Methodological Instructions to Lesson № 13 for Students
Theme: Injuries to the bladder and urethra.
Site: Classroom, hospital ward, X-ray cabinet, operating room, casuality ward, hospital
ward, dressing room, cystoscopic room.
Aim: To study symptoms and principles of treatment injuries to the bladder and urethra.
Professional Motivation:
Lately as a result of increasing of accidents and urbanization we have augmentation of
injuries of the organs of genitourinary tract. Indirect ("contrecoup") injury, caused by falling
from a height and landing on the feet or buttocks, is less common. Rarely acute abdominal
muscle contraction have caused a hydronephrotic kidney to burst.
Basic Level:
1. Anatomy and physiology of urinary tract.
2. To take history and physical examination.
3. X-Ray, instrumental, laboratory, endoscopic methods in injuries of kidneys and ureter
diagnosis.
4. Conservative measures of etiologic, pathogenetic and symptomatic treatment; different
kinds of surgical treatment.
Students' Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. General clinical symptoms of the bladder and urethra injuries.
The urinary bladder may be injured by external forces: during surgery, including accidental
incision in pelvic surgery or in the repair of hernia; and in transurethral manipulations. An injury
or blow to the lower abdomen followed by low abdominal pain and hematuria is strongly
suggestive of vesical injury. Fracture of the pelvis is commonly accompained by injury to the
bladder. The finding of suprapubic tenderness or a mass is suggestive; signs of peritonitis may be
elicited. If the patient can urinate hematuria is to be expected, but he may not be able to urinate
at all. Pain is present low in the abdomen. Pain in the shoulder may be noted if there is urine in
the abdominal cavity. Shock may be profound, especially if multiply injuries have been suffered.
There may be evidence of local trauma such as a bullet or knife wound or ecchymosis. Marked
tenderness in the suprapubic area is to be expected. There may be rebound tenderness if the
laceration involves the peritoneum. Spasms of the muscles of the lower abdomen occurs even
though the extravasation is perivesical. A board-like abdomen suggests intraperitoneal rupture.
The skin over the symphysis commonly becomes quite cool immediately after extraperitoneal
rupture occurs. A large suprabubic mass may be felt or percussed as the perivesical collection of
fluid develops. This will contain blood, urine and sometimes pus. Rectal examination may revael
a large boggy mass obliterating the normal landmarks. Evidence of other injuries is usually
present. If urethra is injured urethral bleeding may be noted. A history of injury, usually severe,
is always obtained. Pain is present in the peritoneum or low in the abdomen. The patient may be
unable to void. Urethral bleeding or hematuria is present. There may be a mass in the suprapubic
area. The area may be dull to percussion. Suprapubic tenderness may be marked. This may be
due to extravasation or to a fracture with associated hematoma. Rectal examination may reveal a
large boggy mass of extravasated blood or urine.
2. Diagnosis of the bladder and urethra injuries. In case of the bladder injury the
hematocrit may demonstrate anemia from loss of blood or hemoconcentration from shock. The
white blood count and neutrophils are increased.
Urinalysis hematuria, either gross or microscopic. The presence of bacteria means
infectoin, either preexisting or new. If a significant amount of urine escapes into the peritoneal
cavity, the serum BUN:creatinine ratio is significantly insreased. A plain film may reveal
fractures of the pelvic bones. Increased grayness from from a perivesical collection of urine and
blood may be seen. A cystogram is the most dependable test for vesical injury. Instill 350-400 ml
ofradiopaque fluid and take anteroposterior and oblique films. Then drain the vesical contents
and take another film. This may reveal small amounts of extravasated fluid lying behind the
bladder or in the cul-de-sac. X-Ray findings with radiopaque fluid are useful to show the site of
extravasation in case of urethra injury. 3. Indications for the consrevative and surgical treatment
of the injuries to the bladder and urethra.
Emergency measures are to treat shock and hemorrhage. If the rupture of the bladder is
extraperitoneal, the site of the injury should be drained surgically. Urologists as a rule favor
suprapubic cystostomy as a more reliable method than catheterization for keeping the bladder
empty and at rest. The peritoneum should be opened and intraperitoneal organs explored for
associated injury. If there is evidence of a fractured pelvis and massive hemorrhage, a
transfemoral iliac angiogram should be done to seek the site of the bleeding. In case of urethral
rupture if a wethral catheter of adequate size can be passed to the bladder, it should be left in
place for 14-21 days. Simple lacerations usually heal well with only this splinting. If a catheter
cannot be passed to the bladder, surgical intervention is imperative.
Conservative therapy is effective for patients with recent nonpenetrating damage of
urethra: rest, cool compression, antibiotics. Within 7-8 days after trauma thermal procedures and
resorption agents are prescribed. In case of ischuria instead of a high cystotomy it is possible to
perform troacar epicystostomy.
In case of fractures of pelvic bones with rupture of urethra patients often are in shock state.
After removing such state the operation is immediately performed: abduction of urine is
provided to prevent its flow and to reduce suffering of the patient, and urethra is restored. If
condition of the patient is very serious, it is necessary to limit operation with abduction of urine
through suprapubic urethrovesical fistula. In case of early hospitalization (within 6 hours from
the moment of trauma), insignificant fractures of pelvic bones or absence of those and massive
urohematomas it is expedient to perform primary urethrourethroanastomosis, i. e. urethra
connection after incision of damaged edges of rupture from perineal access. After that additional
measures are necessary concerning treatment of pelvic fractures and prophylaxis of connected
with them complications.
The primary plastics of urethra has advantage over its restore in late terms. Due to a
primary plasty the duration of hospitaization of the patient is reduced, there's no necessity
bougieurage of urethra, as after some kinds of urethro plasty. In a case of urine flow and signs of
infection, which are observed in case of late hospitalization, the primary plasty is impossible.
Urine is evacuated through suprapubic fistula of urinary bladder with insertion of two synthetic
tubes through suprapubic dissecting for a constant irrigation of urinary bladder with antiseptic
solution. Urinary flows are drainaged. Urethral conduction is restored after improvement of
general patient condition. In late terms epicystostomia is performed, urinary flows are dissected
and drainaged. If not only urethra, but also a rectum is injured, two-canal fistula of sygmoidal
colon is created. In case of separation of urethra from neck of urinary bladder, serious combined
damage it is necessary to limit operation with suprapubic fistula and drainage of paravesical
space. Restoring operation is performed after some period of time.
Key words and phrases: injuries to the bladder and urethra, intraperitoneal rupture,
fractured pelvis, surgical and conservative measures of the treatment.
II. Tests and Assignments for Self-assesment:
Multiply choice. Choose the correct answer/statement:
1. What disease may be found by Zeidovich test?
A. Rupture of the bladder.
B. Rupture of the liver.
C. Rupture of the urethra.
D. Rupture of the kidney.
E. Rupture of the ureter.
Real life situations to be solved.
2. Patient K., 34 years old, crashed by car. At the causality ward fracture of the pelvis was
found. Urethrorrhage. What is the previous diagnosis? What methods of examination is indicated
in this case?
Labour 1. Prove and formulate clinical diagnosis. Student takes complains, disease and
life history of the patient, physical examination, detects main clinical signs of the ruptures of the
bladder, forms diagnostic program, formulates diagnosis.
Questions for the student:
1. What are the clinical symptoms of the ruptures of the bladder?
2. What are the methods of examination of the patients with the ruptures of the bladder?
3. What is the medical tactics in the patients with the ruptures of the bladder?
Labour 2. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination,
detects main clinical signs of the ruptures of urethra, forms diagnostic programme, formulates
diagnosis.
Questions for the student:
4. What are the clinical symptoms of the ruptures of urethra?
5. What are the methods of examination of the patients with the ruptures of urethra?
6. What is the medical tactics in the patients with the ruptures of urethra?
III. Answers to the Self-Assesment:
1-A.
2 – suspitio on the fracture of the urethra; retrograde urethrocystograohy.
Visual aids and material tools:
I. Roentgenograms:
1. 1 Retrograde cystography — intraabdominal rupture of the bladder.
1. 2 Retrograde cystography – extraabdominal rupture of the bladder.
1. 3 Retrograde urethrography – rupture of the urethra.
Students Practical Activities:
Student must know:
1. Classification of injuries to the bladder.
2. Symptoms and clinical course of the injuries to the bladder.
3. Diagnosis of the injuries to the bladder.
4. Differential diagnosis of the injuries to the bladder.
5. Conservative treatment of the bladder injuries.
6. Surgical treatment of the bladder injuries.
7. Symptoms and clinical course of the urethra injuries.
8. Diagnosis of the urethra injuries.
9. Differential diagnosis of the urethra injuries.
10. Principles of treatment of the urethra injuries.
Students should be able to:
1. Detect main clinical signs of the injuries to the bladder and urethra.
2. Define necessary quantity and sequence of patients examination: physical, laboratory,
roentgenological, endovesical.
3. Should be able to detect signs of the injuries to the bladder and urethra on cystograms,
urethrograms etc.
4. Form diagnostic program for the patient with the injuries to the bladder and urethra.
5. Prove and formulate clinical diagnosis.
6. Spend differential diagnosis.
7. Prove conservative treatment and indications for the surgical treatment.