68. Urinary
From Primary Surgery
68.1 The general method for an injury of the lower urinary tract
The two sexes injure their lower urinary tracts in different ways. A woman's urinary tract is vulnerable to obstetric disaster, but seldom to trauma, whereas a man may sustain any of the injuries in Fig. 68-1. He can occasionally rupture his bladder into his peritoneal cavity (A). Much more often, he ruptures it extraperitoneally (B). He can also rupture his posterior urethra (C), his membranous urethra (D), his bulbous urethra (E), or his penile urethra (F). His prostatic urethra is protected by his zostate and is seldom injured. Blows to his lower abdomen burst s bladder (A). Fractures of his pelvis cause injuries B, C, and D. Blows to his urethra cause injuries D, E, and F. He may have more than one injury, and combinations of injuries B, and C, are not uncommon. A penetrating wound can injure any part of his urinary tract.
Always explore, repair, and drain a ruptured bladder. Ruptures of the urethra, on the other hand, are often incomplete and may heal themselves if you treat them conservatively, by diverting a patient's urine with a suprapubic cystostomy for three weeks. This will allow him to recover from any other injuries he may have, and give you time to refer him for endoscopy and expert repair, should the rupture of his urethra unfortunately turn out to have been complete. If you cannot refer him, you may have to repair him yourself. Diagnosis is seldom difficult. The important sign in all injuries of the lower urinary tract is that the patient cannot pass urine after an injury. If his bladder bursts into his peritoneal cavity (A), he has the signs of a slowly developing peritonitis. If it bursts extraperitoneally (B), his urine slowly extravasates, and may eventually become infected. With both of these injuries (A, and B) his bladder usually fails to distend, but occasionally it may do, if there is a flap-like injury to its wall. So failure to pass urine after an injury, combined with failure of the bladder to distend, is usually an indication of injuries A or B. In all more distal injuries (C, D, E, and F) the patient's bladder, including its internal sphincter, is intact, so after a few hours it always distends with urine. The combination of retention of urine with a distended bladder is characteristic of all injuries below the bladder neck, and occasionally of those above it. Another critical sign of injury of the lower urinary tract is blood at the patient's external meatus (even a drop is significant) in all urethraj injuries (occasionally in C, and almost always in D, E, and F). His penis, scrotum, and perineum may also be injured. Injuries to a patient's urinary tract are less urgent than some other abdominal catastrophes. If he has a ruptured spleen or liver, he needs an urgent laparotomy, but you have a few hours (never more than 24) in which to explore his ruptured bladder. Most surgeons would agree that you should not try to pass a urethral catheter, because it may introduce infection, and it can be misleading.
A, rupture of the bladder into the peritoneum. B, rupture outside the peritoneum. C, rupture of the posterior urethra. D, rupture of the mem branous urethra. E, rupture of the bulbous urethra. F, rupture of the penile urethra.
CAN THE PATIENT PASS URINE AFTER AN INJURY?
IS THERE BLOOD AT THE TIP OF HIS MEATUS?
IS HIS BLADDER DISTENDING?
THE GENERAL METHOD FOR INJURIES OF THE LOWER URINARY TRACT
This extends Section 51.3 on the care of a severely injured patient. Suspect that a patient may have injured his lower urinary tract if: (1) he has some injury which makes this likely (especially a fractured pelvis), or (2) he cannot pass urine after an accident, or (3) there is blood at the tip of his urethra. CAUTION ! Don't pass a diagnostic catheter up the patient's urethra because: (1) The information it will give you will be unreliable. (2) You may contaminate the haematoma round the injury. (3) You may damage the slender bridge of tissue that joins the two halves of his injured urethra.
IMMEDIATELY AFTER AN INJURY OF THE LOWER URINARY
TRACT
How did the injury occur? This will tell you the kind of injury to suspect. Has the patient passed urine since the accident? If he wants to pass urine, let him try, gently without straining. If he strains, urine will extravasate into his tissues. If he has passed blood-free urine since the accident, his urinary tract has not been seriously injured. If he can pass no urine, or only a little blood stained urine, with frequency and dysuria, his urethra has been injured. If his bladder is distended, you may have to needle it to reduce his distress. Has he ever had even a little bleeding from the external orifice of his urethra? I f necessary, milk his urethra to demonstrate blood at its tip. You will usually find this bleeding if you look for it. It confirms a rupture (complete or partial) of some part of his urethra (injuries D, E, or F, and occasionally B, or C). He needs a suprapubic catheter. The absence of bleeding is of no significance.
Is there a vague swelling in the patient's perineum, scrotum, or upper thigh? Early, this may be due to bruising, later, it may be caused by urine extravasating from injuries C, D, or E.
Is he tender above his pubis? The swelling may be more severe on one side than on the other. It indicates an injury, but not necessarily to his urinary tract. The swelling may be due to bleeding, or to a mixture of blood and urine from injuries B, C, or D.
If he has a perineal haematoma, its size is no guide as to the probability of a urethral injury. Injuries E, and F, always cause a perineal haematoma; C, and D, may do.
Examine him rectally. Feel his prostate. This will not be easy if his pelvis is fractured. He may have so much tenderness and swelling that you cannot feel anything, except perhaps an indefinite doughy swelling (blood and urine) where his prostate should be. You may feel his prostate displaced upwards, floating freely, and running away from your examini ng finger as in Fig. 68-2. if so, he has ruptured his urethra in sites C, or D. The rupture is complete and he needs primary expert repair, or 'railroading', as in Section 68.5 as soon as his general condition permits. A dislocation of the prostate which you can be sure about on rectal examination is rare. This is such a difficult sign that some surgeons consider it valueless.
At the same time feel for a rectal injury. Can you feel a spicule of bone from a fractured pelvis penetrating his rectum? Is there blood on your glove? If so, goto Section 66.15 on rectal injuries.
If the patient's bladder is distended, aspirate it with a needle and look at his urine. if this is blood stained, either his bladder is bruised or ruptured, or the blood may have come from his kidney.
If you have to do a laparatomy for other trauma, you can examine his bladder with his other viscera.
A, rupture of the bladder into the peritoneum. B, rupture outside the peritoneum. C, rupture of the posterior urethra. D, rupture of the mem branous urethra. E, rupture of the bulbous urethra. F, rupture of the penile urethra.
X-RAYS If you suspect that a patient has ruptured his posterior urethra, X-ray his pelvis. A fracture is usually but not always present. The severity of his bony injuries is no indication of the probability of rupture. An IVP is useful to establish a kidney injury, but is not useful for the bladder. You may need it for diagnosis.
SOME HOURS AFTER AN INJURY OF THE LOWER URINARY TRACT
Can you feel the dome of the patient's distended bladder distinct from the rest of the swelling? If his bladder is intact, it will now have had time to distend, and you may be able to feel it. I n the presence of other signs, a distended bladder makes an injury to his urethra (C, D, E, or F) very likely, and a ruptured bladder (A or B) impossible.
CAUTION ! (1) A distended bladder is a useful but not invariable sign in distinguishing ruptures of the urethra inside the pelvis (C, or D) from Intraperitoneal or extraperitoneal rupture of the bladder (A, or B). (2) A bladder can only distend if it has urine to distend with, so make sure you correct the patient's hypovolaemia and dehydration, so that he has some urine to secrete.
FURTHER MANAGEMENT OF AN INJURY OF THE LOWER
URINARY TRACT
Read on for the management of rupture of the bladder (A, and
B), and injuries to the urethra (C, D, E, and F). If you refer a
patient with a suprapubic cystostomy, try to send someone
with him to help him during the journey.
NEVER PASS A DIAGNOSTIC CATHETER IF THERE IS BLOOD AT THE EXTERNAL MEATUS
68.2 Rupture of the bladder
Intraperitoneal rupture
A drunk patient with a distended bladder
staggers in front of a motor vechicle. He receives a blow
to his abdomen which bursts the dome or the posterior surface
of his bladder, and floods his peritoneal cavity with urine (injury
A, in Fig. 68-1). He feels sudden intense pain followed by shock
and fainting. These immediate acute symptoms soon pass; there
is no lower abdominal swelling, and his pain improves temporarily
before signs of peritonitis follow after about 24 hours.
Extraperitoneal rupture
Commonly, a patient is brought
in with multiple injuries, one of which is a fracture of his pelvis
which has ruptured his bladder outside his peritoneal cavity
(injury B). Although he may want to pass urine, all he can produce
is a drop of blood. The broken ends of his pubic bones
have torn the anterior wall of his bladder close to its neck.
Sometimes, his posterior urethra has ruptured also. Blood and
urine fill his prevesical space and track between his peritoneum
and his transversalis fascia. They infiltrate laterally towards his
anterosuperior iliac spines, and down towards his prostate. If
he is not treated, this mixture of blood and urine becomes pus,
which may ultimately discharge through his sacrosciatic notches
into his buttocks, through his obturator foramina into his
thighs, or out through his inguinal canals. There is such
devastating necrosis within his pelvis that he becomes severely
toxaemic and may die.
In the first few hours after the accident, you may not be able to tell if a patient's fractured pelvis has ruptured his bladder, or has merely caused bleeding behind his pubic bones. But, even if his bladder has been ruptured, nothing much happens for the first 24 hours, so you have a day in which to observe him. Don't delay more than 24 hours, and take great care not to infect the injured area by passing a diagnostic catheter meanwhile.
You can usually tell quite easily if a patient's bladder has ruptured inside or outside his peritoneum from: (1) The history of the injury-a blow to his abdomen suggests rupture inside the peritoneum, whereas a fractured pelvis suggests rupture out - side it. (2) The distribution of the tenderness-in extraperitoneal rupture this is narrowly localised suprapubically, in intraperitoneal rupture it is more diffuse over his lower abdomen and ends in obvious peritonitis.
If you are in doubt, there are twoinvestigations that may confirm that his bladder has ruptured, and show you where it has ruptured, but they are usually not necessary: (1) You can do a retrograde cystogram. Unfortunately, this requires the use of a catheter, and with it the risk of infection. (2) You can do an intravenous pyelogram, which is safer but less reliable.
You will be wiser to wait a few hours to confirm the diagnosis, rather than to operate unnecessarily and find only a haematoma which bleeds profusely or even disastrously when you open it. If you have to do an immediate laparotomy for other reasons, say for a suspected rupture of the patient's spleen, you can easily examine his bladder at the same time.
If you diagnose any kind of rupture of the bladder, you will have to refer the patient urgently, or operate. A lower midline incision will bring you into his prevesical space outside his toneum just above his pubis. If this is full of urine and blood, his bladder has ruptured extraperitoneally. If it is normal, open his peritoneal cavity. If it contains blood and urine, his bladder has ruptured into it. The easiest way to find a tear is to open his bladder, put a finger into it, and feel for the tear. If an extraperitoneal rupture is large and easy to reach, it should not be too difficult to suture. But if the tear is difficult to get at, leave it, insert a suprapubic Foley catheter into his bladder and let it drain. An intraperitoneal rupture is usually larger, so always suture it and insert a suprapubic catheter drain.
Be sure to close a patient's bladder mucosa with catgut. If you use any other sutures, they may form a focus for the formation of stones. If his bladder has ruptured extraperitoneally, be sure to drain his prevesical space adequately.
