Bladder, urethra and genital Injuries

Classification

• Intraperitoneal (50%) – direct blow or sudden increase in abdominal pressure
• Extraperitoneal (40%) – usually form a pelvic fracture
• Combined.

Background

• RTCs and falls from height cause most bladder injuries.
• 75% of patients with bladder injuries have a pelvic fracture
• 55% of patients with a bladder injury have abdominal injuries.
• 13% of patients with a bladder injury will have a urethral injury
• 4% of patients with pelvic fractures will have a bladder injury.

Imaging

• Perform a CT cystogram in the following scenarios:
• Frank Haematuria and any Pelvic fracture
• Microscopic haematuria with
  
  • >1cm displacement disruption of the pelvic ring or
  • >1cm pubic symphysis diastasis
• Inability to void or inadequate urine output
• Abdominal tenderness or distension due to urinary ascites or signs of urinary ascites on imaging
• Uraemia and elevated creatinine due to intraperitoneal reabsorption
• Suspected penetrating traua.

Cystography must be performed using 400-500ml of dilute contrast (50/50) to fill the bladder.

Management

Conservative:

Extraperitoneal injuries are often managed conservatively with a urinary catheter and antibiotic prophylaxis.

Surgery:

Surgery should be performed in the following patients:

• Extraperitoneal Injuries AND:
  • Bladder neck involvement
  • Bone fragment in bladder wall
  • Rectal or vaginal injury
  • Entrapment of the bladder wall
  • Patients undergoing ORIF for a pelvic fracture
  • Patients undergoing a laparotomy for other injuries
• All intraperitoneal injuries
• All penetrating injuries (unless minor and isolated extraperitoneal).

Follow-up

Perform cystography in patients 10-14 days after injury.

Types

• Posterior male urethral injuries are usually caused as a result of pelvic fracture.
• Anterior male urethral injuries are usually as a result of straddle injury, RTC perineal injury or penile fracture
• Female urethral injuries are usually from pelvic fractures associated with vaginal lacerations.

Signs

• Blood at urethral meatus
• Urinary retention
• Haematuria
• Dysuria
• Scrotal/penile/perineal/labial swelling & bruising
• Inability/difficulty to catheterise.

Surgery

Surgery is indicated immediately in penetrating urethral injuries and in injuries involving the bladder neck, the rectum or bony fragment impingement on the urethra.

The European Association of Urology has published guidelines on bladder, urethra and genital injuries (click here)

Usually occur as a result of blunt, penetrating and sporting injuries.

Assessment

Penile injuries

• A fractured penis requires surgical repair
• Penetrating injuries required debridement/soft tissue cover
• Amputations should be saline washed and saline gauze wrapped in a plastic bag on ice for surgery within 24 hours.

Scrotal Injuries

• Look for testicular dislocation which requires replacement & orchidopexy
• An expanding haematocoele may requires surgery
• Pain, nausea, vomiting, tender, bruised & swollen may suggest rupture which often requires surgery
• Explore all penetrating scrotal injuries and administer antibiotics.

Vaginal Injuries

• Suture lacerations under local anaesthetic.
• Vulvar injuries require exploration under GA and cystoscopy to exclude urethral injury.