Bladder injury — the violation of integrity of a wall of body caused by a mechanical trauma, influence of chemicals is rare – urine pressure at some diseases. It is shown by the belly-ache, a swelling and cyanosis of skin over a bosom which are speeded up by false desires to an urination, decrease or absence of a diuresis, a makrogematuriya, dribble of urine from a wound opening, increase of symptomatology of traumatic shock. It is diagnosed by means of a retrograde tsistografiya, a kateterization, ultrasonography, KT, MPT of a bladder, the general analysis of urine, a laparoscopy. In mild cases perhaps conservative maintaining with installation of a catheter, at vnutribryushinny and large vnebryushinny gaps is carried out reconstructive plasticity of body.
In structure of the general traumatism mechanical injuries of a bladder make from 0,4 to 15% (in Russia — from 1 to 7%). In recent years more frequent traumatizing body is noted that it is connected with strengthening of intensity of transport connection, wear of vehicle fleet, increase in number of heavy technogenic catastrophes and the local military conflicts. The peak of a travmatization is observed at 21-50-year age, about 75% of victims — men. Feature of injuries is mainly combined nature of defeat (in 100% of open wounds and in 85% of stupid injuries except a bladder basin bones, a backbone, other bodies are injured). Relevance of timely diagnostics and the emergency medical actions is caused by the adverse forecast – according to rating scales of 31,4% of victims belong to the category of heavy, 49,2% — extremely heavy patients, death rate exceeds 25%.
Bladder injury reasons
At most of patients traumatic injury of a bladder is connected with impact on its wall of external mechanical factors of various origin. In rare instances the trauma is caused by influence of the aggressive chemicals installed in a bladder or existence of the diseases interfering an urination. Are the reasons of injuries:
- Road accidents. More than in a quarter of cases the bladder is injured during road accident. Damage arises at direct stroke in a projection of body, a strong sdavleniye in the vehicle, wound splinters of pelvic bones, structural elements of the car, environment objects.
- Yatrogenny factors. 22-23% of patients are traumatized during medical manipulations. The wall of body can be damaged at its kateterization, an urethra buzhirovaniye, performance of operations — transurethral interventions, Cesarean section, an extirpation of a uterus, a miomektomiya, adenomektomiya, resection of a thick gut, etc.
- Household and operational injuries. In 10% of cases damage happens because of falling from height on a firm subject. In the presence of prerequisites (overflow by urine, cicatricial changes, etc.) the rupture of body because of sharp concussion of a body at a jump is possible. At 4,2% of victims the trauma arises under the influence of production factors.
- Violent acts. Integrity of a bladder can be broken at stupid blows in a stomach, wound by a knife or other sharp objects in fights, at criminal abortions. In wartime by 3-4 times the quantity of fire injuries and open wounds of body splinters of explosive ammunition increases.
- Urological diseases. Extremely seldom spontaneous rupture of a bladder is noted at patients who have the diseases breaking an urination — adenoma and a prostate cancer, a stenosis of an urovezikalny neck, an urethra strikturama. More often urological pathology plays a role of the contributing factor, strengthening stretching of body.
The risk of emergence of the heaviest damages — partial or complete separations — depends not only at most traumatic influence, but also on the place of its appendix, the direction, suddenness. The probability of getting injured significantly increases at alcoholic intoxication which promotes overflow of a bladder because of obtusion of desires to an urination and provokes injury-causing behavior. The assuming factors are also tumoral defeats, fibrous changes of a wall of body after the undergone operations, radiation therapy, inflammatory diseases.
The mechanism of an injury of bladder depends on type of the factors which caused damage. At stupid blow to the nadlobkovy area, antiblow about a sacrum, sdavleniya vnutripuzyrny pressure sharply increases, load of a mochepuzyrny wall amplifies. Emergence of hydrodynamic effect promotes a vnutribryushinny rupture of body on the site of the least developed muscles (usually on a back wall of a bubble near its top). The wound is usually fragmentary, deckle-edged. With the smaller force of mechanical influence the blow causes the closed damages (bruises, hemorrhages in a wall). The similar pathogenesis is characteristic in the presence of urological diseases with violation of a passage of urine.
Considerable shift of a bubble at mechanical injuries leads to a sharp tension of the supporting side and puzyrno-pro-static sheaves with a vnebryushinny rupture of a soft and elastic wall of body. The strong blow is capable to cause a rupture of sheaves, mochepuzyrny blood vessels, a neck separation. At the closed and open damages of vezikalny covers by sharp objects, tools, splinters of bones there is a superficial, deep nadsecheniye or a through section of a wall. Wound at the same time usually linear. The combination to hydrodynamic blow at gunshot and splintered wounds leads to additional radial anguishes of a round wound opening.
Criteria of systematization of traumatic damages are severity, the possible message with the environment, a gap arrangement in relation to a peritoneum, a combination to injuries of other bodies. Such approach allows to predict the course of pathological process and probable complications, to choose optimum tactics of maintaining the patient. Depending on weight of damage of a mochepuzyrny wall of a trauma can be deafs (a bruise, superficial wound of an external cover, an anguish mucous) or through (a complete separation, a neck separation). In turn, through damages divide into three groups:
- Intraperitonealny gaps. Are observed more than at 60% of victims. Are usually caused by direct strokes in the crowded bladder. Because of the expiration of urine in an abdominal cavity quickly are complicated by peritonitis.
- Ekstraperitonealny gaps. Arise in 28% of cases. Are more often provoked by an excess tension of the supporting copular device. The injured bladder is not reported with an abdominal cavity, urine expires in a small pelvis.
- The combined gaps. Are observed at 10% of victims. Multiple damage of a wall of body is usually combined with fractures of pelvic bones. The message between a bladder, belly and pelvic cavities causes special weight of pathology.
To 90% of injuries of peace time are closed, thanks to preservation of integrity of skin the injured bladder is not reported with the external environment. During the military period, at violent acts with use cold and firearms the frequency of open injuries at which integrity of skin is broken increases, there is a message between covers or a cavity of body and the environment. On observations of experts in spheres of traumatology and urology, the combined damages prevail over isolated. At 40-42% of patients fractures of bones of a basin, at 4-10% — ruptures of intestines, at 8-10% — injuries of other internals come to light.
Bladder injury symptoms
Important clinical feature of this damage — frequent prevalence of the general symptomatology over local. Because of the expressed pain syndrome and bleeding at victims signs of haemo dynamic violations accrue, at 20,3% traumatic shock is observed: level HELL decreases, heart rate accelerates, integuments turn pale, become covered sticky cold then, there is a weakness, dizziness, an oglushennost, confusion, and then and consciousness loss. Because of irritation of a peritoneum patients with intraperitonealny gaps feel as urine intensive pain in nadlonny area, in the lower part of an abdominal cavity which extends to all stomach subsequently, is followed by nausea, vomiting, a delay of gases and a chair, tension of belly muscles.
Specific symptoms of a trauma of a mochepuzyrny wall — pain and local changes of field of damage, a dizuriya. At open wounds on a forward wall of a stomach, is more rare — in a zone of a crotch the gaping wound from which urine can expire comes to light. Formation of a painful swelling over a pubis, in a groin, cyanotic color of integuments because of their treatment by blood is characteristic of the closed vnebryushinny injuries. Victims test frequent false desires to an urination with considerable reduction or total absence of a diuresis, allocation of drops of blood from an urethral opening. At preservation of urination at patients with anguishes mucous urine is painted by blood.
The lethality at the traumatic injuries of a bladder especially open and combined, reaches 25% and more. Usually the started peritonitis forms, painful, infectious and toxic, hemorrhagic shock, sepsis are causes of death. Through injuries of a wall of a bladder quickly are complicated by involvement in process of other bodies. Anatomic features of paravezikalny, zabryushinny cellulose, fastsialny spaces promote uric infiltration, distribution of zatek, education urogematy. At a vnutribryushinny gap arises uroastsit. Secondary infection leads to formation of abscesses, phlegmons. At 28,3% of patients uric peritonitis, at 8,1% — develops. The ascending spread of an infection provokes the beginning of sharp pyelonephritis. In 30% of cases at a bubble trauma combination to damages of other bodies the DVS-syndrome is observed. In the remote period at patients uric fistulas are sometimes formed, the urine incontience is observed.
Taking into account gravity of the forecast to all patients with suspicion of an injury of a bladder appoint the comprehensive examination allowing to reveal ruptures of a mochepuzyrny wall, to define their features and quantity, to find possible damage of adjacent bodies. The recommended methods of laboratory and tool diagnostics are:
- General analysis of urine. The research manages to be conducted only at the kept urination. The volume of a single portion is often reduced. At the analysis in a large number there are erythrocytes confirming existence of bleeding.
- Ultrasonography of a bladder. The body is usually reduced in volume, near it blood congestions are defined. A research supplement ultrasonography of kidneys when which carrying out signs of postrenalny violation of outflow of urine, and ultrasonography of an abdominal cavity for identification of free liquid are found.
- Retrograde tsistografiya. It is considered "the gold standard" of diagnostics of this type of injuries. Ruptures of body are shown by zateka of X-ray contrast substance in a puzyrno-pryamokishechny pole, okolopuzyrny cellulose, area of wings of a podvzdoshny bone, a peritoneum cavity.
- Bladder tomography. By means of KT it is possible to receive the three-dimensional image of the damaged body, during MRT it is studied layer-by-layer. Results of a tomography allow to estimate precisely damages, volume urogematy, to reveal the combined injuries.
- Diagnostic laparoscopy. Survey of a bladder through gives the chance to define features of the injured wall, to find flow urine, blood. When performing a research damages of the next bodies are visualized.
Great diagnostic value is played by the bladder kateterization added with injection of liquid in it (Zeldovich's test). Existence of gaps is demonstrated by lack of urination through a catheter or receipt of a small amount of urine with blood. The liquid entered into the injured body is back emitted with a weak stream and not in full. At intraperitonealny gaps liquids, perhaps otkhozhdeny by 2-3 times of bigger volume, that is caused by penetration of a catheter into an abdominal cavity and release of the urine which earlier got to it.
The excretory urography is appointed with care not to provoke development contrast - the induced nephropathy against the background of shock changes of haemo dynamics. Tsistoskopiya usually is not carried out because of risk of entering of an infection. In the general blood test symptoms of anemia — erythrosinging, decrease in level of hemoglobin are defined, it is possible moderated and increase in SOE. Differential diagnostics is carried out with damage of back department of an urethra, injuries of a liver, spleen, various departments of intestines, ruptures of vessels of a bryzheyka. Except the urologist of the patient the traumatologist, the surgeon, the intensivist, the therapist, according to indications — the proctologist, the gynecologist, the cardiologist, the gastroenterologist, the neuropathologist, the neurosurgeon examines.
Treatment of an injury of bladder
Injured urgently hospitalize in traumatologic or urological office, transfer to a high bed rest. Conservative maintaining in the form of a kateterization (usually for 3-5 days before the termination of a makrogematuriya) is possible only at a bladder contusion, anguishes mucous at rough medical manipulations, small ekstraperitonealny gaps with the kept urovezikalny neck. The emergency carrying out reconstructive surgical intervention with drainage of belly or pelvic cavities is shown to other victims. At a stage of preoperative preparation haemo static, antibacterial, anti-inflammatory, analgeziruyushchy medicines, means for stabilization of haemo dynamics are appointed.
The volume of operation depends on features of damage. At vnutribryushinny gaps the bladder before an ushivaniye of a wound is ekstraperitonizirut for the termination of dribble of urine and carrying out full audit, after reconstruction of the damaged body the abdominal cavity is sanified without fail. Vnebryushinny damages take in without ekstraperitonization. Regardless of trauma type after restoration of integrity of a wall to men impose epitsistosty, establish to women an urethral catheter. The abdominal or pelvic cavity is drained. After operation continue introduction of antibiotics, analgetics, antishock infusional therapy.
Forecast and prevention
Violations of integrity of walls of a bladder reasonably are considered heavy, predictively as adverse injuries. Observance of an algorithm of surgical treatment of patients provides reliable decrease in frequency of complications even at heavy damages. Prevention is directed to creation of safe working conditions, observance of traffic regulations, implementation of safety requirements at occupations by injury-causing hobbies and sports, refusal of abuse of alcohol. For reduction of prerequisites to traumatism regular observation and treatment at the urologist is recommended to patients with the diagnosed diseases of a prostate, urethra, bladder.