Erirish Journal of Urology (1978). 50. 162-163
Delayed Rupture of the Bladder A. R . TURNBULL, C. J. SMART and J. D. JENKINS Department of Urology, Southampton University Hospitals, Southampton
Summary-Two cases of delayed rupture of the bladder are presented in which infected urine became extravasated and led to abscess formation with subsequent urinary fistulation. The management of each case is described and the possible cause discussed. A suitable radiological investigation of bladder injuries is outlined.
Injuries t o the lower urinary tract are usually seen in association with pelvic fractures, the majority as a result of road traffic accidents (Mitchell, 1968). Therefore the possibility that such an injury has occurred should be considered in all patients with pelvic fractures. The types of injury likely to occur are extraperitoneal rupture of the bladder or damage t o the proximal urethra. Delayed rupture of the bladder however, is extremely uncommon and may escape recognition. Two such cases are presented which became apparent 2 weeks and 1 month after the initial injury.
displacing the bladder upwards and backwards. Although necrotic material could be irrigated from the bladder into this cavity the communication could not be defined. The abscess in the scrotum was incised and this also communicated with the Cave of Retzius. A silastic urethral catheter was inserted and the retropubic space was drained. Post-operatively a fistula drained through the scrotum, but this dried up within 3 weeks. Five weeks after the operation a cystogram showed there was still a small leak in the region of the bladder neck. The urethral catheter was therefore left in situ for a further month. Cystourethroscopy then showed that the bladder had healed and the catheter was removed. Following this he was able to void satisfactorily with good control.
Case 1
A 42-year-old policeman was involved in a road traffic accident in which he sustained pelvic injuries with wide diastasis of the pubic symphysis. Urological examination showed no blood at the urethral meatus and his prostate was in a normal position. However he was unable to pass urine and was dull to percussion suprapubically. A small Foley catheter was gently introduced and 300 ml of blood-stained urine was released. Intravenous urography showed a normal upper tract, and retrograde cystography showed an intact bladder with no evidence of extravasation. Two trials without catheter during the first 10 days were unsuccessful. Sixteen days after the injury he developed suprapubic cellulitis with an abscess pointing in the right scrotum, suggesting extravasation of infected urine. A urological opinion was sought. Cystourethrography showed that the membranous urethra was distorted, but otherwise the urethra was intact. There was a large slough anteriorly; the rest of the bladder was normal. Suprapubic exploration revealed a large haematoma in the retropubic space
Received 17 August 1977. Accepted for publication 28 September 1977.
case 2
A 60-year-old housewife was admitted following a crush injury to the pelvis in which she sustained bilateral fractures to the ischial and pubic rami. She was noted to have haematuria and was initially cathet'erised. Because of leakage around the catheter this was removed after 1 week, but she developed clot retention and the catheter had to be replaced. An IVP at this time showed an intact bladder. The catheter was again removed 2 weeks later and the patient was then able to void satisfactorily. Four weeks after injury an abscess developed in the left groin which was drained with the release of haematoma and urine. A urethral catheter was replaced but urine continued to drain through a fistula in the left groin in increasing amounts until finally her total urinary output was draining through the fistula. Cystoscopy at this time showed a perforation on the left side of the bladder. Suprapubic exploration was then carried out when it was apparent that a large area of the anterior and left bladder wall had sloughed. A primary closure was effected. Following this the fistula dried up and the patient was discharged 3 weeks postoperatively. She has had no further urinary problems. 162
163
DEI AYED RUPTURE OF THE BLADDER
Comment These 2 cases presented a similar clinical picture with rupture of the bladder becoming evident 2 and 4 weeks after the initial injury. Both patients had had indwelling catheters with the eventual extravasation of infected urine leading to abscess formation. It is likely that the initial injury to the bladder was a severe contusion and that this in conjunction with pressure from a pelvic haematoma led to secondary sloughing. A retrospective study of bladder injuries reported that contusion was the most frequent injury seen, and that this could be managed conservatively with catheter drainage where indicated (Brosman and Fay, 1973). Contusion was diagnosed on the presence of haematuria and the cystographic appearances. It is conceivable that the bladder may have been torn initially and that this was disguised by the presence of an indwelling catheter, but both patients had intravenous urography and 1 retrograde cystography which indicated that the bladder was intact. However, intravenous urography may only demonstrate a small proportion of bladder ruptures and retrograde cystography should be considered as the investigation of choice in all suspected cases of bladder injury (Rieser and Nicholas, 1963; Brosman and Fay, 1973). A suitable technique for this examination has been suggested by Cass and Ireland (1973). Two
hundred and fifty millilitres of contrast are introduced into the bladder under gravity and an AP X-ray taken. If no extravasation is noted a further 150 ml are added and the X-rays repeated. The bladder is then washed out with normal saline before the final films are taken. Whether the rupture occurred as a primary or secondary event, the presentation was still delayed with subsequent sloughing of the bladder wall. This possibility should therefore be borne in mind when managing cases of bladder injury.
References Brosman, S. A. and Fay, R. (1973). Diagnosis and management of bladder trauma, Journal of Trauma, 13, 687-694. Cass, A. S. and Ireland, G. W. (1973). Bladder trauma associated with pelvic fractures in severely injured patients. Journal of Trauma, 13, 205-212. Mitchell, J. P. (1%8). Injuries to the urethra. British Journal of Urology, 40,649-670. Rieser, C. and Nicholas, E. (1%3). Rupture of the bladder: unusual features. Journal of Urology, 90, 53-57.
The Authors J. D. Jenkins, MChir, FRCS, Consultant Urologist. C. J. Smart, FRCS, Consultant Urologist. A. R. Turnbull, MS, Lecturer in Surgery. Requests for reprints to: J. D. Jenkins, Consultant Urologist, Southampton Group Hospitals, Shirley, Southampton.
Delayed Rupture of the Bladder A. R . TURNBULL, C. J. SMART and J. D. JENKINS Department of Urology, Southampton University Hospitals, Southampton
Summary-Two cases of delayed rupture of the bladder are presented in which infected urine became extravasated and led to abscess formation with subsequent urinary fistulation. The management of each case is described and the possible cause discussed. A suitable radiological investigation of bladder injuries is outlined.
Injuries t o the lower urinary tract are usually seen in association with pelvic fractures, the majority as a result of road traffic accidents (Mitchell, 1968). Therefore the possibility that such an injury has occurred should be considered in all patients with pelvic fractures. The types of injury likely to occur are extraperitoneal rupture of the bladder or damage t o the proximal urethra. Delayed rupture of the bladder however, is extremely uncommon and may escape recognition. Two such cases are presented which became apparent 2 weeks and 1 month after the initial injury.
displacing the bladder upwards and backwards. Although necrotic material could be irrigated from the bladder into this cavity the communication could not be defined. The abscess in the scrotum was incised and this also communicated with the Cave of Retzius. A silastic urethral catheter was inserted and the retropubic space was drained. Post-operatively a fistula drained through the scrotum, but this dried up within 3 weeks. Five weeks after the operation a cystogram showed there was still a small leak in the region of the bladder neck. The urethral catheter was therefore left in situ for a further month. Cystourethroscopy then showed that the bladder had healed and the catheter was removed. Following this he was able to void satisfactorily with good control.
Case 1
A 42-year-old policeman was involved in a road traffic accident in which he sustained pelvic injuries with wide diastasis of the pubic symphysis. Urological examination showed no blood at the urethral meatus and his prostate was in a normal position. However he was unable to pass urine and was dull to percussion suprapubically. A small Foley catheter was gently introduced and 300 ml of blood-stained urine was released. Intravenous urography showed a normal upper tract, and retrograde cystography showed an intact bladder with no evidence of extravasation. Two trials without catheter during the first 10 days were unsuccessful. Sixteen days after the injury he developed suprapubic cellulitis with an abscess pointing in the right scrotum, suggesting extravasation of infected urine. A urological opinion was sought. Cystourethrography showed that the membranous urethra was distorted, but otherwise the urethra was intact. There was a large slough anteriorly; the rest of the bladder was normal. Suprapubic exploration revealed a large haematoma in the retropubic space
Received 17 August 1977. Accepted for publication 28 September 1977.
case 2
A 60-year-old housewife was admitted following a crush injury to the pelvis in which she sustained bilateral fractures to the ischial and pubic rami. She was noted to have haematuria and was initially cathet'erised. Because of leakage around the catheter this was removed after 1 week, but she developed clot retention and the catheter had to be replaced. An IVP at this time showed an intact bladder. The catheter was again removed 2 weeks later and the patient was then able to void satisfactorily. Four weeks after injury an abscess developed in the left groin which was drained with the release of haematoma and urine. A urethral catheter was replaced but urine continued to drain through a fistula in the left groin in increasing amounts until finally her total urinary output was draining through the fistula. Cystoscopy at this time showed a perforation on the left side of the bladder. Suprapubic exploration was then carried out when it was apparent that a large area of the anterior and left bladder wall had sloughed. A primary closure was effected. Following this the fistula dried up and the patient was discharged 3 weeks postoperatively. She has had no further urinary problems. 162
163
DEI AYED RUPTURE OF THE BLADDER
Comment These 2 cases presented a similar clinical picture with rupture of the bladder becoming evident 2 and 4 weeks after the initial injury. Both patients had had indwelling catheters with the eventual extravasation of infected urine leading to abscess formation. It is likely that the initial injury to the bladder was a severe contusion and that this in conjunction with pressure from a pelvic haematoma led to secondary sloughing. A retrospective study of bladder injuries reported that contusion was the most frequent injury seen, and that this could be managed conservatively with catheter drainage where indicated (Brosman and Fay, 1973). Contusion was diagnosed on the presence of haematuria and the cystographic appearances. It is conceivable that the bladder may have been torn initially and that this was disguised by the presence of an indwelling catheter, but both patients had intravenous urography and 1 retrograde cystography which indicated that the bladder was intact. However, intravenous urography may only demonstrate a small proportion of bladder ruptures and retrograde cystography should be considered as the investigation of choice in all suspected cases of bladder injury (Rieser and Nicholas, 1963; Brosman and Fay, 1973). A suitable technique for this examination has been suggested by Cass and Ireland (1973). Two
hundred and fifty millilitres of contrast are introduced into the bladder under gravity and an AP X-ray taken. If no extravasation is noted a further 150 ml are added and the X-rays repeated. The bladder is then washed out with normal saline before the final films are taken. Whether the rupture occurred as a primary or secondary event, the presentation was still delayed with subsequent sloughing of the bladder wall. This possibility should therefore be borne in mind when managing cases of bladder injury.
References Brosman, S. A. and Fay, R. (1973). Diagnosis and management of bladder trauma, Journal of Trauma, 13, 687-694. Cass, A. S. and Ireland, G. W. (1973). Bladder trauma associated with pelvic fractures in severely injured patients. Journal of Trauma, 13, 205-212. Mitchell, J. P. (1%8). Injuries to the urethra. British Journal of Urology, 40,649-670. Rieser, C. and Nicholas, E. (1%3). Rupture of the bladder: unusual features. Journal of Urology, 90, 53-57.
The Authors J. D. Jenkins, MChir, FRCS, Consultant Urologist. C. J. Smart, FRCS, Consultant Urologist. A. R. Turnbull, MS, Lecturer in Surgery. Requests for reprints to: J. D. Jenkins, Consultant Urologist, Southampton Group Hospitals, Shirley, Southampton.
