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Injuries of the pelvis
Published in Ashley W. Blom, David Warwick, Michael R. Whitehouse, Apley and Solomon’s System of Orthopaedics and Trauma, 2017
In Level 1/Major Trauma Centres, after initial resuscitation, patients are now taken early to the CT scanning unit for a full ‘trauma CT scan’. This comprises a CT scan of the head, neck, chest, abdomen and pelvis. Contrast is often also given. This is very helpful in excluding a bladder rupture or urethral injury. CT scanning provides a detailed anatomical view of the posterior structures, which are not seen well on conventional radiographs. CT scans can be reformatted to provide Judet views, multiplanar reconstructions (axial, coronal and sagittal images), and 3D reconstructions (Figure 29.11). Using CT scanning, 3D printing techniques can be used to print plastic moulds of pelvic fractures. This provides assistance in preoperative planning and plate contouring prior to fixation.
Pediatric genitourinary trauma
Published in David E. Wesson, Bindi Naik-Mathuria, Pediatric Trauma, 2017
Either standard or CT cystography can be utilized to assess the bladder for injury (Figure 19.4). CT cystography has been shown to be equally diagnostic of bladder rupture as conventional cystography with an overall sensitivity and specificity of 95% and 100%, respectively [64, 65]. Water-soluble iodinated contrast is instilled by gravity through a Foley catheter placed in the bladder. It is important that the bladder is adequately filled to capacity for age for the study. The bladder capacity in a child may be estimated using the formula (age + 2) × 30 cc [66]. Plugging a Foley catheter at the time of initial CT scan for trauma may not result in adequate distention of the bladder and may lead to a missed diagnosis of bladder injury.
Urologie Pain
Published in Mark V. Boswell, B. Eliot Cole, Weiner's Pain Management, 2005
Hossein Sadeghi-Nejad, Carin V. Hopps, Allen D. Seftel
One of the first therapeutic approaches described for the treatment of IC was hydrodistention of the bladder with the patient under anesthesia. In addition to providing therapeutic benefit, hydrodistention also provides information that may facilitate diagnosis as described above. The literature has detailed variable techniques for hydrodistention in terms of pressure and duration of distention. In an early study of 25 patients with IC, treatment by bladder distention was performed at a pressure that was similar to systolic blood pressure for a period of up to 3 hours (Dunn, Ramsden, Roberts, Smith, & Smith, 1977). While 16 patients were symptom-free at a mean follow-up of 14 months, bladder rupture occurred in 2 individuals. Although this study suggested that prolonged bladder distention had a role for the treatment of IC, it also demonstrated that care must be taken to avoid morbidity. Hanno (2002) recommends initial cystoscopy, bladder washings for cytology, and distention of the bladder for 1 to 2 minutes at a pressure of 80 cm H2O, followed by emptying of the bladder and refilling to assess for the presence of glomerulations or ulceration. A therapeutic distention is then performed for 8 minutes, and if a biopsy is necessary, it is performed following therapeutic distention. In patients with bladder capacity less than 600 ml, therapeutic response was excellent in 26% and fair in 29%, while in patients with larger bladder capacities, response was excellent in 12% and fair in 43% (Hanno & Wein, 1991). Overall, responses were brief, but those patients with a therapeutic benefit lasting 6 months are excellent candidates for repeat hydrodistention. It is thought that therapeutic benefit is secondary to damage of mucosal afferent nerve endings (Dunn, Ramsden et al., 1977).
Lower urinary tract injuries in patients with pelvic fractures at a level 1 trauma center – an 11-year experience
Published in Scandinavian Journal of Urology, 2023
Lasse Rehné Jensen, Andreas Røder, Emma Possfelt-Møller, Upender Martin Singh, Mikael Aagaard, Allan Evald Nielsen, Lars Bo Svendsen, Luit Penninga
Urological injuries occur in 3–16% of patients with pelvic fractures and are most common in males [5,6]. Due to the protected anatomical location of the bladder, blunt bladder injuries can be associated with pelvic fractures. Bladder rupture can either be extraperitoneal (60%), intraperitoneal (30%) or a combination (10%) [6]. The lower risk of concomitant urethral injuries to pelvic fractures in females is due to the short length, limited mobility and lack of insertions to the pubic symphysis [7]. The risk for urethral injury is highest for major, instable and displaced pelvic fractures, and are rare in single and ipsilateral ramus fractures. Urethral injuries have not been reported in isolated fractures of the acetabulum, ileum and sacrum [8]. Genitourinary injuries are associated with morbidity and mortality following major pelvic trauma due to the risk of septicemia, uroplania, hematuria, prolonged catheter treatment and voiding problems [5,9]. Importantly, urological trauma may result in long-term complications such as urethral or bladder neck stenosis, incontinence, erectile dysfunction (ED) or use of permanent indwelling catheter that severely impair quality of life [8,10–15]. The specific management of urological injuries in pelvic trauma patients has limited support in evidence.
Posttraumatic hemorrhagic bladder rupture managed with transurethral foley catheter placement and bilateral transcatheter vesical artery embolization
Published in Acta Chirurgica Belgica, 2023
Ruben Vanheer, Liesbeth De Wever, Geert Maleux
Posttraumatic bladder injury is commonly seen in association with pelvic fractures and patients present with suprapubic pain, macroscopic hematuria and dysuria [1]. In addition, bladder rupture may result in extraperitoneal or intraperitoneal perforation. Extraperitoneal perforation is managed in most cases by insertion of an indwelling Foley catheter, whereas intraperitoneal bladder rupture mostly warrants surgical bladder repair in order to avoid sepsis [1]. In the presented case, extraperitoneal bladder rupture was identified in CT; however, transurethral Foley catheter insertion and external pelvic ring fixation did not result in hemorrhage control as demonstrated on the repeat CT, 3 h after external fixation surgery. Persistent perivesical hemorrhage was controlled with superselective embolotherapy. This minimally invasive technique to stop bladder hemorrhage is safe and effective for various types of persistent bladder bleeding, including hemorrhagic radiocystitis [2] and malignant bladder masses [3]. Although this procedure is considered a safe procedure, serious pelvic, ischemic complications may occur in up to 10% of cases [4], requiring cystectomy. In the presented case, it was decided to perform a catheter-directed embolization instead of immediate bladder surgery related to the minimal invasive nature of embolotherapy and the technical complexity of bladder surgery in association with a large perivesical hematoma and open-book fracture.
Fetal Bladder Rupture as a Complication of Adjunctive Therapy in Severe Maternal SARS-CoV-2 Pneumonia
Published in Fetal and Pediatric Pathology, 2022
Jorge Gutierrez, Waldo Sepulveda, Raul Ramirez, Gina Acosta, Sergio Ambiado
With the current COVID-19 pandemic, pregnant women are developing SARS-CoV-2 pneumonia. Some of these will develop the most severe form of the disease and require invasive ventilatory support. In our obstetric population involving 458 women with confirmed COVID-19 infection, 25.5% developed a severe form of disease, 5.6% required admission to the intensive care unit, and 2.8% required mechanical ventilation [12]. An integral part of the management of cases requiring invasive ventilatory support includes the use of high doses of sedative and opioid drugs. These medications easily reach high concentrations in the fetal circulation through transplacental transfer. High doses in the fetal compartment can then have a deleterious effect on the fetal detrusor muscle [13]. Acute and severe retention of urine could therefore develop and lead to bladder rupture, as shown in our case. Bladder rupture is unlikely to occur in cases of distal urinary obstruction. This is probably because of the slow installation of the megacystis. In the case reported here, however, the rapid introduction of continuous high levels of opioids resulting in an abrupt atonic bladder may explain the acute urinary retention and bladder rupture.