Bladder Trauma

Ureteral Trauma

Pathogenesis

In the abdomen the ureters are protected by the spine and the paravertebral muscles while the bony pelvis protects the lower ureter. Usually the ureter is damaged as a result of penetrating trauma. Injuires may also occur as a result of severe flexion of the torso and rapid decelaration. Hematuria is rarely seen with ureteric injuries.

Diagnosis

These injuries are best evaluated by an abdominal CT scan with intravenous contrast.

Management

Traumatic avulsions are best repaired immediately. Partial tears are usually repaired, but they could be managed nonoperatively.

Incidence

The bladder is usually protected by the bony pelvis in older children and adults. It is an abdominal organ in infants and toddlers and also when it is distended. Under these conditions it is not well protected. Bladder rupture occurs in 10-15% of patients with pelvic fractures. It also ruptures as a result of direct trauma when it is full.

Presentation

Patients usually present with diffuse lower abdominal pain and tenderness and also microscopic hematuria.

Diagnosis

Bladder injuries are diagnosed by cystography.

Note! If blood is noted at the urinary meatus, urethral injury must be ruled out with a retrograde urethrogram (RUG) before inserting a catheter for the cystogram.

An appropriate cystogram for trauma requires that the bladder be filled to capacity, emptied and washed out to look for extravasated contrast. Films must be taken in the anteroposterior, lateral and both oblique alignments.

Capacity of the bladder at various ages can be calculated by the following formulae:

· Bladder capacity in an infant in mL

= 38 + [2,5 x age in months]

· Bladder capacity in the older child in mL

= [age in years + 2] x 30

Management

Extraperitoneal bladder rupture is managed by an indwelling catheter.

The cystogram is repeated in 7 to 10 days. The catheter can be removed if no extravasation is seen. If contrast still extravasates, the catheter is left in place for another week.

Upon repeat cystography at that time, the bladder is invariably healed.

If a laparotomy is performed for other intra-abdominal and pelvic injuries, the bladder can be debrided and repaired primarily.

Intraperitoneal bladder rupture requires laparotomy. Intraperitoneal urine is rapidly absorbed leading to azotemia and acidosis. After primary repair an indwelling urethral catheter is left for 7 to 10 days, when a cystogram is done.

The catheter can be removed if the cystogram demonstrates no leak.

Дата добавления: 2014-10-15