Rupture of the
bladder
This may be intraperitoneal (20 per cent) or
extraperitoneal (80 per cent) (Figs 65.5 and
65.6). Intraperitoneal rupture may be
secondary to a blow, kick or fall on a fully distended bladder and it is more
common in the male than in the female, and usually follows a bout of beer
drinking. More rarely, it is due to surgical damage. Extraperitoneal rupture is
usually caused by a fractured pelvis or is secondary to major trauma or surgical
damage.
lntraperitoneal
rupture
lntraperitoneal rupture
•
Sudden, agonising pain in the hypogastrium, often accompanied by syn cope
•
The shock later subsides and the abdomen commences to distend
•
No desire to micturate
•
Varying degrees of abdominal rigidity and abdominal distension are
present on examination
•
No suprapubic dullness, but there is tenderness
•
There may be shifting dullness
•
If the urine is sterile, symptoms and signs of peritonitis are delayed
Extraperitoneal
rupture
In many cases of pelvic trauma, this is
difficult to distinguish from rupture of the membranous urethra. This injury is
dealt with in Chapter 66 on ‘The prostate and seminal vesicles’.
Confirming a suspected diagnosis of intraperitoneal rupture
•
Plain X-ray in the erect position may show the ground-glass appearance of
fluid in the lower abdomen
• Intravenous urography (IVU) may confirm a leak from the bladder
•
A peritoneal ‘tap’ may be of value if facilities for radiological
examination are not available
•
If doubt still exists and if there is no sign of fracture then retrograde
cystography can be performed safely. With careful asepsis a small [14 French
gauge (FG)] catheter is passed. Usually some blood-stained urine will drain. A
solution made from 60 ml of 35 per cent Hypaque® or Conray® with 120 ml of
sterile isotonic saline is injected into the bladder and radiographs are taken (Fig.
65.7)
Treatment of
intraperitoneal rupture
The mainstay is to provide adequate drainage
of the bladder. The standard treatment is to perform a lower midline laparotomy,
urine is removed by suction, after which the patient is placed in
Trendelenberg’s position. The edges of the rent, which are usually situated in
the posterior part of the dome of the bladder, are trimmed and sutured with two
layers of interrupted catgut stitches, and the operation completed by placement
of a suprapubic and urethral catheter. The peritoneum should be irrigated with
copious amounts of warm saline. Very rarely, the bladder will rupture through an
unsuspected tumour and it is perhaps wise in atypical cases to take a biopsy
before suturing the defect.
Wounding of the
bladder during operation
Operations in which the bladder is liable to
be injured are: (1) inguinal or femoral herniotomy; (2) hysterectomy by either
the abdominal or vaginal route; and (3) excision of the rectum. In the latter
two operations, the bladder should be catheterised prior to operation to
minimise the risks of this accident. If the injury is recognised at the time,
the bladder must be repaired in two layers and urethral catheter drainage
maintained for 7 days. If it is not recognised, the treatment is similar to that
of rupture of the bladder.
When
accidental perforation of the bladder occurs during endoscopic resection of a
bladder tumour, or the prostatic capsule is perforated during transurethral
prostatectomy, the perforation is usually extraperitoneal. When the accident
is recognised at the time, drainage of the bladder with a large urethral
catheter and the administration of antibiotics usually suffice. If, however, a
mass of extravasated fluid is palpable per
abdomen it is best to place a small drain into the extraperitoneal
perivesical space through a small stab incision. A laparotomy will usually be
required if an intraperitoneal perforation is caused by transurethral resection
of a large bladder tumour on the dome of the bladder.