Damage to the bladder

It is necessary to distinguish closed, or subcutaneous, and open damage to the bladder. In peacetime are found mainly subcutaneous, and in the military - open trauma of the bladder.
Subcutaneous damage to the bladder arise under the influence of the forces from the outside or from the side of the cavity bladder. The former include injuries to the anterior abdominal wall in the fall, landslides, severe blow to the stomach and a strong reduction of the abdominal wall, for example, when the lifting of heavy generic strivings. All these factors can cause rupture of the bladder only if he is full of urine. Due to prirastajte bladder muscle wall of his thinning, elasticity its largely exhausted, the bladder protrudes above the pubic bone pressed directly to the front wall of the abdomen, i.e. becomes available direct impact of traumatic force. Empty the bladder whole is placed in the pelvis, well protected by its bone belt and therefore less damage from the outside.
Inside the bladder wall can be broken when the forced introduction of tools - metal catheter, bougie, lithotripter, the cystoscope, when electrocautery tumors of the bladder, or when a sudden sharp increase intravesical pressure, for example with the rapid filling it with liquid during kamnedrobilniy or washing.
If subcutaneous injury bubble accompanied by violation of the integrity of all layers of the wall, then talk about penetrating the bubble bursting. In this case urine from the cavity bladder partly or fully penetrates into the surrounding tissue. If breached integrity are not all layers, for example only serous cover or only mucosa, then such damage is called non-invasive. Urine not follow beyond the bubble.
Direct damage caused by the direct impact of traumatic forces, such as injury, fall, hyperextension of the bubble, most often occur with pathological changes in the walls of the bladder, such as ulcers, cancer or diverticula it, or at sharp hyperextension bladder due to breach of its sensitivity - if the spinal " dryness", or when severe intoxication.
The majority of the closed bladder damage associated with fractures of pelvic bones, mainly to the pubic and sciatic, rarely iliac bone and socket depressions. Bone splinters embedded in the gallbladder wall, or break it happens in the displacement of fragments to the pubic bone, which bubble tight fixed gallbladder-pubic ligament.
For direct damages bladder often torn Vernisage wall it, where weaker expressed muscle layer. Since in this area the bladder wall spliced with the parietal peritoneum, the latter is broken too, is intraperitoneal gap. When ruptured bladder bone splinter Ranitsa often front and lateral walls, not covered by the peritoneum, is vnebrachnyi rupture of the bladder.
Subcutaneous bubble breaks, which are accompanied by simultaneous damage to other organs of the pelvis, spine, intestines, liver), constitute the category of the combined damage; if other organs are not affected - category isolated damage.
Hit aseptic urine in the peritoneal cavity first calls only phenomena of peritoneal irritation, but later, as a rule, are susceptible to infections and developed pattern of diffuse peritonitis.
When vnebrachnyi breaks urine flows out in kolapushinu tissue, forming a number of cavities and pockets where the accumulated urine decomposes, causes necrosis pelvic fiber, which is rapidly developing infection and urinary cellulitis.
If subcutaneous break the bubble, combined with a fracture of the pelvis, creates favorable conditions for the development of chronic osteomyelitis.
Infection entering the blood stream, causing General intoxication and septic condition. While developing phenomenon of pyelonephritis and kidney failure, i.e. the picture of urosepsis.
Subcutaneous gap bladder is often accompanied by shock, pain in the lower abdomen and continuous urge to urinate, which remain barren -
Urine is not allocated at all or in severe pain receive a single drop of blood-stained urine (bloody anuria).
The diagnosis. Hematuria in every abdominal trauma or fractures of the pelvis likely speaks about the damage to the bladder or urethra.
Intraperitoneal-bubble soon join the symptoms of peritonitis. Percussion see the stupidity in the lateral parts of the abdomen at the patient on the back, disappearing from one side when turning on the opposite side (free liquid in the cavity of the abdomen). When finger rectal examination is defined by the overhang of the gallbladder-pryamokishechnye abdominal fold due to accumulation in her urine.
When vnebrachnyi breaks on the foreground there is infiltration inguinal-iliac regions that appear swollen and severely painful. Percussion in such cases, there is a dull sound.
If for diagnostic purposes to enter into the bladder rubber catheter, then through him as if nabroshena and intraperitoneal gap weak stream is a small amount of bloody urine. If the catheter intraperitoneal rupture happened to go into the peritoneal cavity, it produces a large quantity of fluid, consisting of urine and reactive peritoneal exudate. Such cases are, however, rare, and the risk of infection during catheterization is very high. Death in closed injuries of the bubble is observed more often among the wounded, undergo catheterization, than those, which the catheter was not introduced. So catheterization in principle precluded and valid only in case of doubt as a last resort and then only immediately before operational intervention.
Often it is necessary to differentiate subcutaneous gap bubble from damage to the urethra. When the last of the urethra stands out the blood out of urination (urethrorrhea), the bladder is full of urine, percussion noted dulling the sound above the pubic area symmetrically on each side of the center line, and not in the iliac regions or in the lateral parts, as it happens when you break the bubble.
Treatment. In each case closed ruptured bladder shown immediate surgical intervention;
Especially urgent is the operation intraperitoneal gap. Every hour delay affects the results. Slit between the navel and the pubic hair on the middle line reveal the peritoneum. The intestine is extended upwards. Remove shed abroad in the peritoneal cavity urine, find a defect in the wall of the bladder and sew up his two-row ketotofin seam. Peritoneal cavity tightly sewn after introduction in it of 1 000 000 UNITS of penicillin and 1 gram streptomycin. In order to avoid leakage of urine through a protection gap in the peritoneal cavity open nabroshena the bladder and into it drainage tube.
When nabroshena break median suprapubic incision naked preduzme space, delete poured out the blood and urine, reveal the bladder and drain it. At rupture of the anterior bladder wall, you can use them to introduce drainage. It is necessary to ensure the outflow of pus and urine, which has been poured out or can seep into the pelvic tissue. For this purpose the cavity of the basin is drained by longitudinal slit crotch on either side of the urethra, through the sciatic-pryamokishechnye fossa, or via locking holes (on Boyarskomu). At last the way cross-section with a length of 1,5-2 cm on the inner thigh, some distance one transverse finger from the inguinal folds, naked leading thigh muscles. Stupidly raslov them, come to locking muscle, which also rasslaivath closer to the medial edge locking holes, and thus penetrate into the cavity and small pelvis. Operation make the right and left. On each side enter the vent line. When the bubble breaks, complicated fractures of pelvic bones, remove all loose bone fragments and repetiruyut areas of osteomyelitis in the damaged bone.

Note readers!
From the roadmap literature of publishing house "Medicine" in 1978.
USTIMENKO E. M. Traumatic rupture of the bladder. M., "Medicine" 1978, 7 l, Il., 10 000 copies, 80 K.
The monograph considers the issues of clinic, diagnostics, special methods of examination and treatment of traumatic rupture of the bladder,- Provides a detailed analysis of possible diagnostic errors. Great attention is paid to the treatment and prevention of postoperative complications. Advanced position supported by extracts from medical records, x-rays.
Selected the most appropriate methods of surgical treatment of traumatic rupture of the bladder in each case.
The analysis of mortality and potential tactical mistakes.
The monograph is intended for surgeons and urologists.