Surgery tests. Urinary dysfunction syndrome

Injuries and injuries to the bladder are considered severe trauma to the abdomen and pelvis, requiring emergency medical care.

ICD 10 code

S37.2. Bladder injury.

ICD-10 code

S37 Trauma to the pelvic organs

Epidemiology of bladder injury

Among abdominal injuries requiring surgical treatment, injuries to the bladder account for about 2%: closed (blunt) injuries - 67-88%. open (penetrating) - 12-33%. In 86-90% of cases, the causes of closed bladder injuries are road traffic accidents.

In case of closed (blunt) injuries, intraperitoneal ruptures of the bladder occur in 36-39%, extraperitoneal - 55-57%, combined extra- and intraperitoneal injuries - 6% of cases. In the general population, extraperitoneal ruptures occur in 57.5-62%, intraperitoneal ruptures - 25-35.5%, combined extra- and intraperitoneal injuries - 7-12% of cases. With closed (blunt) injuries, the dome of the bladder is damaged in 35%; with open (penetrating) injuries, the side walls are damaged in 42%.

Combined injuries are common - in 62% of cases with open (penetrating) injuries and 93% with closed or blunt injuries. In 70-97% of patients, pelvic bone fractures are detected. In turn, with fractures of the pelvic bones, damage to the bladder of varying degrees occurs in 5-30% of cases.

In 29% of cases, combined injuries of the bladder and posterior wall of the urethra are encountered. 85% of patients with a pelvic fracture experience severe concomitant injuries, which causes high mortality rates - 22-44%.

The severity of the condition of the victims and the outcome of treatment are determined not so much by damage to the bladder, but by their combination with damage to other organs and severe complications resulting from the leakage of urine into the surrounding tissues and the abdominal cavity. A common cause of death is severe combined injuries to the bladder and other organs.

With an isolated injury to the bladder, the mortality rate in the second period of the Great Patriotic War was 4.4%, while with a combination of injuries to the bladder and pelvic bones - 20.7%, and injury to the rectum - 40-50%. The results of treatment for combined closed and open injuries of the bladder in peacetime remain unsatisfactory. Compared with the data of the Great Patriotic War, in modern local wars and armed conflicts the proportion of multiple and combined injuries has increased significantly; The rapid delivery of the wounded to the stages of medical evacuation contributed to the fact that some of the wounded did not have time to die on the battlefield, but were admitted with extremely severe wounds, sometimes incompatible with life, which made it possible to expand the possibilities of providing them with surgical care at an earlier date.

Combined gunshot wounds are observed in 74.4% of cases, the mortality rate for combined gunshot wounds of the pelvic organs is 12-30%. and discharge from the army exceeded 60%. Modern diagnostic methods and the sequence of surgical care with combined gunshot wounds make it possible to return 21.0% of the wounded to duty and reduce mortality to 4.8%.

Iatrogenic injuries to the bladder during gynecological operations occur in 0.23-0.28% of cases (of which obstetric operations - 85%, gynecological operations 15%). According to the literature, iatrogenic injuries account for up to 30% of all observations of bladder injuries. In this case, concomitant damage to the ureter occurs in 20% of cases. Intraoperative diagnosis of bladder injuries, in contrast to ureteral injuries, is high - about 90%.

Causes of bladder injury

Bladder injuries can result from blunt or penetrating trauma. In both cases, bladder rupture is possible; a closed injury can lead to a simple contusion (damage to the bladder wall without leakage of urine). Bladder ruptures can be intraperitoneal or extraperitoneal, or combined. Intra-abdominal ruptures usually occur in the area of ​​the apex of the bladder; they most often occur when the bladder is full at the time of injury, which is especially common in children, since their bladder lies in the abdominal cavity. Extraperitoneal ruptures are more common in adults and occur due to pelvic fractures or penetrating injuries.

Bladder injuries can be complicated by infection, urinary incontinence, and bladder instability. Concomitant injuries to the abdominal organs and pelvic bones are common, since significant traumatic force is required to damage the anatomically well-protected bladder.

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Mechanisms of bladder injury

The vast majority of bladder injuries are the result of trauma. The bladder is a hollow muscular organ located deep in the pelvic cavity, protecting it from external influences. A full bladder can be easily damaged by applying relatively little force. whereas to damage an empty bladder requires a destructive blow or a penetrating wound.

Typically, damage to the bladder occurs as a result of a sharp blow to the lower abdomen, with a full bladder and relaxed muscles of the anterior abdominal wall, which is typical for a person under the influence of alcohol. In this situation, intraperitoneal rupture of the bladder often occurs.

In case of a fracture of the pelvic bones, direct damage to the bladder by bone fragments or rupture of its walls due to their traction by ligaments when bone fragments are displaced is possible.

There are also various iatrogenic causes (for example, damage to the bladder during catheterization, cystoscopy, endoscopic manipulations).

The most common causes of closed bladder injuries are:

• road traffic accidents, especially if the injured elderly pedestrian is intoxicated with a full bladder:
• burning from a height (catatrauma);
• work injuries:
• street and sports injuries.

The likelihood of bladder injury increases in the presence of severe injuries to the pelvic and abdominal organs.

It should also be noted that intraperitoneal ruptures of the bladder in 25% of cases are not accompanied by fractures of the pelvis. This fact indicates that intraperitoneal ruptures of the bladder are compressive in nature and develop due to an increase in intravesical pressure, leading to a rupture in the most pliable place, the segment of the dome of the bladder covered by the peritoneum.

The main cause of extraperitoneal rupture is direct pressure from the pelvic bones or their fragments, and therefore the sites of the pelvic fracture and the rupture of the bladder usually coincide.

Damage to the bladder correlates with diastasis of the symphysis, semi-sacral diastasis, fractures of the branches of the sacral, iliac, and pubic bones and is not associated with a fracture of the fossa acetabulum.

In childhood, viutriperitoneal ruptures of the bladder occur more often, due to the fact that in children most of the bladder is located in the abdominal cavity and for this reason is more vulnerable to external trauma.

In case of a fall from a height and a mine explosion injury, it is possible

Iatrogenic bladder injuries occur during gynecological and surgical operations on the pelvic organs, hernia repair and transurethral interventions.

Typically, perforation of the bladder wall is performed by a proctoscope loop during resection of the organ wall when the bladder is full or when the movement of the loop does not coincide with the surface of the bladder wall. Electrical stimulation of the obturator nerve during bladder resection for tumors located on the inferolateral walls increases the likelihood of intra- and extraperitoneal perforations.

Pathological anatomy of bladder injury

There are bruises (concussions) and ruptures of the bladder walls. When a wall is bruised, submucosal or intramural hemorrhages are formed, which most often resolve without leaving a trace.

Incomplete ruptures can be internal when the integrity of only the mucous membrane and submucosal layer is violated, or external when there is damage (most often by bone fragments) to the outer (muscular) layers of the wall. In the first case, bleeding occurs into the cavity of the bladder, the intensity of which depends on the nature of the damaged vessels: venous bleeding stops quickly; arterial bleeding often leads to tamponade of the bladder with blood clots. With external ruptures, blood pours into the peri-vesical space causing deformation and displacement of the bladder wall.

With a complete rupture, the integrity of the bladder wall throughout its entire thickness is compromised. In this case, intraperitoneal and extraperitoneal ruptures are distinguished. Complete intraperitoneal tears are located on the superior or superoposterior wall at or near the midline; most often single, even, but can be multiple and irregular in shape; have a sagittal direction. Bleeding from these ruptures is small due to the absence of large vessels in this area and the contraction of damaged vessels along with the emptying of the bladder into the abdominal cavity. The leaked urine is partially absorbed (leading to an early increase in the concentration of urea and other products of protein metabolism in the blood), causing chemical irritation of the peritoneum, followed by aseptic and then purulent peritonitis. With isolated intraperitoneal ruptures, peritoneal symptoms increase slowly, over several hours. By this time, a significant amount of fluid accumulates in the abdominal cavity due to urine and exudate.

Extraperitoneal ruptures, as a rule, arising from pelvic fractures, are usually localized on the anterior or anterolateral surface of the bladder, are small in size, regular in shape, and often single. Sometimes a bone fragment also injures the opposite wall on the side of the bladder cavity or simultaneously damages the wall of the rectum. Quite rarely, usually with fractures of the pelvic bones caused by a fall from a height and a mine-explosive injury, the neck of the bladder is separated from the urethra. In this case, the bladder moves upward along with the internal sphincter, which makes it possible to partially retain urine in the bladder and periodically empty it into the pelvic cavity. This further separates the bladder and urethra.

Extraperitoneal ruptures, as a rule, are accompanied by significant bleeding into the peri-vesical tissue from the venous plexus and fractures of the pelvic bones, into the bladder cavity from the vascular network of the neck and vesical triangle. Simultaneously with bleeding, urine enters the paravesical tissues, leading to their infiltration.

As a result, a urohematoma is formed, deforming and displacing the bladder. Impregnation of the pelvic tissue with urine, purulent-necrotic changes in the wall of the bladder and surrounding tissues, absorption of urine and decay products lead to increasing intoxication of the body, weakening of local and general protective mechanisms. A granulation shaft is usually not formed

the associated infection leads to rapid melting of the fascial partitions: alkaline decomposition of urine begins, precipitation of salts and incrustation of infiltrated and necrotic tissues begins, urinary phlegmon of the pelvic and then retroperitoneal tissue develops.

The inflammatory process from the area of ​​the bladder wound spreads to its entire wall, purulent-necrotic cystitis and osteomyelitis develop with combined fractures of the pelvic bones. The pelvic vessels are involved in the inflammatory process immediately or after a few days, and thrombo- and periphlebitis develop. The detachment of blood clots sometimes leads to pulmonary embolism with the development of pulmonary infarction and infarction pneumonia. If surgical care is not provided in a timely manner, the process takes on a septic character: toxic nephritis, purulent pyelonephritis develops, and hepatic-renal failure appears and rapidly increases. Only with limited ruptures and small portions of urine entering the surrounding tissues does the development of purulent-inflammatory complications occur later. In these cases, separate ulcers form in the pelvic tissue.

In addition to bladder ruptures, so-called bladder concussions are encountered, which are not accompanied by pathological abnormalities during radiological diagnostics. Concussion of the bladder is the result of damage to the mucous membrane or muscles of the bladder without compromising the integrity of the walls of the bladder, characterized by the formation of hematomas in the mucous and submucosal layer of the walls.

Such injuries are not of serious clinical significance and resolve without any intervention. Often, against the background of other injuries, such injuries are ignored and not even mentioned in many studies.

According to Cass, the true prevalence of bladder concussions among all injuries is 67%. Another type of bladder injury is incomplete or interstitial injury: with a contrast study, only the submucosal distribution of the contrast agent is determined, without extravasation. According to some authors, such injuries occur in 2% of cases.

Classification of bladder injury

As can be seen from the above, damage to the bladder can be very diverse, both in terms of the mechanism of occurrence and the extent of damage.

To determine the clinical significance of bladder injuries, their classification is very important.

Currently, the classification of bladder injuries according to I.P. is quite widespread. Shevtsov (1972).

• Causes of bladder damage
  • Injuries.
  • Closed injuries.
• Localization of bladder injuries
  • The top.
  • Body (front, back, side wall).
  • Neck.
• Type of bladder injury
  • Closed damage:
    • injury;
    • incomplete break:
    • complete break;
    • separation of the bladder from the urethra.
  • Open damage:
    • injury;
    • the injury is incomplete;
    • the wound is complete (through, blind);
    • separation of the bladder from the urethra.
• Damage to the bladder in relation to the abdominal cavity
  • Extraperitoneal.
  • Intraperitoneal.

The classification of bladder injuries proposed by Academician N.A. has become widespread in practice. Lopatkin and published in the “Guide to Urology” (1998).

Type of damage

• Closed (with intact skin):
  • injury;
  • incomplete rupture (external and internal);
  • complete break;
  • two-stage bladder rupture:
  • separation of the bladder from the urethra.
• Open (wounds):

  The mortality rate is about 20%, and, as a rule, it is associated with concomitant severe injuries.

definition

Bladder rupture is classified as a group of diagnoses based on organ trauma. Injuries may result from blunt, penetrating, or iatrogenic (treatment-induced) trauma. The likelihood of injury varies according to the degree of stretching of the organ walls—a full bladder is more susceptible to injury than an empty one. Treatment ranges from conservative approaches that focus on maximizing artificial urinary diversion to major surgical procedures aimed at long-term recovery.

Reasons why a bladder rupture may occur

There are only a few reasons why the walls of the bladder can rupture.

• Blunt trauma is characterized by rupture of the bladder wall without damage to external tissues

Often the cause of blunt trauma is pelvic fractures, when bone fragments or sharp parts damage the integrity of the bladder wall. Approximately 10% of patients with a pelvic fracture suffer significant damage to the bladder area. The susceptibility of this organ to injury is associated with its degree of stretching at the time of injury. A blunt blow to the stomach with a fist or a kick can cause the bladder to rupture when its capacity is significantly full. Bladder rupture has been reported in children who suffered a blow to the lower abdomen while playing with a soccer ball.

• Penetrating trauma

This group includes gunshot wounds and stab wounds. Patients often suffer concomitant injuries to the abdominal cavity and pelvic organs.

• Obstetric traumatism

During prolonged labor or difficult labor, when there is constant pressure from the fetal head on the mother's bladder, her bladder may rupture. This happens due to the thinning of the organ wall at the point of constant contact. Direct wall rupture occurs in 0.3% of women who have had a cesarean section. Previous operations complicated by adhesions are a serious risk factor, since excessive scarring can disrupt the normal density and stability of tissues.

• Gynecological traumatism

Bladder injuries can occur during a vaginal or abdominal hysterectomy. Blind dissection of tissue in the wrong plane, between the base of the bladder and the neck of the fascia, usually damages the bladder wall.

• Urological trauma

Possible during bladder biopsy, cystolitholapaxy, transurethral resection of the prostate or transurethral resection of a bladder tumor. Perforation of the bladder walls during biopsy reaches an incidence of 36%.

• Orthopedic traumatism

Orthopedic equipment can easily perforate the bladder, especially during internal fixation of pelvic fractures. In addition, thermal injury may occur during the placement of cementitious substances used for arthroplasty.

• Idiopathic bladder injury

Patients diagnosed with chronic alcoholism and individuals who chronically drink large amounts of fluid are susceptible to hypertensive bladder injury. Previous bladder surgery is a risk factor for scarring.

This type of injury can result from a combination of an overfilled bladder and minor external trauma occurring during a fall.

Classification and emergency care for suspected bladder injury

The classification of bladder injuries is based on several characteristics that describe the injury.

• Extraperitoneal bladder rupture— the contents of the organ do not penetrate into the abdominal cavity.
• Intraperitoneal bladder rupture- the contents penetrate into the abdominal cavity. A common occurrence of ruptures at the moment of maximum filling of the bladder.
• Combined bladder rupture— the contents penetrate into the abdominal cavity and pelvic cavity.

Types of damage

• Open Bladder injury is a common occurrence with penetrating wounds in the bladder area or other violations of the integrity of the outer layers.
• Closed Bladder injury is blunt trauma.

Severity of injury

• Injury(the integrity of the bladder is not compromised).
• Incomplete break bladder walls.
• Complete break bladder walls.

Presence of damage to other organs

• Isolated bladder injury - only the bladder is damaged.
• Combined bladder injury - other organs are also damaged.

If a bladder rupture is suspected, all measures should be taken to ensure the survival of the victim until the ambulance arrives.

• Needs to be applied a tight bandage in the pubic area if there is a penetrating wound.
• The patient is positioned on his side with his knees bent, if it is possible.
• On place cold on the lower abdomen.
• Provide patient immobility.

Diagnosis of bladder injury

Laboratory tests can be a key tool in diagnosing minor bladder injuries.

Serum creatinine levels can help diagnose organ wall rupture. In the absence of acute kidney injury and urinary tract obstruction, elevated serum creatinine may be a sign of urinary leakage.

Visual Research

CT scan

Often, a computed tomography (CT) scan is the first test performed in patients with blunt abdominal trauma. Transverse images of the pelvic organs provide information about their condition and possible damage to bone structures. This procedure has the potential to largely replace conventional fluoroscopy as the most sensitive means of detecting bladder perforation.

A CT scan of the bladder is performed by filling the bladder with a urethral catheter and performing a non-contrast study to assess damage. The finished result is able to reflect even minor perforations, helping to more clearly determine how often urine leakage occurs and in what area.

• Cystography

Is the historical standard for imaging suspected bladder trauma. Although the examination should ideally be performed under fluoroscopic guidance, clinical circumstances often do not allow this. In such cases, simple cystography is performed. Tests can be easily performed in bed using portable imaging equipment.

Specialists perform a number of procedures if urethral trauma is excluded and the use of a catheter is possible.

• The results of the initial x-ray examination are obtained.
• Placed in the bladder.
• Slowly fill the bladder under the influence of gravity to a volume of 300-400 ml with contrast liquid.
• An x-ray of the anterior wall of the bladder is obtained.
• If no leakage is observed, continue filling the bladder.
• Oblique and lateral images are obtained.
• Drain the contrast liquid.

The importance of properly performed filling and subsequent drainage is of paramount importance in diagnosis. Injuries may be missed if radiographs of the bladder are not performed correctly. A well-executed procedure can detect leaks with 85-100% accuracy.

If the patient is quickly taken to the operating room, an immediate bladder examination is performed. In this case, if damage to the urethra is excluded, a urethral catheter is used. Otherwise, a suprapubic cystostomy can be performed, draining urine into the external environment through the stoma. After this, the bladder is carefully examined for perforation, for which it is filled with fluid. In some cases, intravenous indigo carmine or methylene blue is used to color the urine, which is very helpful in visualizing possible perforations.

If surgery is delayed or not indicated, access to the bladder is achieved using urethral or suprapubic catheterization. A CT scan or a regular x-ray of the bladder is used for control purposes.

Histological examination of tissue is usually not performed in conditions of damage and subsequent repair of the bladder. However, if bladder perforation occurs secondary to a pathological process or foreign masses are noticed, samples may be sent for analysis. The results will reflect the underlying disease.

Treatment methods for bladder rupture

Majority extraperitoneal injuries bladder can be effectively drained through a urethral or suprapubic catheter and treated conservatively. Depending on the expected size of the defect, there is a need for artificial drainage of urine for 10 to 14 days. Then a control x-ray is taken to determine the quality of healing. Approximately 85% of these injuries show signs of healing within 7-10 days. After this, the catheter can be removed and the first voiding test can be performed. In general, almost all extraperitoneal bladder injuries heal within 3 weeks.

Essentially, every intraperitoneal injury bladder requires surgical treatment. Such lesions will not heal on their own with prolonged drainage of the bladder alone, because urine will continue to flow into the abdominal cavity, despite the presence of a functional catheter. This leads to metabolic disorders and culminates in urinary ascites, bloating and intestinal obstruction. All gunshot wounds must be surgically explored because the likelihood of injury to other abdominal organs and vascular structures is quite high.

Bladder injuries can be of different types: open and closed, isolated and combined, intraperitoneal, extraperitoneal and mixed.

Injuries of this nature require immediate medical attention. This is justified by the fact that, in addition to the bladder, neighboring organs can also be injured. Among other things, urine may leak from the damaged bladder and fill the abdominal cavity. Often such injuries are incompatible with life.

Penetrating wounds or blunt trauma can lead to similar consequences. In these cases, there is a high probability of bladder rupture. If the injury is closed, then the damage occurs to the walls of the bladder, while urine remains inside the organ.

Blunt trauma can rupture the bladder, and it can also be intraperitoneal, extraperitoneal, or a combination. If the urethra is damaged, there is a possibility of its narrowing or complete closure. This occurs after blunt trauma or infection in the wound. Most often, urethral injury occurs due to a blow to the perineal area, where the organ is located.

Signs of damage

Most often, bladder damage occurs due to closed trauma. Anatomically, the bladder is located in the pelvis, it is reliably protected from many injuries. But there are circumstances when even such protection cannot protect it from damage. This happens in case of bone damage, fractures, when a broken bone in the pelvis injures an organ. The cause may be car accidents, falls from a height, household injuries, etc.

Along with damage to the bladder, the urethra can also be injured. In this case, there is a possibility of internal bleeding.

If the injury is closed, its symptoms are as follows:

1. Severe abdominal pain that spreads to the perineum.
2. The bladder cannot be emptied.
3. Bleeding.
4. Discharge of urine containing blood.
5. Bloating.

If the urethra is injured, the following signs may appear:

1. Urine comes out with delay.
2. At night, urination occurs frequently.
3. Involuntary urination.
4. Frequent urination, uncontrollable leakage.
5. Urine passage is infrequent and delayed.

Diagnostic measures

An initial examination of the victim by a doctor may yield some results. But for a complete picture of what is happening, you should undergo diagnostics, which includes:

• retrograde cystography;
• computed tomography;
• X-ray of the pelvic organs;
• ultrasonography.

It should be noted that with a closed form of injury it is very difficult to make a diagnosis. Symptoms may be mild even if the bladder ruptures. But if you miss time and do not perform the operation, the consequences of the injury can be disastrous for the person.

Treatment of pathologies

First aid:

1. If there is a wound, apply an aseptic bandage.
2. The patient should be laid on his back and a cushion placed under his head, legs bent at the knees and rest ensured.
3. If the injured person is in shock, it is better to lay him down so that his head is lower than his torso.
4. In case of a bladder injury, something cold is applied to the injury site, but the victim himself needs to be warmed up.
5. Wait for the doctors to arrive or take the person to the hospital yourself.

Treatment involves surgery. The most commonly used method is laparotomy. In this case, the walls of the bladder are restored.

If the injury is closed, there are hematomas in the pelvic area, an autopsy is not performed. In case of a gunshot wound of the bladder without damage to the peritoneum, the operation is performed through the wound by drainage. If the injury is closed, then treatment largely depends on the characteristics of the injury. When treating bladder injuries, several specialists may be involved: a urologist, a surgeon, a traumatologist. Treatment has its own specifics depending on the type of injury.

Contusion:

1. Drainage through a catheter, most often carried out initial observation.
2. Transurethral drainage is carried out until the bladder is restored.

Intraperitoneal rupture of the bladder:

1. With such an injury, a rupture of the apex of the organ is observed.
2. Surgery.
3. For minor damage, drainage is performed through a catheter.
4. Surgery using laparoscopy is possible.

Extraperitoneal bladder rupture:

1. Transurethral drainage.
2. On the 10th day, cystography is performed, which most often shows good treatment results.
3. In case of extraperitoneal rupture, taking antibiotics is considered mandatory in order to prevent bacteriological infection.

Sometimes a doctor prescribes reconstructive surgery, which is performed in the following cases:

1. If the catheter cannot be drained for some reason, such as blood clots blocking its passage or persistent extravasation.
2. If nearby organs, such as the vagina or rectum, are damaged.
3. If the neck of the bladder is damaged.

Non-surgical therapy is possible for mild organ damage and includes:

1. Insertion of a urethral catheter into the bladder for a certain number of days.
2. Maintaining bed rest.
3. Treatment to stop bleeding.
4. A course of antibacterial therapy.
5. Taking anti-inflammatory drugs.
6. Anesthesia.

Causes of bladder injuries

1. Falling from a height onto a hard surface or object.
2. A jump in which a sharp shaking of the body occurs in the presence of a filled bladder.
3. A strong blow to the stomach, a bruise.
4. Use of firearms or bladed weapons.
5. Medical actions: catheter insertion, bougienage, surgery.
6. Alcohol, drunk in large quantities, contributes to bladder injury, since at this moment the person cannot control the urinary system.
7. Some diseases can also cause organ injury. These include prostate adenoma, prostate cancer, and narrowing of the urethra.

Possible complications:

1. Bleeding that is difficult to stop, leading to shock, often incompatible with life.
2. The occurrence of urosepsis, when an infection from the bladder enters the bloodstream and spreads throughout the body.
3. Purulent formations in the blood and urine surrounding the bladder.
4. The formation of fistulas due to suppurations that come out through the tissue, forming a passage to the internal organs.
5. Peritonitis is characterized by inflammation of the walls and interior of the abdominal cavity.
6. Osteomyelitis is an inflammation of the pelvic bone tissue.

Preventive measures

1. Prevent urinary system diseases.
2. Avoid situations where injury may occur.
3. Avoid excessive drinking.
4. If there was an injury that was operated on, you should regularly visit a urologist for three years to prevent possible complications.

You should also keep PSA – prostate-specific antigen – under control. This is a protein that is responsible for the functioning of the prostate gland. If blood tests provide information about its increase, then there may be abnormalities in the functioning of the prostate gland, even oncology.

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First aid for bladder injury

Emergency care for anuria

With postrenal anuria, the patient requires emergency hospitalization in the urology department. The most common cause of such anuria is the presence of a stone in the kidney or ureter. For pain in the lumbar region, the prescription of antispasmodics and analgesics is indicated.

Emergency care for kidney injury

Providing emergency care at the prehospital stage with signs of traumatic shock and internal bleeding is reduced to anti-shock measures and the administration of hemostatics (adroxonium, vikasol), as well as cardiovascular drugs. In case of isolated kidney or subcapsular injuries, on-site treatment measures are limited to the administration of antispasmodics, and sometimes promedol and other narcotic drugs, cardiovascular drugs. These activities can be continued in the ambulance. In case of severe damage to the kidney with ruptures, bleeding continues. It is necessary to begin drip administration of blood replacement and anti-shock solutions, which must be continued in the hospital, where blood transfusion is also possible.

In the hospital, surgical tactics are twofold. It depends on the severity of the injury. In case of subcapsular damage, conservative therapy is carried out (hemostatic and antibacterial drugs), strict bed rest is prescribed for 3 weeks. If the kidney ruptures, emergency surgical intervention is performed, the volume of which depends on the degree of damage (nephrectomy, resection of the lower pole, primary suture).

The main task of an emergency doctor is to promptly deliver the victim to a hospital where there is a urology department. During transportation, anti-shock measures are taken.

Emergency care for bladder injuries

Providing first medical aid begins immediately with anti-shock and hemostatic measures. They can continue during transportation of the patient. The main task of an ambulance and emergency doctor is to quickly deliver the patient to an on-duty surgical hospital or, better yet, to an institution where there is an on-duty urological service. It is very important to make a correct diagnosis, as this immediately directs the doctor on duty at the emergency room to carry out emergency diagnostic and therapeutic measures. The main diagnostic method performed in a hospital is ascending cystography with the introduction of a contrast agent into the bladder cavity. At the same time, its leakage into the abdominal cavity or into the perinephric tissue is clearly visible on radiographs. Treatment of ruptures and injuries to the bladder is surgical: suturing the bladder wound, applying an opicystostomy, draining the pelvis. For intraperitoneal injuries, the operation begins with laparotomy and revision of the abdominal organs.

Emergency care for urethral trauma

Based on clinical symptoms and objective examination, there is every opportunity to make a diagnosis of damage to the urethra. Insertion of a catheter into the urethra is completely contraindicated. Treatment measures are aimed at combating shock and internal bleeding. They must begin immediately and not stop during transport. Before transporting over a long distance, especially under difficult road conditions, it is advisable to perform a capillary puncture of the bladder.

The main task of an ambulance and emergency doctor is the urgent delivery of the victim to a hospital where there is a surgical or urological department.

In case of severe pelvic injuries and multiple injuries to the body, patients are transported on a board to the trauma department. In the hospital, the method of choice is epicystostomy. With timely delivery of the patient and successful anti-shock therapy in young and middle age, in the absence of multiple injuries and concomitant diseases, primary plastic surgery is possible, which is performed after recovery from shock during the first 1 - 2 days. To do this, it is necessary to carry out special urological studies: excretory urography and urethrography.

For open injuries (wounds), an aseptic bandage is applied. Persons with damage to the pelvic bones should be placed on a shield with a bolster under their legs bent at the knees. In case of hematuria without signs of internal bleeding and shock, it is possible to transport patients while sitting, in case of profuse hematuria with severe anemia and a drop in blood pressure - on a stretcher. In case of pain and shock, anti-shock measures are taken.

studfiles.net

Bladder injury symptoms and treatment

Bladder injuries most often result from fractures of the pelvic bones, which occur as a result of a car accident, fall, blow, or household injury. Injuries can be closed or open, intraperitoneal or extraperitoneal. Moreover, in 80% of cases, damage occurs as a result of closed injuries. But open bladder injuries are much more dangerous than closed ones, as they are complicated by damage to neighboring organs and the introduction of various infections.

Treatment of bladder injury

First aid in the treatment of bladder injury

Here are some valuable tips on providing first aid to a victim of a bladder injury:

If there is a wound, an aseptic dressing must be applied.

Lay the injured person on his back, raising his head and placing bolsters under his knees. Ensure complete rest. If there are signs of traumatic shock, the patient should be placed on his back at an angle of 45° so that the pelvis is elevated in relation to the head.

Apply cold to the lower abdomen and warm the victim himself.

Take him to the hospital immediately for treatment.

Due to the severe pain in the bladder area experienced by the victim, a painful shock occurs. Therefore, the provision of medical care must begin with anti-shock measures and surgical treatment of the wound, which will make it possible to determine the nature of the injury and the extent of surgical intervention.

Treatment of bladder injuries is exclusively surgical. Only minor minor injuries do not require surgery. In this case, antibacterial therapy is carried out, and, if necessary, a catheter is installed.

Bladder Trauma Symptoms

Main symptoms of bladder injury

With a closed injury to the bladder, internal bleeding begins, the victim feels severe pain in the lower abdomen, he is unable to empty the bladder on his own, blood appears in the urine, and bloating is observed.

With open injuries to the bladder, the following symptoms are observed: pain in the lower abdomen, which gradually spreads throughout the abdomen or to the perineal area, frequent but ineffective urge to urinate, urine leaking from the wound mixed with blood.

With extraperitoneal bladder injury, the symptoms are as follows: blood in the urine, pain in the lower abdomen, muscle tension above the pubis and in the iliac regions, which does not disappear even when the bladder is emptied.

With intraperitoneal ruptures of the bladder, urination disorders, bleeding or bloody urine are observed, then signs of peritonitis appear.

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Bladder injuries

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Scope of assistance for injuries of the genitourinary system at the stages of medical evacuation

For closed kidney injuries, first medical aid includes anti-shock measures, administration of antibiotics, and catheterization of the bladder for acute urinary retention.

Qualified medical care. In case of mass admission, victims with closed kidney injury are sent to the hospital department for conservative treatment (hemostatic agents, infusion therapy, analgesics, anti-inflammatory drugs). Conservative treatment is carried out in cases where the general condition of the wounded person is satisfactory, there is no profuse hematuria, symptoms of ongoing internal bleeding and growing perirenal urohematoma. Indications for surgical treatment are combined injuries of the abdominal organs, ongoing internal bleeding, increasing urohematoma, profuse hematuria (with a large number of blood clots).

The kidney is removed in cases of crushing of the renal parenchyma, in case of deep ruptures of the kidney body penetrating into the pelvis, as well as in cases of damage to the vessels of the renal pedicle.

For gunshot wounds of the kidney, first medical aid includes correction and replacement of the bandage, anti-shock measures, administration of antibiotics and tetanus toxoid for wounds, catheterization of the bladder for acute urinary retention.

Qualified medical care. In case of open kidney damage, the wounded with signs of ongoing internal bleeding and profuse hematuria are immediately sent to the operating room; in case of shock of II-III degree without signs of bleeding - to the anti-shock ward; those in agony are sent to the hospital wards; all other wounded with possible kidney damage - to the operating room first. .

Surgical intervention begins with laparotomy, damage to the abdominal organs is eliminated, the kidney is examined and the necessary operation is performed. Inspection of the damaged kidney must be carried out after applying a tourniquet to the vascular pedicle. After removal of a kidney or other operation, a counter-aperture is applied in the lumbar region and the wound is drained through it. The posterior layer of the peritoneum above the removed kidney is sutured.

Indications for nephrectomy are: crushing of the entire renal parenchyma, multiple and single deep ruptures of the kidney penetrating into the pelvis, crushing of one of the ends of the kidney with deep cracks reaching the hilum of the kidney or pelvis. Nephrectomy is also indicated for damage to the renal pedicle.

Before removing a damaged kidney, it is necessary to determine the presence of a second kidney, which is achieved by preoperative intravenous urography or ultrasound, as well as by palpation of the kidney during revision of the abdominal cavity. The presence and function of the second kidney can be established as follows: the ureter of the damaged kidney is clamped, 5 ml of 0.4% indigo carmine solution is injected intravenously and after 5–10 minutes it is determined in the urine obtained by catheterization of the bladder.

Organ-preserving operations include suturing kidney wounds and resection of its ends. Surgical treatment of kidney wounds is carried out by economical excision of crushed areas of the parenchyma, removal of foreign bodies and blood clots, and careful suturing of bleeding vessels. To stop bleeding, a temporary soft clamp is applied to the vascular pedicle for no more than 10 minutes. It is better to close the renal wound using U-shaped sutures.

It is more expedient to perform resection of the ends of the kidney using a ligature method. Suturing kidney wounds and ligature resection of its ends must be combined with the application of a nephrostomy. Drainage of the retroperitoneal space is carried out through the lumbar region by bringing out 2-3 tubes. The wound in the lumbar region is sutured to drainage.

Injuries to the ureters are rarely diagnosed during the provision of qualified surgical care during surgery. If a wound to the ureter is detected, the latter is stitched onto a thin polyvinyl chloride tube, which at one end is brought out through the renal pelvis and parenchyma to the outside through the lumbar region along with pararenal and paraureteral drainages. If the surgeon has an internal stent, it is advisable to suture the ureteral wound after installing the stent. If the ureteral defect is significant (over 5 cm), its central end is sutured into the skin, and the ureter is intubated with a polyvinyl chloride tube. Reconstructive operations are performed in a specialized hospital for those wounded in the chest, abdomen, and pelvis.

Specialized urological care for closed injuries and gunshot wounds of the kidneys includes delayed surgical interventions, reconstructive operations, treatment of complications (suppuration, fistulas, pyelonephritis, narrowing of the urinary tract) and elimination of manifestations of renal failure.

When the bladder is injured, first medical aid includes temporary stopping of bleeding, pain relief, intravenous infusion of polyglucin, cardiac drugs, antibiotics and tetanus toxoid. In case of overdistension of the bladder, catheterization or capillary puncture is performed. The wounded with bladder damage are evacuated first of all in a lying position.

Qualified medical care. Injured patients with bladder injuries are subject to surgical treatment. If bleeding and shock continue, anti-shock measures are carried out in the operating room, where the wounded are delivered immediately after admission. The operation is urgent.

In case of intraperitoneal injuries to the bladder, an emergency laparotomy is performed. The bladder wound is sutured with a double-row suture using absorbable material. Extraperitonealization is performed. The abdominal cavity, after removing the spilled urine, is washed with saline solution. The bladder is drained using a cystostomy, and the paravesical space is drained through the surgical wound using several tubes.

The technique for applying a suprapubic vesical fistula is as follows. An incision 10–12 cm long is made in the midline between the navel and the womb, the skin, tissue and aponeurosis are dissected, and the rectus and pyramidal muscles are pulled apart. By blunt means in the proximal direction, the prevesical tissue is separated from the bladder along with the fold of the peritoneum. Two provisional sutures are placed on the wall of the bladder at the very top, using which the bladder is pulled into the wound. Having isolated the peritoneum and tissue with tampons, dissect the bladder between the stretched ligatures. After making sure that the bladder is opened, a drainage tube with a lumen diameter of at least 9 mm is inserted into it. The end of the tube inserted into the bladder must be cut obliquely (the cut edges are rounded), and a hole is made on the side wall equal to the diameter of the tube lumen. The tube is first inserted to the bottom of the bladder, then pulled back 1.5–2 cm and sewn to the wound of the bladder with catgut thread.

The wall of the bladder is sutured with a double-row suture with absorbable threads. A rubber graduate is introduced into the prevesical tissue. The wound is sutured in layers, with one of the skin sutures additionally fixing the drainage tube.

For extraperitoneal wounds of the bladder, wounds accessible for suturing are sutured with double-row catgut (Vicryl) sutures; wounds in the area of ​​the bladder neck and bottom are sutured from the mucosal side with catgut; If it is impossible to suturing them, the edges of the wounds are brought together with catgut, drainage is brought from the outside to the wound site. Urine is drained from the bladder using a cystostomy and a urethral catheter. In case of extraperitoneal injuries, it is necessary to drain the pelvic tissue not only through the anterior abdominal wall, but also through the perineum. To do this, after suturing the bladder wall from the wound of the abdominal wall with a forceps, they bluntly pass from the peri-vesical tissue to the perineum through the obturator foramen (according to I.V. Buyalsky-McWhorter) or under the symphysis pubis on the side of the urethra (according to P. A. Kupriyanov), The skin is cut above the end of the forceps and the captured drainage tube is inserted in a reverse motion.

If drainage of the pelvic tissue was not performed during the primary intervention, if urinary leakage develops, the pelvic tissue is opened using a typical approach according to I. V. Buyalsky-McWhorter. The wounded person is placed on his back with the knees bent and the leg abducted at the hip joint. An 8–9 cm long incision is made on the anterior inner surface of the thigh, parallel to the femoral-perineal fold and 2–3 cm below it. The adductor muscles of the thigh are bluntly separated and approached to the obturator foramen of the pelvis. At the descending ramus of the pubis, the obturator externus muscle and the obturator membrane are dissected along the fibers. Pushing apart the muscle fibers with a forceps, they penetrate into the ischiorectal fossa. By stupidly pushing apart the levator ani muscle, they enter the prevesical tissue, where blood and urine accumulate. The presence of 2-3 tubes in the prevesical space ensures drainage of the pelvic tissue, prevention and treatment of urinary leaks, thrombophlebitis and other dangerous complications.

When providing specialized surgical care, complications that develop after bladder injuries are treated. Intraperitoneal injuries are complicated by peritonitis and abdominal abscesses. Extraperitoneal injuries can lead to the formation of urinary infiltration, urinary and purulent streaks with the transition to phlegmon of the pelvic and retroperitoneal tissue. Subsequently, osteomyelitis of the pelvic bones, thrombophlebitis, cystitis, pyelonephritis, and urosepsis may occur.

Success in the treatment of urethral injuries depends on correctly chosen tactics and consistent implementation of treatment measures. The scope of assistance at the stages of medical evacuation for closed injuries is the same as for injuries to the urethra.

First medical aid comes down to measures to prevent and combat shock and bleeding, administration of antibiotics, tetanus toxoid. In case of urinary retention, a suprapubic capillary puncture of the bladder is performed.

Qualified medical care. Anti-shock measures are ongoing for the victim. Urine diversion (excluding bruises and tangential wounds without damage to the mucous membrane) is performed by applying a cystostomy. Surgical treatment of the wound is performed, hematomas and urinary leaks are drained. In case of damage to the posterior urethra, the pelvic tissue is drained according to I. V. Buyalsky-McWhorter or according to P. A. Kupriyanov. If the surgeon has the appropriate skills, it is advisable to perform tunnelization of the urethra with a silicone tube with a diameter of 5–6 mm. Primary urethral suture is strictly prohibited. Restoration of the urethra is carried out in the long term after final scarring and elimination of inflammatory phenomena. A soft polyvinyl chloride catheter can be installed only if it is freely and non-violently passed through the urethra into the bladder. Closed injuries in the form of a bruise or incomplete rupture of the urethral wall without significant urethrorrhagia, with preserved ability to urinate and satisfactory condition, are treated conservatively (antispasmodics, tranquilizers; for urethrorrhagia - vikasol, calcium chloride; sodium ethamsylate; antibiotics for prophylactic purposes). If damage to the urethra is accompanied by urinary retention, a soft catheter is installed for 4–5 days or a suprapubic puncture of the bladder is performed. Damage in the form of a complete rupture, interruption, or crushing of the urethral wall is treated surgically.

Specialized urological care consists of surgical treatment of wounds according to indications, application of a suprapubic urinary fistula, extensive drainage of the pelvic tissue, perineum and scrotum, surgery to restore the integrity of the urethra, and treatment of wound infectious complications. Plastic surgeries are performed after special studies that make it possible to judge the degree and nature of damage to the urethra. Primary suture is possible only for wounds of the hanging part of the urethra without large diastasis of the ends. It is advisable to restore the anterior section of the urethra by applying secondary sutures, and in case of damage to the posterior section - if the wounded person is in good condition - immediately after admission or after scarring and elimination of inflammation. If the condition is severe, the operation is postponed to a later date.

Operations to restore the integrity of the urethra are performed with mandatory urine diversion through a suprapubic vesical fistula.

For injuries to the scrotum, first medical aid includes stopping ongoing bleeding from the edges of the wound by ligating blood vessels, administering antibiotics, tetanus toxoid, and further anti-shock therapy.

Qualified and specialized medical care for wounded people with injuries to the scrotum and its organs comes down to primary surgical treatment of the wound, during which only clearly non-viable tissue is removed and bleeding is stopped. Depending on the type of damage, surgical treatment of wounds of the testicle, its epididymis, and spermatic cord is performed. When the scrotum is torn off, the testicles are immersed under the skin of the thighs. Indications for removal of the testicle are its complete crushing or separation of the spermatic cord. In case of multiple testicular ruptures, its fragments are washed with a 0.25–0.5% solution of novocaine with the addition of an antibiotic and sewn together with rare catgut (Vicryl) sutures. All operations end with wound drainage.

For bruises of the scrotum, conservative treatment is carried out. The presence of an intravaginal hematoma is an indication for surgery.

For injuries to the penis, qualified medical care includes primary surgical treatment of the wound, which amounts to the final stop of bleeding, economical excision of clearly non-viable tissue, and infiltration of tissue with an antibiotic solution. In case of lacerations, skin flaps are not excised, but are used to cover the defect by applying guide sutures. Damage to the cavernous bodies is sutured with catgut, grasping the tunica albuginea in the transverse direction. In the presence of combined damage to the urethra, a suprapubic vesical fistula is applied.

When providing specialized medical care, economical surgical treatment of the wound and plastic surgery are performed to replace extensive skin defects in the early stages or after cleansing the wounds of necrotic tissue and the appearance of granulations. Surgical treatment of impaired functions of the corpora cavernosa and operations to restore the penis are carried out after the elimination of all inflammatory phenomena in the scar area. Suppression of erections that occur after penile surgery is achieved by prescribing narcotics, estrogens, bromine preparations and neuroleptic mixtures.

Instructions for military field surgery