tetanus toxoid and tetanus toxoid;
• carrying out anti-shock and infusion-transfusion therapy to prepare for evacuation.

In modern military conflicts, all wounded people with combined injuries of the bladder and pelvic bones are obliged to make an intraocular Novocain blockade according to Shkolnikov and Selivanov.

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

Modern multicomponent general anesthesia allows performing operations for vital signs (continued bleeding, damage to internal organs, including bladder injuries, etc.) to the wounded in a state of shock while performing anti-shock therapy.

At the stage of specialized care, the wounded come for the treatment and correction of complications: long-lasting non-healing fistula, urinary leakage, acute and chronic phlegmon of the pelvic fat and osteomyelitis of 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 vesicle wall, in a number of cases, the use of muscle flaps on the vascular pedicle to close non-healing fistulas.

In the treatment of purulent-septic complications, antibiotics, immunostimulants are widely used. Transfusion of protein solutions. Components of blood, various physiotherapy methods.

The outcomes of injuries of the bladder are determined by the timeliness of the surgical intervention. Early excretion of urine, draining drainage, correct and timely treatment of bone tissue and rectal wounds can significantly reduce the lethality in this severe category of the wounded.