Lower Urinary Tract

Trauma
dr.Agung P N, Sp.U
Injuries to the bladder
1
Etiology
Bladder injuries occur
most often from external
force and are often
associated with pelvic
fractures
Iatrogenic injury may
result from gynecologic and
other extensive pelvic
procedures as well as from
hernia repairs and
transurethral operations.
2
Mechanism of vesical injury
A direct blow over the full
bladder causes increased
intravesical pressure.
If the bladder ruptures, it will
usually rupture into the
peritoneal cavity.
3
Pathogenesis and Pathology

Bladder When the pelvis is fractured by

Injuries blunt trauma, fragments from
the fracture site may perforate
the bladder. These perforations
usually result in extraperitoneal
rupture.
If the urine is infected,
Intraperitoneal Extraperitoneal extraperitoneal bladder
perforations may leads to 
deep pelvic abscess and severe
pelvic inflammation.
4
Pathogenesis and Pathology

Bladder When the bladder is filled to near

Injuries
capacity, a direct blow to the lower
abdomen may result in bladder
disruption. This type of disruption
is ordinarily intraperitoneal. Since
the reflection of the pelvic
peritoneum covers the dome of the
Intraperitoneal Extraperitoneal
bladder, a linear laceration will
allow urine to flow into the
abdominal cavity.
 5

Clinical Findings
90% of cases  Pelvic fracture accompanies bladder rupture
The diagnosis of pelvic fracture can be made initially in the emergency
room by lateral compression on the bony pelvis, the fracture site will show
crepitus and be painful to the touch.

SYMPTOMS

Blunt Injury, Pelvic or Spontaneous

Lower lower Unable to voiding
Abdominal abdominal urinate gross
Trauma pain hematuria (+)
6
Clinical Findings
Signs
A large pelvic
Marked
Heavy bleeding Acute abdomen hematoma 
tenderness of
+ Pelvic fracture may occur with indistinct
the suprapubic
 Hemorrhagic Intraperitoneal landmarks of
area and lower
shock bladder rupture rectal
abdomen.
examination

Laboratory Findings

- Catheterization usually is required in patients with pelvic trauma but not if bloody urethral
discharge is noted (urethral injury) urethrogram is needed before catheterization..
- Urine taken from the bladder at the initial catheterization should be cultured to determine
whether infection is present.
 7

Clinical Findings
X-ray Findings
Plain abdominal film

• Pelvic fracture
• Haziness over lower abdomen from blood and urine extravasation

CT Scan
• Kidney and ureteral injuries detection

Cystography

• Bladder disruption

CT Cystography
8 X-ray findings

Extraperitoneal bladder rupture. Intraperitoneal bladder rupture.

Extravasation (arrow) seen outside the Cystogram shows contrast surrounding
bladder in the pelvis on cystogram. loops of bowel.
 9

Complications
• Pelvic abscess  may develop from extraperitoneal bladder
rupture; if the urine becomes infected, the pelvic hematoma
becomes infected too.

• Intraperitoneal bladder rupture with extravasation of urine into

the abdominal cavity causes delayed peritonitis.

• Partial incontinence  may result from bladder injury when the

laceration extends into the bladder neck.
Meticulous repair may ensure normal urinary control.
 10

Treatment
A. Emergency Measures
Shock and hemorrhage should be treated

B. Surgical Measures
- Entering the pelvic hematoma can result in increased
bleeding from release of tamponade and in infection of the
hematoma, with subsequent pelvic abscess.
- The bladder should be opened in the midline and carefully
inspected.
- After repair, a suprapubic cystostomy tube is usually left in
place to ensure complete urinary drainage and control of
bleeding
 11

Treatment
1. Extraperitoneal bladder rupture

Extraperitoneal bladder rupture can be managed with

urethral catheter drainage only (typically 10 days of healing
time.)

Large blood clots in the bladder or injuries involving the

bladder neck should be managed surgically.

Such injuries are best managed with indwelling urethral

catheterization and suprapubic diversion.
 12

2. Intraperitoneal rupture

- Intraperitoneal bladder ruptures should be repaired via a

transperitoneal approach after careful transvesical inspection and
closure of any other perforations.

- The bladder is then closed in separate layers by absorbable

suture.

- All extravasated fluid from the peritoneal cavity should be

removed before closure. At the time of closure, care should be
taken that the suprapubic cystostomy is in the extraperitoneal
position.
 13

3. Pelvic fracture

- In such cases, the patient can be ambulatory within 4–5

days without damage or difficulty.

- Unstable pelvic fractures requiring external fixation have a

more protracted course.
 16

4. Pelvic hematoma

- There may be heavy uncontrolled bleeding from rupture of pelvic

vessels even if the hematoma has not been entered at operation.

- If bleeding persists, it may be necessary to leave the tapes in

place for 24 hours and operate again to remove them.

- Embolization of pelvic vessels with Gelfoam or skeletal muscle

under angiographic control is useful in controlling persistent pelvic
bleeding
 14

Prognosis
- With appropriate treatment, the prognosis is excellent.
- The suprapubic cystostomy tube can be removed
within 10 days, and the patient can usually void
normally.
- Patients with lacerations extending into the bladder
neck area may be temporarily incontinent, but full
control is usually regained.
LOWER URINARY TRACT (URETHRA) :

URETHRA ANTERIOR
Etiology
Stradle
injury 
laceration
or
contusion
urethra

Self
instrument
ation or
iatrogenic
 partial
disruption
Figure: Injury to the bulbous urethtra
Left: usually a perineal blow or fall astride an object;
crushing of urethra against inferior edge of pubic
symphysis
Right: extravasation of blood and urine enclosed within
colles’s fascia
 Pathogenesis and Pathology
• A sign of crush injury without
Confusion urethral disruption.
• Perineal hematoma usually resolves
without complication.

• A severe injury may result in laceration,

allowing extravasatin of urine  extend
to scrotum, along the penile shaft and
Penetration up to the abdominal wall.
• It is limited by colles’ fascia and often
result in sepsis, infection and serious
morbility
 Signs and Symptoms
Bleeding from the urethra
Local pain into the perineum and something massive perineal
hematom.
Perineum is very tender
A mass may be found, as may blood at the urethral meatus
Massive urinary extravasation and infection in the perineum
and scrotum.
The lower abdominal wall may also be invlved.

The skin usually swollen and discolored

Laboratory X-Ray
Findings Findings
Blood is not usually
excessive, particularly if A urethrogram,
secondary injury has with instillation of
occured 15-20 mL if water
soluble contrast
material,
White count may demonstrate
extravasation
be eleveted with and the location
infection. of injury
Figure:
Ruptured bulbar urethra following strader injury
Extravasation on urethrogram
Complication

Heavy bleeding from

the corpus spongiosum

Sepsis and infection

Stricture at the site of

injury
 Treatment
General Measures
• Major blood usually doesn’t accur from straddle injury if
heavy bleeding does occur, local pressure for control,
followed by resucitation is required.
Spesific Measures
• Urethral contusion
• Urethral Lacertaion
• Urthral laceration with extensive urinary extravasation
• Immediate repair
Treatment of Complication

Stricture at the
site of injury
may be
extensive and
required delayed
reconstruction
INJURIES TO THE
POSTERIOR URETHRA
INJURIES TO THE URETHRA
• Men > Women
• Associated with pelvic fractures or straddle type Falls.
• Various parts of the urethra may be lacerated, transected, or
contused.
• Management varies according to the level of injury.
• The urethra can be separated into 2 broad anatomic divisions:
- the posterior urethra, : prostatic and membranous portions
- the anterior urethra : bulbous and pendulous portions.
 30

Males: urethra has three

regions (see right)
_________trigone

1. Prostatic urethra__________
2. Membranous urethra____

3. Spongy or penile urethra_____ female

ETIOLOGY
• The membranous urethra passes through the pelvic floor
and voluntary urinary sphincter and is the portion of the
posterior urethra most likely to be injured.
• Pelvic fractures  the membranous urethra is sheared
from the prostatic apex at the prostatomembranous
junction.
ETIOLOGY
 SIGN
• Blood at the urethral meatus
• Suprapubic tenderness and the presence of pelvic fracture .
• A large developing pelvic hematoma may be palpated.
• Perineal or suprapubic contusions.
• Rectal examination : a large pelvic hematoma with the
prostate displaced superiorly.
• Note : Superior displacement of the prostate does not occur
if the puboprostatic ligaments remain intact.
 X-RAYS FINDINGS
• Fractures of the bony pelvis
are usually present.

• A urethrogram shows the

site of extravasation at the
prostatomembranous
junction
• there is free extravasation
of contrast material into the
perivesical space
INSTRUMENTAL EXAMINATION
• The only instrumentation involved should be for
urethrography.

• Catheterization or urethroscopy  pose an increased risk

of hematoma, infection, and further damage to partial
urethral disruptions.
DIFFERENTIAL DIAGNOSIS

Bladder rupture may be But Cystography

associated with posterior cannot be done Careful evaluation of
urethral injuries in preoperatively, since a the bladder at
approximately 20% of urethral catheter should operation is necessary.
cases not be passed.
COMPLICATIONS
• Stricture : the incidence of stricture can be reduced to
about 5%  suprapubic cystostomy approach with
delayed repair is used.

• Impotence : The incidence of impotence after primary

repair is 30– 80%.

• Incontinence
TREATMENT
• Shock and hemmorhage
Emergency should be treated !
Measure
• Immediate management
Surgical • Delayed urethral reconstruction
Measure • Immediate urethral realignment
INITIAL MANAGEMENT
• consist of suprapubic cystostomy to provide urinary drainage.

• The bladder should be opened in the midline + inspected for

lacerations.

• If a laceration is present, the bladder should be closed with

absorbable suture material and a cystostomy tube inserted for
urinary

• The cystostomy tube should not be removed before voiding

cystourethrography shows that no extravasation persists.
DELAYED URETHRAL
RECONSTRUCTION
• Reconstruction of the urethra
after prostatic disruption can be
undertaken within 3 months,
assuming there is no pelvic
abscess or other evidence of
persistent pelvic infection.
• Before reconstruction, a
combined cystogram and
urethrogram should be done to
determine the exact length of the
resulting urethral stricture.
IMMEDIATE URETHRAL
REALIGNMENT
• Some surgeons prefer to realign the urethra immediately.
Persistent bleeding and surrounding hematoma create
technical problems.

• The incidence of stricture, impotence, and incontinence

appears to be higher than with immediate cystostomy and
delayed reconstruction.
PROGNOSIS
• If complications can be avoided, the prognosis is
excellent.
• Urinary infections ultimately resolve with appropriate
management
THANKS!
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