Date of publication: 2017-09-04 15:23
Posterior urethral injury is a contraindication to urethral catheter insertion. Such an injury should be suspected if blood is present at the urethral meatus, in all pelvic fractures, or if a high-riding prostate is found on digital rectal examination.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Alternatively, primary urethral realignment may be attempted at bedside via flexible cystoscopy and guidewire placement. This procedure may eliminate the need for subsequent formal urethroplasty.
Shlomo Raz, MD Professor, Department of Surgery, Division of Urology, University of California, Los Angeles, David Geffen School of Medicine
Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons , American Medical Association , American Urological Association , California Medical Association
Disclosure: Nothing to disclose.
With a more complex injury, contrast material can extend to the thigh, penis, perineum, or into the anterior abdominal wall. Extravasation will reach the scrotum when the superior fascia of the urogenital diaphragm, or the urogenital diaphragm itself, becomes disrupted.
Classic rupture is described as large horizontal tears in the bladder dome. This is the least supported area of the bladder and only portion of the organ covered by peritoneum. In such cases, the mechanism of injury is a sudden large increase in intravesical fluid pressure that overcomes the mechanical strength of the bladder wall. This is more likey to occur at greater bladder volumes, as the detrusor muscle fibers are more widely separated along the thinned and stretched bladder wall, offering a lower resistance to spikes in intravesical fluid pressure.
Aside from iatrogenic injuries, patients with signs and symptoms of bladder injury will likely relay a history typical for pelvic trauma. This is fairly straightforward, and generally includes motor vehicle collisions, deceleration injuries, or assaults to the lower abdomen. If the patient is unconscious, family members or emergency services personnel may be able to provide the history.
Clinical signs of bladder injury are relatively nonspecific. Patients often present with the triad of gross hematuria, suprapubic pain or tenderness, and difficulty urinating or inability to void.
Patients diagnosed with alcoholism and individuals who chronically imbibe a large quantity of fluids are susceptible to idiopathic bladder injury. Previous bladder surgery is a risk factor for such, as areas of scarring are weakened and prone to rupture. In reported cases, all bladder ruptures were This type of injury may result from a combination of bladder overdistention and minor external trauma, such as that from a minor stumble or fall.
Deceleration injuries usually produce both bladder trauma (rupture) and pelvic fractures (which can cause bladder perforation). Accordingly, approximately 65% of patients with pelvic fracture also have significant bladder injury. The propensity of the bladder to sustain injury is positively associated with its degree of distention at the time of trauma. A blunt blow to the abdomen, as with a punch or kick, can rupture the bladder when full similarly, bladder rupture has been documented in children struck in the abdomen by a soccer ball while playing the sport. [ 8 , 9 , 65 ]
Most patients with bladder rupture complain of suprapubic or abdominal pain but many can still void. The ability to urinate does not exclude bladder injury or perforation, however.
Bradley C Gill, MD, MS Chief Resident, Department of Urology, Glickman Urological and Kidney Institute Clinical Instructor of Surgery, Cleveland Clinic Lerner College of Medicine, Education Institute Consulting Staff, Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic
Bradley C Gill, MD, MS is a member of the following medical societies: American College of Surgeons , American Urological Association , International Society of Urology
Disclosure: Nothing to disclose.
Bladder contusion is an incomplete or partial-thickness tear of the bladder. This produces a hematoma within the bladder at the location of injury. Bladder contusion commonly results from blunt trama or extreme physical activity (eg, long-distance running). Patients typically present with gross hematuria. On cystography, the bladder usually appears normal, or it may have a teardrop shape secondary to compression by the hematoma.