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Chapter 26

Contents

CHAPTER XXVI  

Wounds of the Urinary Bladder (155 Casualties)

Leon M. Michels, M. D.  

There were 155 wounds of the urinary bladder (4.9 percent) in the 3,154 abdominal injuries in this series (table 86). One hundred and thirty-four were multivisceral; some portion of the intestinal tract as well as the bladder was wounded in every one of these cases.  

TABLE 86.-Essential data in 155 wounds of urinary bladder  

Type of wound

Cases

Frequency

Deaths

Case fatality rate

In 3,154 abdominal injuries

In 155 bladder injuries

 

 

Percent

Percent

 

 

Univisceral

21

0.67

13.5

0

0

Multivisceral

134

4.25

86.5

46

34.3


Total

155

4.91

100.0

46

29.7


NATURE OF THE INJURY ;

The most frequent sites of entry of missiles causing wounds of the bladder were the buttocks and the anterior abdominal wall. Each of these sites was penetrated 56 times. Other sites of entry were the thigh, hip, perineum, back, flank, and, in one instance, the midaxilla. The missiles were retained in the body in about two-thirds of the cases. Thirty-five wounds were caused by bullets, seventy-one by shell fragments, and three by blunt trauma. In the remaining cases, the wounding agent was not recorded.

The wound was an intraperitoneal laceration of the bladder in 137 cases an extraperitoneal laceration in 9 cases, and a severe contusion without laceration in 9 cases. 

CLINICAL CONSIDERATIONS  

The physical findings in bladder injuries were not pathognomonic. Tenderness, rigidity, and the presence or absence of peristalsis depended chiefly upon complicating intra-abdominal wounds and the amount of intra-abdominal or retroperitoneal hemorrhage. Discharge of urine through the abdominal wound was observed in 6 cases, and hematuria was present in 150 cases. Both 


314

findings pointed to injury of some portion of the urinary tract but did not necessarily implicate the bladder.  

Diagnosis was made correctly before operation in 149 of the 155 cases. It was based partly on inferences derived from the nature of the wound. The path of the missile, as determined by an alinement of wounds of entrance and exit, or by the location of the wound of entrance in relation to the roentgenologic position of the retained foreign body (bodies), was the most important diagnostic consideration. A possible injury of the bladder always had to be borne in mind in fractures of the bony pelvis, as well as in occasional instances of abdominal injury following pressure or blast.  

Although hematuria and the existence of a urinary fistula pointed to injury of the urinary tract, their absence by no means warranted the conclusion that it had not occurred. Filling the bladder with some solution for diagnostic purposes was not regarded as good practice. If the organ had been punctured, additional contaminated material was likely to escape into the peritoneal cavity, and, more important, extravasation of fluid could occur retroperitoneally and infraperitoneally. Another contraindication to this practice was the fact that the majority of the patients had other abdominal lesions. Since laparotomy was required in all cases, nothing was lost, and the patient's safety was enhanced, by delaying instillation of saline solution through a urethral catheter until the abdomen was opened and conditions could be ascertained and controlled. Not all surgeons employed this method even then.  

There were 2 fatalities in the 5 bladder injuries overlooked at operation. Both patients died on the day after operation, of other causes, and the vesical wounds were found at autopsy. The three other patients developed urinary fistulas, through wounds in the thigh, rectum, and abdomen. All were subjected to cystostomy, with satisfactory results.  

In one case, a suspected injury to the bladder could not be demonstrated at operation, but an indwelling catheter was nevertheless introduced. When it was removed, on the sixth day, a small foreign body was passed by the urethra. Recovery was thereafter uneventful.  

TREATMENT  

Since multivisceral wounds were present in most patients with bladder injuries, laparotomy was required, regardless of the vesical wound. It was therefore easy to inspect the intraperitoneal portion of the bladder and carry out such repairs as were necessary. After the peritoneum had been closed and suprapubic cystostomy performed, the extraperitoneal portion of the bladder was inspected, and whatever surgery might be required in that area was carried out.  

The bladder injury, as already noted, was not identified at operation in 6 cases. Seven patients died in the course of operation. In 10 other cases there was no record of the type of procedure. In the remaining 132 cases,  


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repair was done in 116, in 110 of which suprapubic cystostomy was also performed, and 13 patients were submitted to suprapubic cystostomy alone. An indwelling catheter was used in the three other cases. The space of Retzius was drained routinely. 

Sulfonamides were occasionally implanted in the peritoneal cavity or in the wound, and penicillin, when it became available, was occasionally used in the same manner. After operation, all patients received a sulfonamide drug by mouth or by vein, penicillin by the intramuscular route, or both agents in combination. 

POSTOPERATIVE COMPLICATIONS  

In spite of the high frequency of other intra-abdominal injuries, recorded postoperative complications were not numerous in this series of bladder injuries. Atelectasis occurred in 3 cases, and wound infection in 3. Evisceration occurred later in one of the infections. Fecal fistulas developed in 2 cases. Other single recorded complications included pneumonia, cardiac failure, urinary fistula, secondary hemorrhage, pyelitis, epididymitis, and subphrenic abscess. An abscess of unspecified location occurred in one case and pyrexia of undetermined origin in another. There was no instance of infection of the paravesical tissues in any of the surviving patients in the period (1 to 20 days) in which they were followed in forward hospitals, and there was only one instance of retroperitoneal cellulitis among the patients who died.  

FACTORS OF MORTALITY  

In analyzing the case fatality rate in these 155 wounds of the bladder, it must be borne in mind that 134 of them were multivisceral. Furthermore, in practically all the multiple injuries, the other wounds presented greater technical problems and were of far more serious import than wounds of the bladder. This was particularly true of wounds of the pelvic blood vessels and wounds of the intestinal tract; an intestinal injury was present in every multivisceral wound (table 87).  

All 46 deaths (tables 86, 87, and 88) occurred in patients with other intra­abdominal injuries, the case fatality rate rising as the number of other visceral injuries increased. The existence of the bladder wound apparently increased the risk associated with the other injuries. The case fatality rate for 353 univisceral injuries of the ileum and jejunum, for instance, was 13.9 percent (table 50). In the 40 cases in which a bladder injury was associated with the intestinal injury, the rate was 22.5 percent. The case fatality rate for 251 univisceral injuries of the colon was 22.7 percent (table 55). When a bladder injury was associated with the intestinal injury, the rate rose to 42.9 percent. On the other hand, none of the 21 casualties with univisceral lesions of the bladder died, which makes the case fatality rate 34.3 percent (46 deaths) in the 134 multivisceral cases.  


316

TABLE 87.-Influence of wounds of intestinal tract on case fatality rates in 155 wounds of urinary bladder

Injuries

Cases

Deaths

Case fatality rate

Total

155

46

29.7

    

Without intestinal injuries

21

0

0

    

With intestinal injuries

134

46

34.3

         

Wounds of-

 

 

 

              

extraperitoneal rectum

6

1

16.7

              

intraperitoneal rectum

17

3

17.6

              

small bowel

40

9

22.5

              

colon, exclusive of rectum

21

9

42.9

              

large and small bowel and rectum

50

24

48.0


The causes of death (table 88) were those usually responsible for fatalities in abdominal injuries. The shock-mortality relationship followed the expected pattern; namely, the greater the degree of shock when the patients were first seen, the higher the case fatality rate. The rate was 8 percent in patients not in shock, 25 percent in patients in moderate shock, and 63 percent in patients in severe shock.  

TABLE 88.-Primary cause of death in relation to time of death in 42 wounds of urinary bladder1

Cause

Day of operation

Postoperative day

Total cases

1st

2d

3d

4th

5th

6th to 8th, inclusive 

Shock

9

2

4

---

---

---

---

15

Peritonitis

1

1

3

1

1

---

---

7

Respiratory

---

---

2

1

1

---

1

5

Anuria

---

---

1

1

2

---

---

4

Pulmonary embolism

1

---

---

---

1

1

1

4

Other2

4

---

---

1

1

---

1

7


Total

15

3

10

4

6

1

3

42


1Exclusive of 4 deaths in which the causes are not known and which occurred, respectively, at operation and on the second day, the third day, and between the sixth and eighth days after operation.  
2Miscellaneous causes included gas gangrene in 3 cases, a heart lesion and retroperitoneal cellulitis in 1 case each, and (probably) an anesthetic cause in 2 cases.

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