INJURIES TO THE BLADDER AND URETHRA
Injuries to the bladder and urethra commonly occur along with pelvic trauma or may be due to surgical interventions.
Classification
Bladder injuries are classified as follows:
a. Contusion of bladder
b. Intraperitoneal rupture
c. Extraperitoneal Rupture
d. Combination of intraperitoneal and extraperitoneal bladder rupture.
Urethral injuries are classified as follows:
a. Partial or complete rupture
b. Anterior or posterior urethral rupture.
Causes
Injuries to the bladder and urethra are commonly associated with pelvic fracture multiple trauma. Certain surgical procedures (endoscopic urologic procedures, gynaecologic surgery, surgery of the lower colon and rectum)
Urethral rupture occurs during pelvic fracture (posterior) or when the urethra or penis is manipulated accidentally during surgery or injury (anterior).
Pathophysiology
Intraperitoneal bladder rupture occur when the bladder is full of urine and the lower abdomen sustains blunt trauma. The bladder ruptures at it weakest point, the dome. Urine and blood extravasate into the peritoneal cavity. Extraperitoneal bladder rupture occurs when the lower bladder is perforated by a bony fragment during pelvic fracture or with a sharp instrument during surgery. Urine-blood extravasate into the pelvic cavity.
Clinical manifestation
1. Inability to void.
2. Haematuria, presence of blood at urinary meatus.
3. Shock and haemorrhage pallor, rapid and increasing pulse rate.
4. Suprapubic pain and tenderness.
5. Rigid abdomen [indicates intraperitoneal rupture]
6. Absence of prostate on rectal examination in posterior urethral rupture.
7. Swelling / discoloration of penis, scrotum and anterior perineum in anterior urethral rupture.
Diagnostic evaluation
1. Retrograde urethrogram to detect any rupture of urethra.
2. Cystogram to detect and localize perforation/ rupture of bladder.
3. Plain film of abdomen - may show associated pelvic fracture
4. Excretory urogram to survey the kidney for injury.
Medical Management
Bladder injury
1. Treatment of shock and haemorrhage.
2. Surgical intervention carried out for intraperitoneal bladder rupture. Extravasated blood and urine will first be drained and urine diverted with suprapubic cystotomy or indwelling catheter.
3. Small extraperitoneal bladder rupture will heal spontaneously with indwelling suprapubic or foleys catheter drainage.
4 Large extraperitoneal bladder ruptures are repaired surgically.
Urethral injury Management
1. Immediate repair urethra is manipulated into its correct anatomical position with reanastomosis after evacuation of hematoma.
2. Delayed repair suprapubic cystotomy drainage for 6-12 weeks allows the urethra to realign itself while hematoma and edema resolve, then surgical reanastomosis.
3. Two-stage urethroplasty reconstruction of the urethra occurs in 2 separate surgeries with urinary elimination diverted until final procedure.
Complications
1. Shock, haemorrhage, peritonitis
2. Urinary tract infection
3. Urethral stricture disease.
Nursing intervention
1. Monitor vital signs and CVP frequently.
2. Establish IV access and replace blood and fluids as ordered.
3. Inspect urethral meatus for blood and if present, do not catheterize, but prepare for diagnostic evaluation and suprapubic cystotomy.
4. Obtain urine specimen, if possible and assess for degree of haematuria and presence of infection.
5. Prepare patient for surgical repair [by assisting with preoperative work up and describing post operative experiences.]
6. Post operatively, maintain patency and flow of indwelling urinary catheter(s). 6.
7. Inspect suprapubic, incision and peurose drains from perivesical areas for bleeding, extravasations of urine or signs of infection.
8. Administer analgesics as ordered.
9. Position for comfort (usually semi-fowler's position) if not contraindicated by other injuries, and prevent pulling of catheter tubing.
10. Provide information to the patient and family about the condition and progress.
11. Teach patient to care for indwelling catheters flat will remain in place de healing or after surgery.
a. Empty frequently.
b. Cleanse catheter and insertion area with soap and H₂O.
c. Inspect urine for blood, cloudiness or concentration.
d. Drink plenty of fluids to keep urine flowing.
12. Teach patient to report s/s of UTI.
13. Instruct patient (after surgical repair of bladder rupture) that bladder capacity may be temporarily decreased causing frequency and nacturia; this resolve overtime.
14. Explain possibility of recurrent urethral stricture disease to patients w urethral injury; instruct in daily self-catheterization to dilate urethra prescribed.
15. Inform patient (after severe urethral injury) of chance of impotence incontinence.
