68.1 The general method for an injury of the lower urinary tract

The two sexes injure their lower urinary tracts in different ways. A woman’s urinary tract is vulnerable to obstetric disaster, but seldom to trauma, whereas a man may sustain any of the injuries in Fig. 68-1. He can occasionally rupture his bladder into his peritoneal cavity (A). Much more often, he ruptures it extraperitoneally (B). He can also rupture his posterior urethra (C), his membranous urethra (D), his bulbous urethra (E), or his penile urethra (F). His prostatic urethra is protected by his zostate and is seldom injured. Blows to his lower abdomen burst his bladder (A). Fractures of his pelvis cause injuries B, C, and D. Blows to his urethra cause injuries D, E, and F. He may have more than one injury, and combinations of injuries B, and C, are not uncommon. A penetrating wound can injure any part of his urinary tract.

Always explore, repair, and drain a ruptured bladder. Ruptures of the urethra, on the other hand, are often incomplete and may heal themselves if you treat them conservatively, by diverting a patient’s urine with a suprapubic cystostomy for three weeks. This will allow him to recover from any other injuries he may have, and give you time to refer him for endoscopy and expert repair, should the rupture of his urethra unfortunately turn out to have been complete. If you cannot refer him, you may have to repair him yourself.

Diagnosis is seldom difficult. The important sign in all injuries of the lower urinary tract is that the patient cannot pass urine after an injury. If his bladder bursts into his peritoneal cavity (A), he has the signs of a slowly developing peritonitis. If it bursts extraperitoneally (B), his urine slowly extravasates, and may eventually become infected. With both of these injuries (A, and B) his bladder usually fails to distend, but occasionally it may do, if there is a flap–like injury to its wall. So failure to pass urine after an injury, combined with failure of the bladder to distend, is usually an indication of injuries A or B.

Figure 68.1: INJURIES TO THE MALE LOWER URINARY TRACT. A, rupture of the bladder into the peritoneum. B, rupture outside the peritoneum. C, rupture of the posterior urethra. D, rupture of the membranous urethra. E, rupture of the bulbous urethra. F, rupture of the penile urethra.

In all more distal injuries (C, D, E, and F) the patient’s bladder, including its internal sphincter, is intact, so after a few hours it always distends with urine. The combination of retention of urine with a distended bladder is characteristic of all injuries below the bladder neck, and occasionally of those above it. Another critical sign of injury of the lower urinary tract is blood at the patient’s external meatus (even a drop is significant) in all urethraj injuries (occasionally in C, and almost always in D, E, and F). His penis, scrotum, and perineum may also be injured.

Injuries to a patient’s urinary tract are less urgent than some other abdominal catastrophes. If he has a ruptured spleen or liver, he needs an urgent laparotomy, but you have a few hours (never more than 24) in which to explore his ruptured bladder. Most surgeons would agree that you should not try to pass a urethral catheter, because it may introduce infection, and it can be misleading.