Closed injuries and bladder trauma

In peacetime, closed injuries and bladder injuries - 0,4% in relation to all types of injuries and 15% among persons with injuries of the genito-urinary organs. With pelvic injuries, they are found in 7.5%, closed abdominal injury - 13.4% of the affected. Isolated extraperitoneal lesions occur on average in 26% of cases, intraperitoneal lesions - 12%. 

The most common damage to the bladder is combined with a fracture of the pelvic bones (40-42%), rupture of the intestine (4-10%), other internal organs (8-10%) with simultaneous damage to the pelvic bones (12-36%).

[1], [2], [3], [4]

What causes closed injuries and bladder trauma?

Spontaneous ruptures of the bladder, its damage during instrumental studies: cystolithotripsy, TUR, and hydraulic stretching to increase the capacity are described.

In the mechanism of rupture, the nature and strength of the traumatic effect, the degree of filling the urinary bladder with urine, is important. A sudden increase in intravesical pressure is transmitted with equal force to all the walls of the urinary bladder containing urine. At the same time, its lateral walls, surrounded by bones, and the base of the bladder adjacent to the pelvic diaphragm, counteract the increased intravesical pressure, while the least protected and most tapered part of the bladder, which faces the abdominal cavity, is torn. Intraperitoneal ruptures of the wall of the bladder, arising from this mechanism, spread from the inside out: first, the mucous membrane, then the submucosa and the muscle layer, lastly the peritoneum.

In a number of cases, the peritoneum remained intact, leading to a subperitoneal spread of the contents of the bladder. A similar hydrodynamic rupture can be caused by compression of the overflowing bladder by receding fragments of the pelvic ring with its fractures without direct injury of the vascular wall with bone fragments.

Additional influencing factor is the tension of the pubic-cystic ligament in the divergence of pubic bone fragments and the pubic articulation. In this case, the extraperitoneal section of the bladder is often ruptured. Finally, the damage to the bladder near its neck causes displaced fragments of pubic and sciatic bones, although during surgery they are rarely found in the wound of the bladder.

This fact explains the elasticity of the pelvic ring, whereby bone fragments, injuring the bladder at the time of injury, can subsequently exit the wound canal. Not all fractures of the pelvic bones, even with a discontinuity in the continuity of the pelvic ring, are accompanied by ruptures of the bladder. Apparently, for its damage it is necessary to have a sufficient amount of urine in it, which contributes to the proximity of the walls to the bones of the pelvis and a smaller displacement of the bladder at the time of injury.

Distinguish bruises, incomplete ruptures of the wall of the bladder (urine does not pour out beyond it) and complete ruptures with a sweat of urine into the surrounding tissues or abdominal cavity. An incomplete break turns into a complete breakdown as a result of inflammatory and necrotic changes in the wound, overflow of the bladder with urine and an increase in intravesical pressure at the time of urination. Such a mechanism leads to a two-stage rupture.

Symptoms of closed injuries and bladder injuries

Closed bladder lesions are characterized by a combination of symptoms of damage to the bladder itself, signs of damage to other organs and pelvic bones, manifestations of early and late complications of trauma. Hematuria, urination disorders, pain, lower abdominal pain or suprapubic area, during a primary examination of a patient with an anamnesis history, one can suspect a bladder injury.

With isolated lesions, pain occurs in the suprapubic region. Violation of urination and hematuria. Disorders of urination with bladder damage are different. The nature of the disorder is related to the degree of emptying the bladder through the wound opening into the surrounding tissue or into the abdominal cavity. With bruises and incomplete ruptures of the bladder there is a rapid, painful urination, it is possible an acute retention of urination.

Sometimes, with mild injuries, urination remains normal. Complete gaps are characterized by the absence of independent urination with frequent and painful urge, but unlike the delay of urination, tympanitis is determined above the pubis. With extraperitoneal damage, it is soon replaced by an increasing bluntness that does not have clear boundaries, with intraperitoneal ruptures tympanitis is combined with the presence of free fluid in the abdominal cavity. When the bladder ruptures against a background of infertile urge to urinate, it is sometimes possible to separate a few drops of blood, a prolonged absence of urination and urge to it.

An important symptom of injury bladder - hematuria, the intensity of which depends on the damage to the villa and its location. With bruises, external and internal incomplete, intraperitoneal ruptures, the macrohematuria is short-lived or even absent, whereas with significant discontinuities in the neck and the urinary bladder has a pronounced character. However, isolated bladder ruptures are extremely rarely accompanied by significant blood loss and shock.

With intraperitoneal ruptures of the bladder, peritoneal symptoms develop slowly, increase gradually (within 2-3 days), are weak and unstable, which is often the cause of late diagnosis of urinary peritonitis.

Initially, the pain localized in the suprapubic region becomes diffuse, intestinal paresis, abdominal distention, stool and gas retention, nausea, vomiting. After cleansing enema, there is a stool and gases come off. The abdomen is involved in breathing, the tension of the muscles of the abdominal wall and soreness in palpation of the abdomen are insignificant or moderately pronounced, the peritoneal symptoms are poorly expressed, the peristalsis of the intestine is listened for a long time.

After 24 hours the patient's condition worsens, signs of intoxication join, leukocytosis, azotemia develop. Entering the infected urine in the abdominal cavity leads to an earlier appearance of a pattern of diffuse peritonitis, but the clinic of dynamic intestinal obstruction, accompanied by a sharp swelling of the intestine, is at the forefront. In the absence of anamnestic information about the trauma, such a clinical picture is regarded as food poisoning.

With extraperitoneal damage a few hours after the injury, the intensity of the hematuria decreases, but the frequency and soreness of the urination urination increases. In the suprapubic and inguinal areas, the swelling of the skin and subcutaneous tissue appears as a testic swelling. The condition of the victim gradually worsens due to the increasing urinary intoxication and development of pelvic phlegmon or abscesses, as evidenced by high body temperature, in laboratory tests - neutrophilic leukocytosis with a left shift, hypochromic anemia, increasing residual nitrogen, urea and creatinine in the serum.

In 50-80% of cases, people with combined bladder damage are in a state of collapse and shock, significantly changing the nature of clinical manifestations and making diagnosis difficult. Isolated fractures of pelvic bones with peri-bubble hematoma can also be manifested by pain, dysuria, stress and painfulness upon palpation of the anterior abdominal wall, delay of gases, stool and urine. These symptoms are probably associated with irritation of the parietal peritoneal hematoma, compression of the neck of the bladder.

Suspicion of bladder damage indication to special studies that confirm the fact of damage to the bladder, determine its appearance and plan therapeutic tactics.

Complications of closed injuries and bladder injuries

Complications of bladder injuries most often occur because of late diagnosis of damage or untimely treatment.

Complications of bladder damage:

• increasing urohematoma:
• phlegmon of the pelvis;
• localized abscesses;
• urinary peritonitis;
• Adhesive intestinal obstruction;
• sepsis.

If the neck of the bladder, vagina, rectum is damaged, without timely elimination, urinary incontinence, urinary fistulas, strictures develop. In the future, plastic surgery may be required

Extensive trauma to the sacrum, sacral roots or pelvic nerves leads to denervation of the bladder and impaired urinary function. If the cause of bladder dysfunction is a violation of innervation, then for some time you may need a catheterization. With some severe injuries of the sacral plexus, a violation of urination can be sustained due to a decrease in the tone of the muscles of the bladder and its neurogenic dysfunction.

Complications with bruises and incomplete bladder ruptures are rare: hematuria, urinary tract infection, a decrease in the volume of the bladder, less often the formation of pseudodiverticles of the bladder.

[5], [6], [7], [8],

Diagnosis of closed blisters and injuries of the bladder

The diagnosis of closed bladder injuries is based on an analysis of the circumstances and mechanism of injury, physical examination data, laboratory and radiation diagnostic methods.

At the prehospital stage, the diagnosis of bladder damage is difficult: only 20-25% of the victims are sent to hospitals with the correct diagnosis, where the recognition of extraperitoneal ruptures does not cause special difficulties. The high frequency of combinations of bladder damage with fractures of the pelvic bones alarms doctors, and in the presence of appropriate complaints, urination disorders, blood in the urine, there is a need for additional ultrasonography and X-ray studies that allow in the early stages to establish the correct diagnosis and to perform operative treatment in the first hours after hospitalization .

The situation with the diagnosis of intraperitoneal ruptures is quite different. A typical picture of intraperitoneal damage occurs in about 50% of the affected people, and therefore the monitoring of patients is delayed. Clinical signs of trauma (severe general condition, frequent pulse, bloating, presence of free fluid in the abdominal cavity, symptoms of irritation of the peritoneum, impaired urination and other signs) are absent or expressed weakly against shock and blood loss.

Abrasions, bruises and other signs of trauma in the abdomen and pelvis, clarification of the mechanism of damage, assessment of the patient's condition and the degree of filling of the bladder help to suspect his damage. Palpation through the rectum is determined by the presence of its damage, hematoma and urinary leakage of bone fractures, overhanging of the vesicovial-rectal fold.

When examining the patient it is necessary to pay attention to abrasions and subcutaneous hematomas of the anterior abdominal wall, bruises on the perineum and inner thighs. It is necessary to visually assess the color of urine.

The most characteristic symptoms of bladder damage are macrogematuria (82%) and abdominal tenderness during palpation (62%). Other symptoms of bladder trauma are microhematuria, inability to urinate, hematoma in the suprapubic region, muscle tension in the anterior abdominal wall, arterial hypotension, decreased diuresis.

If the patient is in a state of intoxication, the above symptoms do not appear immediately. With intact urogenital diaphragm, the urine inclusions are limited to the pelvic area. In the case of rupture of the upper fascia of the urogenital diaphragm, urine infiltrates the scrotum, perineum and abdominal wall. When the lower fascia of the diaphragm ruptures, the urine infiltrates the penis and / or thigh.

The most simple, accessible and not requiring high qualification and special equipment method of diagnosis of bladder damage is diagnostic catheterization, performed with caution, with a soft catheter, in the absence of signs of damage to the urethra.

Symptoms indicating bladder damage:

• absence or insignificant amount of urine in the bladder in a patient who has not been urinating for a long time:
• a large amount of urine, much higher than the physiological capacity of the bladder;
• admixture of blood to the urine (it is necessary to exclude the kidney origin of hematuria);
• inconsistency between the volumes of fluid injected and discharged through the catheter (a positive symptom of Zeldovich);
• the released liquid (a mixture of urine and exudate) contains up to 70-80 g / l of protein.

To detect free blood and urine in the abdominal cavity in recent years, widely used ultrasound, laparoscopy and laparocentesis (diagnostic puncture of the anterior wall of the abdomen). The catheter introduced into the abdominal cavity is alternately directed under the hypochondrium, in the ileum and the pelvic cavity, removing the contents of the abdominal cavity by a syringe. When receiving blood, a liquid with an admixture of bile, intestinal contents or urine, the internal organs are damaged and urgent laparotomy is performed. In the case when the liquid does not enter the abdominal cavity, 400-500 ml of physiological sodium chloride solution is introduced into the abdominal cavity, then it is sucked and examined for blood, diastase and urine admixture. The negative result of laparocentesis makes it possible to refrain from laparotomy.

To detect a small amount of urine in the wound discharge and intraperitoneal fluid obtained during laparocentesis or during the operation, the presence of substances selectively concentrating in the urine and being its indicators is determined. The most suitable endogenous substance is ammonia, whose concentration in the urine is thousands of times greater than in blood and other biological fluids.

Method for determination of urine in the test fluid. To 5 ml of the test fluid, add 5 ml of a 10% solution of trichloroacetic acid (to precipitate the protein), mix and filter through a paper filter. In a clear and colorless leachate for alkalinization, pour 3-5 ml of a 10% solution of caustic potassium (KOH) and 0.5 ml of Nessler reagent. If the test liquid contains more than 0.5-1% of urine, it acquires an orange color, becomes cloudy and a brown precipitate appears, which is regarded as damage to the urinary organs. In the absence of urine in the test fluid, it remains a transparent, slightly yellow color.

Ultrasound, catheterization of the bladder and abdominal puncture are the most acceptable methods of diagnosing bladder damage in the practice of providing emergency care.

The same methods - the main diagnostic techniques at the stage of providing qualified surgical care, which does not have the equipment for X-ray equipment.

The diagnostic value of cystoscopy in bladder ruptures is limited by the complexity of laying the patient in the urological chair (shock, fractures of the pelvic bones), the inability to fill the bladder with ruptures, intensive hematuria, which prevents inspection due to poor visibility. In this regard, strive to perform cystoscopy in case of suspected bladder damage should not be. It can be used at the final stage if the clinical and radiological data do not confirm, but do not exclude the presence of damage with sufficient reliability, and the patient's condition allows for the carrying out of cystoscopy.

Be sure to conduct a laboratory blood test to assess the severity of hemorrhage (hemoglobin, hematocrit and erythrocyte) and urine. A high level of electrolytes, serum creatinine and urea causes suspicion of intraperitoneal rupture of the bladder (urine enters the abdominal cavity, urinary ascites and absorbed by the peritoneum).

[9], [10]

Macrogamaturia

Macrogematuria is a permanent and important, but not unique, symptom that accompanies all types of bladder damage. Numerous studies show that macrohematuria in the hip fracture is strongly correlated with the presence of rupture of the bladder. During bladder rupture, the hematuria develops in 97-100%, and the hip fracture - 85-93% of observations. The simultaneous presence of these two conditions is a strict indication for cystography.

Isolated hematuria without any knowledge of trauma to the lower urinary tract is not an indication for the conduct of cystography. Additional factors that make it possible to suspect bladder damage are arterial hypotension, a decrease in hematocrit, a general severe condition of the patient, and a buildup of fluid in the pelvic cavity. If trauma to the pelvic bones is not accompanied by macrogemuria, then the probability of a serious bladder injury is reduced.

With urethrorrhagia before cystography it is necessary to perform a retro gradual urethrography in order to identify possible damage to the urethra.

Microgematuria

The combination of fracture of the pelvic ring and microhematuria indicates a damage to the urinary tract, but if there is less than 25 erythrocytes in the general urine analysis in the field of vision with a large magnification of the microscope, the probability of rupture of the bladder is small. In all patients with bladder rupture, hematuria is detected - more than 50 erythrocytes in the field of vision at high magnification.

The conduct of cystography is advisable if, according to the data of a urinalysis with a large increase, the number of erythrocytes exceeds 35-50 and even 200 in the field of vision.

Care should be taken when dealing with injuries in childhood, because according to the conducted studies, when detecting 20 red blood cells in the field of vision with a large increase without carrying out cystography, you can miss up to 25% of bladder ruptures.

Survey radiography can reveal bone fractures, free fluid and gas in the abdominal cavity.

Excretory urography with descending cystography in most bladder lesions, especially complicated by shock, is of little informative due to the fact. That the concentration of contrast medium is insufficient to detect urine inclusions. The use of excretory urography for bladder and urethra damage in 64-84% of observations gives a false-negative result, as a result of which its use for diagnostics is inexpedient. The usual cystographic phase during the standard excretory urography does not allow to exclude damage to the bladder.

Cystography

Retrograde cystography is the "gold standard" for diagnosing bladder damage, which can reveal a violation of the integrity of the bladder. Conduct differential diagnosis between intra- and extraperitoneal ruptures, establish the presence and localization of feces. In addition to high information content, the method is safe, does not make the victim's condition worse; does not cause complications from entering the contrast medium in the abdominal cavity or peri-bubble tissue - if there is a rupture behind the cystography, surgery should be performed with drainage of the abdominal cavity or drainage of the feces. It is advisable to combine retrograde cystography with the breakdown of Ya.B. Zeldovich.

In order to ensure high information content of the catheter study, at least 300 ml of 10-15% solution of contrasting water-soluble substance in a 1-2% solution of novocaine with a broad-spectrum antibiotic are slowly introduced into the bladder. Perform a series of X-ray images of the bladder in the frontal (anteroposterior) and sagittal (oblique) projections. Be sure to take a picture after emptying the bladder to clarify the localization and nature of the spread of swelling in the peri-bubble and retroperitoneal tissue, which increases the effectiveness of the study by 13%.

The main radiographic evidence of bladder damage is the presence (stagnation) of the contrast medium beyond its limits, the indirect radiography is the deformation and displacement of it up or to the side. Indirect signs are more often observed with extraperitoneal rupture and peri-bubble hematomas.

Characteristic direct radiographic signs of intraperitoneal rupture are distinct lateral boundaries, a concave and uneven upper contour of the bladder due to overlapping of the cystic shadow with cast out contrast. With intraperitoneal ruptures, loops of the intestine are contrasted: a rectal-vesicle (rectal-uterine) depression. The shadows of the contrast substance poured into the abdominal cavity are well delineated because of their location between the loops of the swollen bowel.

Signs of extraperitoneal rupture fuzzy contour of the bladder, vagueness: stains of radiocontrast substance in the perivascular fiber in the form of separate bands (tongues of flame, diverging rays) with a small cloud-like shadow - medium; solid blackout without clear contours - a large gap.

All the fines, as a rule, lie below the upper edge of the / ossa acetabulum.

If the above rules are not observed, there is a possibility of obtaining a false result. On the basis of these cystographies, a classification of bladder damage based on the protocol of the European Association of Urologists (2006) is based.

[11], [12], [13]

Ultrasonography

The use of ultrasound for the diagnosis of bladder damage is not recommended as a routine method of investigation because its role in detecting bladder damage is low.

Ultrasound can detect free fluid in the abdominal cavity, fluid formation (urogematic) in the cellulose of the small pelvis, blood clots in the bladder cavity, or lack of visualization of the bladder when it is filled through the catheter. The use of ultrasound is currently limited due to the fact that patients with polytrauma are more likely to have CT scan - a more informative diagnostic method.

CT scan

Despite the fact that CT is the method of choice for the study of blunt and penetrating injuries of the abdomen and thigh, nevertheless its routine application even with a complete bladder is inexpedient, since it is impossible to differentiate urine from the transudate. For this reason, in order to diagnose bladder damage, CT is performed in combination with retrograde contrast of the bladder - CT-cystography.

CT-cystography makes it possible to diagnose bladder damage to an accuracy of 95% and specificity of 100%. In 82% of cases, CT data completely coincide with the data obtained during the operation. In the diagnosis of intraperitoneal damage of the bladder, CT-cystography is sensitive in 78% and specific in 99%. When performing CT scintigraphy, performing additional scanning after emptying the bladder does not increase the sensitivity of the method.

Thus, CT with bladder contrast and retrograde cystography from the point of view of the diagnosis of bladder damage have the same informative value, but the use of CT also makes it possible to diagnose the combined injuries of the abdominal organs, which undoubtedly increases the diagnostic value of this method of investigation.

[14], [15], [16],

Angiography

In carrying out angiography reveals a hidden source of bleeding and at the same time produce a damaged vessel embolization during the study.

[17], [18], [19], [20], [21], [22],

Magnetic resonance imaging

MRI in the diagnosis of bladder trauma is used mainly to diagnose the combined damage of the urethra.

With clinical signs of damage to the abdominal cavity, it is not uncommon for the final diagnosis of the type of bladder damage to be made when it is inspected during surgery. After the revision of all organs of the abdominal cavity, the integrity of the bladder is checked. Through the wound of the bladder, if its size is sufficient, an audit of all the walls is performed to exclude also extraperitoneal ruptures.

Treatment of closed blisters and injuries of the bladder

Suspicion of bladder damage is an indication for an emergency hospitalization of the patient.

Therapeutic tactics depends on the nature of the bladder injury and the combined injuries of other organs. When shocked before surgery, anti-shock measures are carried out. With a bruise and incomplete rupture of the bladder, treatment is conservative: prescribe bed rest, hemostatic, analgesic, antibacterial and anti-inflammatory drugs.

To prevent a two-stage rupture, a permanent urinary catheter is placed in the bladder. The duration of the bladder drainage is individual and depends on the severity of the injury, the patient's condition, the nature of the damage, the duration of hematuria, the duration of resorption of the pelvic hematoma (an average of 7-10 days). Before removing the urethral catheter, it is necessary to perform cystography and make sure there are no streaks of contrast agent.

Treatment of complete closed injuries is always prompt. The best results are observed at early terms of operative intervention. Before surgical intervention, damage to the bladder is a paramount task - stabilization of the patient's general condition.

In many patients with closed extraperitoneal rupture of the bladder, its catheterization is effective, even if there is extravasation of urine over the peritoneum or in the lobe of the external genitalia.

According to Corriere and Sandlera, 39 patients with bladder rupture were cured solely due to drainage and a good result was observed in all the observations. Cass, curing 18 patients with extraperitoneal rupture of the bladder with only one of its drainage, observed complications in only 4 cases.

According to some authors, it is preferable to transurethral drainage of the bladder, leading to a lower level of complications. Urethral catheter left for 10 days to 3 weeks. Removed after cystography.

With small extraperitoneal bladder damage that occurred during endourologic operations, conservative treatment is possible with a bladder drainage within 10 days. By this time in 85% of the cases, the bladder lesions will heal independently.

Indications for surgical treatment of extraperitoneal blunt trauma:

• damage to the neck of the bladder;
• fragments of bones in the thickness of the bladder and infringement of the wall of the bladder between fragments of bones;
• inability to adequately drain the bladder with a urethral catheter (clot formation, ongoing bleeding);
• concomitant damage to the vagina or rectum.

Practice shows that the earlier the surgical procedure is performed with similar intra- and extraperitoneal bladder lesions, the better the results.

The purpose of the operation - revision of the bladder, suturing its defects with a single-suture seam using absorbable suture material, draining urine by epicystostomy and draining the paravezic urinary stools and urogemata of the small pelvic tissue.

With intraperitoneal damage, a median laparotomy is performed. The abdominal cavity is thoroughly drained. The wound of the bladder is closed with one- or two-row sutures with catgut or synthetic absorbable threads. After suturing the defect of the wall of the bladder, the tightness of the seam is checked. In the abdominal cavity, thin polyvinylchloride drainage is left. 

For the introduction of antibiotics and the abdominal cavity is sewn up to the place of the delivered Drainage. If there is a difficulty in detecting a defect in the vesicle wall during surgery and to check the tightness of the suture at the end of the operation, a 1% solution of methylene blue or 0.4% solution of indigo carmine is administered to the bladder via the catheter, following the place where the paint enters the abdominal cavity. If suturing the wound of the bladder is difficult, spend it extraperitonization.

Extraperitoneal, easily accessible ruptures of the bladder are sutured with absorbable material with a two- or single-row suture. With the localization of lesions in the region of the bottom and neck of the bladder, due to their inaccessibility, it is possible to apply immersion sutures from the side of its cavity. To the wound hole, drains are taken from the outside, deduced depending on the location of the wound through the suprapubic access: however, it is preferable through the crotch along the Kupriyanov or the lock hole at the Buyalsky-McWarger. Then the catheter is fixed to the thigh with a tension for a day and is removed no earlier than 7 days later.

With detachment of the neck of the bladder from the urethra, stitching of divergent parts is almost impossible because of the technical difficulties of suturing in this area and the development of urinary infiltration by the time of surgical intervention. To restore the patency of the urethra and prevent the formation of strictures of a large extent after the evacuation of urogematomes into the bladder, a catheter is guided through the urethra.

Then, retreating 0.5-1.5 cm from the edge of the cervical suture, 1-2 catgut ligatures are applied to the right and left, while the detrusor of the bladder and the prostatic capsule are pierced near the opening of the urethra. Ligatures gradually tie, bring the bladder closer and remove diastase between the neck of the bladder and the proximal end of the urethra. The bladder is fixed in its anatomical bed. The urinary bladder and the periapubular space are drained with silicone (chlorovinil) tubes.

The urethral catheter is stored up to 4-6 days. If it is not possible to apply a close fitting fixation ligature, a Foley catheter is used, which is filled with a liquid and tightened by the catheter to bring the bladder neck closer to the prostate, place seams in easily accessible places and fix the catheter with tension to the hip. In case of a serious condition of the patient and prolonged intervention, comparison of the neck of the bladder with the urethra is postponed to a later date, and the operation is terminated with cystostomy and drainage of the pustular space.

The bladder drains at any of its ruptures, using predominantly epicystostom, and the drainage tube should be positioned as close as possible to the tip of the bladder.

The tube is fixed with catgut to the wall of the bladder, after suturing the bladder wound below the tube, the stroma region is sutured to the aponeurosis of the rectus muscles. The high location of the drainage tube prevents the development of pubic bone osteomyelitis. Only in some cases, with isolated small bladder damage in women, absence of peritonitis and urinary leakage, tightness of the seam of the bladder wound, it is permissible to drain with a permanent catheter for 7-10 days.

In the postoperative period, it is advisable to actively remove urine by means of a siphon drainage device, a drainage device UDR-500, a vibro-aspirator. Stationary vacuum suction. If necessary, flow through the bladder is flushed with antibacterial solutions entering the intra-drainage irrigation system of double-lumen drainage or an additional capillary tube installed through the suprapubic access. Improving the outcomes of closed bladder injuries is determined by early diagnosis and timely surgery. Mortality in a number of institutions was reduced to 3-14%. The cause of the death of the victims is
Multiple severe injuries, shock, blood loss, diffuse peritonitis and urosepsis.

When the patient's condition is extremely serious, cystostomy is performed and the perivascular tissue is drained. Reconstructive surgery is performed after stabilization of the patient's condition.

Patients with a pelvic fracture should undergo a recovery operation on the bladder before intraosseous fixation of the fragments.

In the postoperative period, antibiotics of a wide spectrum of action, hemostatic preparations, analgesics are prescribed. In the overwhelming majority of cases, when using this method of treating the lesion, complete healing takes place within a period not exceeding 3 weeks.

Intraperitoneal rupture of the bladder is an absolute indication for an emergency operation; contraindication - only the patient's agonizing state. If there is a suspected combination of damage to the abdominal organs, it is advisable to include an abdominal surgeon in the surgical team.

Operative access is lower-median laparotomy. After opening the abdominal cavity, a thorough audit of the organs is carried out in order to exclude their combined injuries. In the presence of such damage, the abdominal stage of the operation is performed first.

Rupture of the bladder is usually observed in the area of the transitional fold of the peritoneum. If it is difficult to detect the place of rupture of the bladder, it is advisable to use an intravenous injection of 0.4% indigo carmine solution or 1% methylene blue solution that stain the urine blue and thereby facilitate the detection of bladder damage.

After detection of damage to the wall of the bladder, epicystostomy is performed, and the rupture is closed with a double-suture using a resorbable material. Sometimes the bladder is additionally drained with a urethral catheter, and for 1-2 days a permanent washing of the bladder with solutions of antiseptics is established.

In the absence of associated damage to the abdominal organs, the operation is completed by sanation and drainage. Drainage tubes are installed through the counter-percutaneous incisions in the cavity of the small pelvis and along the right and left lateral channels of the abdominal cavity. When diffuse peritonitis is performed nasogastrointestinal intubation of the intestine.

In the postoperative period, antibacterial, hemostatic, anti-inflammatory, infusion therapy, intestinal stimulation and correction of homeostatic disorders are performed.

The duration of drainage of the abdominal cavity and bladder is determined individually, depending on the features of the course of the postoperative period. At the same time, they focus on the indicators of intoxication, the duration of hematuria, the presence of infectious and inflammatory complications.