A drunk patient with a distended bladder staggers in front of a motor vechicle. He receives a blow to his abdomen which bursts the dome or the posterior surface of his bladder, and floods his peritoneal cavity with urine (injury A, in Fig. 68-1). He feels sudden intense pain followed by shock and fainting. These immediate acute symptoms soon pass; there is no lower abdominal swelling, and his pain improves temporarily before signs of peritonitis follow after about 24 hours.
Commonly, a patient is brought in with multiple injuries, one of which is a fracture of his pelvis which has ruptured his bladder outside his peritoneal cavity (injury B). Although he may want to pass urine, all he can produce is a drop of blood. The broken ends of his pubic bones have torn the anterior wall of his bladder close to its neck. Sometimes, his posterior urethra has ruptured also. Blood and urine fill his prevesical space and track between his peritoneum and his transversalis fascia. They infiltrate laterally towards his anterosuperior iliac spines, and down towards his prostate. If he is not treated, this mixture of blood and urine becomes pus, which may ultimately discharge through his sacrosciatic notches into his buttocks, through his obturator foramina into his thighs, or out through his inguinal canals. There is such devastating necrosis within his pelvis that he becomes severely toxaemic and may die.
In the first few hours after the accident, you may not be able to tell if a patient’s fractured pelvis has ruptured his bladder, or has merely caused bleeding behind his pubic bones. But, even if his bladder has been ruptured, nothing much happens for the first 24 hours, so you have a day in which to observe him. Don’t delay more than 24 hours, and take great care not to infect the injured area by passing a diagnostic catheter meanwhile.
You can usually tell quite easily if a patient’s bladder has ruptured inside or outside his peritoneum from: (1) The history of the injury—a blow to his abdomen suggests rupture inside the peritoneum, whereas a fractured pelvis suggests rupture outside it. (2) The distribution of the tenderness—in extraperitoneal rupture this is narrowly localised suprapubically, in intraperitoneal rupture it is more diffuse over his lower abdomen and ends in obvious peritonitis.
If you are in doubt, there are twoinvestigations that may confirm that his bladder has ruptured, and show you where it has ruptured, but they are usually not necessary: (1) You can do a retrograde cystogram. Unfortunately, this requires the use of a catheter, and with it the risk of infection. (2) You can do an intravenous pyelogram, which is safer but less reliable.
You will be wiser to wait a few hours to confirm the diagnosis, rather than to operate unnecessarily and find only a haematoma which bleeds profusely or even disastrously when you open it. If you have to do an immediate laparotomy for other reasons, say for a suspected rupture of the patient’s spleen, you can easily examine his bladder at the same time.
If you diagnose any kind of rupture of the bladder, you will have to refer the patient urgently, or operate. A lower midline incision will bring you into his prevesical space outside his peritoneum just above his pubis. If this is full of urine and blood, his bladder has ruptured extraperitoneally. If it is normal, open his peritoneal cavity. If it contains blood and urine, his bladder has ruptured into it. The easiest way to find a tear is to open his bladder, put a finger into it, and feel for the tear. If an extraperitoneal rupture is large and easy to reach, it should not be too difficult to suture. But if the tear is difficult to get at, leave it, insert a suprapubic Foley catheter into his bladder and let it drain. An intraperitoneal rupture is usually larger, so always suture it and insert a suprapubic catheter drain.
Be sure to close a patient’s bladder mucosa with catgut. If you use any other sutures, they may form a focus for the formation of stones. If his bladder has ruptured extraperitoneally, be sure to drain his prevesical space adequately.