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.