RUPTURE OF THE BLADDER

INDICATIONS Inability of the patient to pass urine within 24 hours of an injury, combined with: (1) The absence of a distended bladder (A, or B, in Fig. 68-1). (2) Increasing peritoneal irritation (A). (3) The appearance of a suprapubic swelling that might be extravasated blood and urine (B, or C). (4) Penetrating injuries that might have involved his bladder.

Make sure you have corrected the patient’s hypovolaemia and dehydration, so that if his bladder is intact, it will contain some urine and be easier to find.

EQUIPMENT A general set. 2/0 plain catgut for the mucosa of the bladder, and 2/0 chromic catgut for its muscle wall.

ANTIBIOTICS Give the patient perioperative antibiotics (2.7).

OPERATION Take him to the theatre as carefully as you can, so as not to displace the broken fragments of his pelvis any further. Lie him supine with his legs slightly apart, so that you can, if necessary, pass a catheter. Drape him so as to expose his whole abdomen. Clean his urinary meatus, and its surroundings. If you are right handed, you may find it convenient to work from the left side of the table.

INCISION Make a midline incision from just below the patient’s umbilicus to 1 cm above his pubic symphysis. Cut through the aponeurosis, and retract his rectus muscles. This will expose his prevesical space. Open it up with your fingers and inspect the front of his bladder. If you find urine, look where it is coming from.

CAUTION! (1) Don’t open his peritoneum yet. (2) If there is any danger that he may have other abdominal injuries, inspect the rest of his abdominal organs later in the operation.

If blood and urine flood up from his prevesical space, his bladder has ruptured extraperitoneally. Suck and mop the blood away. if bleeding is excessive, pack the space with gauze. Proceed as for extraperitoneal rupture, as described below.

If no blood and urine flood up from his prevesical space, find the upper surface of his bladder with its peritoneal reflexion, and use gauze dissection to displace this upwards. You will recognize that it is his bladder from the muscle fibres on its surface.

Incise his peritoneum by making a generous opening just above its attachment to his bladder. Enlarge the incision upwards as far as is necessary. Examine his abdominal organs and look for a retroperitoneal haematoma. If you find any other injuries, treat them first.

If his peritoneal cavity is normal, close it.

If his peritoneal cavity contains urine mixed with blood, his bladder has ruptured into it. Suck and mop away the blood and urine. The tear will probably be on its upper surface and you will find it easily. Proceed as for intraperitoneal rupture of the bladder, as described below.

If you are in doubt, open the patient’s bladder as described below and inspect it from inside. Tears are more easily found from inside. Be prepared to find more than one tear.

EXTRAPERITONEAL RUPTURE OF THE BLADDER

The tear will probably be in the anterior wall of the patient’s bladder, just above his prostate. It may be difficult to find when his bladder is empty and there is clot everywhere. Recognize his bladder by the muscle bundles in its walls, and the prominent veins on its surface.

If the tear is small, or difficult to find, don’t suture it, or try to look for it in the blood and urine in front of his bladder. Instead, insert a suprapubic catheter, drain his retropubic space, and close his abdomen.

If the tear is large and easy to repair, suture it from inside.

Open the bladder between stay sutures, as for a Freyer’s prostatectomy (23.19). There will now be two (or more) holes in its wall—the original tear, and the incision you have just made. Put your finger into it, and feel the tear from inside.

CAUTION! If the tear is near the ureters, pass a fine catheter up them to help to prevent you tying them off.

Go round to the left side of the table, if you are not already there. Suture the tear with a single layer of plain catgut stitches going deeply into the muscle.

Repair the patient’s bladder in two layers, as for a prostatectomy (22.17), with an inner layer of continuous 3/0 plain catgut, and an outer layer of continuous chromic 2/0 catgut.

DRAINING THE BLADDER You will now need to drain the patient’s bladder.

If there has been no blood at his external meatus, his urethra is probably unharmed. So drain his bladder through an indwelling 22 Ch Foley catheter passed up through his external meatus.

If there has been any blood at the patient’s external meatus, his urethra has probably been injured. Avoid a urethral catheter. Instead, insert a 26 Ch Foley catheter through the cystotomy wound and sew his bladder wall round it with catgut (22.7).

Drain his prevesical space with a large (6 corrugations) rubber drain, or leave the wound partly open. Close the wound and anchor both his suprapubic catheter and his prevesical drain to his skin with stitches.

INTRAPERITONEAL RUPTURE OF THE BLADDER

Tilt the head of the table slightly downwards, and pack off the patient’s intestines to make more room in his pelvis.

If there is an obvious tear in his bladder, feel and if possible look at the interior of his bladder through it. Alternatively, open his bladder through a separate incision anteriorly. Be sure to find and protect his ureters before you insert any sutures.

Control all bleeding inside the bladder, so as to reduce the risk of clot retention. Close the tear in his mucosa with continuous plain catgut, and its serosa with chromic catgut.

Remove the packs, level the table, mop up any free fluid in his peritoneal cavity, and close it. Drain his bladder with a urethral or suprapubic catheter, and drain his suprapubic space on the indications given above.

If there is frank peritonitis, insert a suprapubic peritoneal drain.

THE POSTOPERATIVE CARE OF A BLADDER INJURY

This is the same for both kinds of rupture. Connect the catheter to a closed drainage system, and check that it is draining. As soon as the patient has recovered from shock, raise him gradually into the sitting position.

If he has an extraperitoneal rupture, give him a broad spectrum antibiotic for 5 days in the hope of preventing the huge haematoma in his pelvis from becoming infected.

Prevesical drain

Remove this at 5 days.

Indwelling urethral catheter.

Remove this at 7 to 14 days. When it is removed he should be able to pass urine normally.

Suprapubic catheter (if you decide to insert one).

Keep this in until after you have removed his urethral catheter. Remove this at 10 days. Try spigotting it first to see if he can pass urine.

DIFFICULTIES WITH BLADDER INJURIES

If there is SEVERE BLEEDING as you open the patient’s prevesical space, fragments of his fractured pelvis have torn the vessels of his pelvic wall. The bleeding vessel may be impossible to find. When you remove the blood, most of the bleeding will probably stop. If it does not, pack his prevesical space and its lateral recesses, and leave the pack in for 15 minutes. Then, with an enlarged incision and a good light, have another look. You may find and be able to tie the bleeding vessel. If you don’t find it, replace the pack, give him antibiotics, and remove it 24 hours later.

If he has an OPEN WOUND of his bladder, explore it, close the tear in its wall, do a suprapubic cystostomy, and drain his prevesical space. The tear may be posterior, in which case you may be forced to cut open the front of his bladder, in order to repair it from the inside.

If you have OPENED HIS BLADDER ACCIDENTALLY during the course of another operation, what you should do depends on when you recognize it.

If you recognise an accidentally opened bladder during the operation, close it in two layers and insert a suprapubic or urethral catheter. Leave it to drain for about two weeks before removing it.

If you recognize it only some days later, insert a catheter as above, and also a peritoneal drain through a stab incision in one of his rectus muscles, being careful to avoid his inferior epigastric arteries. Don’t put the suprapubic tube and the peritoneal drain too close together.

You are most likely to injure the bladder accidentally during Caesarean section (18.8), or when you repair a sliding hernia (14.2), or when you drain a patient’s peritoneal cavity suprapubically for peritonitis. The main way of preventing injury is to catheterize a patient’s bladder after you have anaesthetized him, before doing any of these procedures. if you decide to catheterize him first, leave the catheter in place to prevent his bladder filling up before you come to operate.

If he gets CLOT RETENTION, wash out his bladder thoroughly through his urethral or suprapubic catheter to remove all clot.