Bladder, urethral & genital injuries

Classification

1. Intraperitoneal (50%) – direct blow or sudden
   increase in abdominal pressure
2. Extraperitoneal (40%) – usually form a pelvic fracture
3. 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 trauma

Cystography must be performed using 300-350ml of dilute contrast 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:

1. 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 
2. All intraperitoneal injuries
3. All penetrating injuries (unless minor and isolated extraperitoneal)

Follow-up

Perform cystography in patients managed conservatively 10 days after injury

Patients who underwent surgery can have the catheter removed after 5-10 days without the need for cystography unless complex injury or risk of impaired healing

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.

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

Assessment

• Male + haematuria Perform retrograde urethrogram
• Female+ haematuria Perform cystoscopy
• Female + blood in vagina Speculum examination 

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
• A haematocoele 3x size of other testicle requires surgery
• Pain, nausea, vomiting, tender, bruised & swollen may suggest rupture which often requires surgery due to poor sensitivity of USS doppler
• 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