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Fracture of Pelvis with Perforation of Urinary Bladder1
FRACTURE OF PELVIS WITH PERFORATION OF URINARY BLADDER1 ALFONSO E. GUERRA
External violence occasionally produces odd changes in structure and function of an organ. The case here described represents an unusual urinary complication following trauma. CASE REPORT
J. C., a young Mexican 18 years old, was admitted to the Urological Service on July 10, 1942, complaining of difficulty in urination and inability to walk. He stated that 4 months previously, while riding on the back of a truck which stopped suddenly, he had been thrown violently against the casette, loosing consciousness. On regaining it soon afterward, he felt intense pain in his left hip and thigh, inability to move his leg, and an urgent desire to urinate; however he was able to pass but a few drops of blood every few minutes. This bleeding stopped within 24 hours, chills and high fever developing by that time. It was not until 2 days later that he was able to void a small amount of bloody urine after a great deal of painful effort. Since tlien the difficulty has persisted; that is, passing a small amount of urine every 15 to .20 minutes after considerable effort and preceded by pain in suprapubic and perinea! regions. Further questioning on past history, family history, and so forth did not throw any more light on the case. Examination revealed a well-developed young man in no apparent pain nor distress except during urination. He was stretched in bed, with his left thigh flexed and adducted. External genitalia were normal. All the region just above the pubis was hard to palpation, dull to percussion but not tender. Digital examination per rectum revealed a definite unyielding hardness to its anterior and partly to its lateral walls, extending as far as the finger could reach. All other physical signs were negative. His temperature was 37.5°0., pulse 96, and respiration 24. The leukocyte count was 11,000 with 70 per cent polymorphonuclears. Plain x-ray films disclosed an old fracture of the neck of the femur and of the left inferior ramus of the pubis. A urethrogram showed the opaque medium filling a very irregular and tortuous posterior urethra, not emptying into the bladder but into an area 2 cm. in diameter, on its left side and on a level with the upper border of the pubis, approximately half way between the internal and external sphincter. The urological diagnosis was fracture of the left ramus of the pubis and rupture of the posterior urethra with chronic periurethritis and periurethral abscess. An attempt to pass a filiform failed but with this manipulation the infective process flared up within 24 hours. The pain became constant, the fever and pulse rate shot up, and the leukocyte count went up to 14,000. Sulfathiazole did not 1 Read at annual meeting, South Central Section, American Urological Association, Oklahoma City, Okla., September 25, 1942. 307
308
ALFONSO E. GUERRA
improve matters, and with a modified preoperative diagnosis of acute periurethritis a cystostomy was performed. All anatomical planes down to the bladder consisted of hard fibrous tissue. The peritoneum was adherent to this mass and was barely stripped back sufficiently to incise the bladder. This organ was found to be somewhat ovoid in shape, rigid, inelastic, uncollapsible, of about 100 cc in capacity, its walls imparting to the examining finger the sensation of a hard smooth cartilaginous cavity lined with velvet. A fragment of bone an inch long was discovered freely loose inside. The bladder neck was funnel-shaped and undilatable. To its left was found a jagged opening about half a centimeter in diameter and of unknown depth. A No. 12 F rubber catheter was passed down the bladder neck and out through the meatus, tying the two extremes over the pubis. The abscess seen in the urethrogram was drained through the retropubic space, yielding about 15 cc of purulent material. A Pezzer sound and a cigarette drain were left in place, and the wound was closed in the usual manner. All symptoms and signs of acute infection quickly subsided. Subsequent cystoscopic examinations through the cystostomy opening showed the jagged hole becoming smaller and the bladder acquiring some degree of distensibility. It was found impossible to dilate the posterior urethra beyond No. 12 F caliber. The catheter and the Pezzer sounds were removed after about 6 weeks and within a few days the patient was back where he started; that is, passing small amounts of urine frequently although with less difficulty and pain, some of the urine escaping through a small fistula where the cigarette drain had been placed to drain off the periurethral abscess. Several urethrograms were taken and all gave the same results; the opaque substance followed the path of least resistance past the external sphincter, into the posterior urethra, into the abscess, and then slowly into the bladder. There was no evidence that the internal sphincter could yield to the pressure of the instillation. The size of the abscess varied directly with the amount of substance pushed into it. Our iµterpretation of the findings was this: We had before us a bladder encased in hard fibrous tissue. This was the result of organization of previous acute pericystitis and periurethritis, leaving that organ with no ability to discharge its contents by contraction and with a rigid bladder neck unable to yield to hydrostatic pressure. As the ureters continued to pump urine, the intracystic pressure increased only to be transmitted through a fistula into an abscess cavity which had distensibility, elastic recoil, and control by the external sphincter. Pain was the sign of overdiste:p_tion and intra-abdominal pressure the means of emptying it. Nature had accidentally provided the patient with an organ having the function of storing and expelling urine as a supplement to a useless bladder. Four possible solutions were considered: To leave it alone, condemning the patient to permanent frequency, ascending pyelonephritis, and probable acute exacerbation of the local infection; to drain the abscess through perineal section, leaving a permanent urinary fistula and no urinary control; to transplant the ureters and resect bladder and all infected tissue, a risky procedure in view of the
PELVIC FRACTURE AND BLADDER PERFORATION
309
adherence of the peritoneum to the pericystic :fibrosis; to leave a permanent cystostomy, an easy but unpleasant way out of the difficulty. Case histories presented at medical meetings attempt to show what has been found and what has been done. We present this one because we believe the :findings are unusual, as stated previously, a bladder encased in post-inflammatory cartilaginous-like tissues, and an accidental formation of a cavity with bladderlike function. But we do not show what has been done, rather ask what should be done. Monterrey, Mexico.
External violence occasionally produces odd changes in structure and function of an organ. The case here described represents an unusual urinary complication following trauma. CASE REPORT
J. C., a young Mexican 18 years old, was admitted to the Urological Service on July 10, 1942, complaining of difficulty in urination and inability to walk. He stated that 4 months previously, while riding on the back of a truck which stopped suddenly, he had been thrown violently against the casette, loosing consciousness. On regaining it soon afterward, he felt intense pain in his left hip and thigh, inability to move his leg, and an urgent desire to urinate; however he was able to pass but a few drops of blood every few minutes. This bleeding stopped within 24 hours, chills and high fever developing by that time. It was not until 2 days later that he was able to void a small amount of bloody urine after a great deal of painful effort. Since tlien the difficulty has persisted; that is, passing a small amount of urine every 15 to .20 minutes after considerable effort and preceded by pain in suprapubic and perinea! regions. Further questioning on past history, family history, and so forth did not throw any more light on the case. Examination revealed a well-developed young man in no apparent pain nor distress except during urination. He was stretched in bed, with his left thigh flexed and adducted. External genitalia were normal. All the region just above the pubis was hard to palpation, dull to percussion but not tender. Digital examination per rectum revealed a definite unyielding hardness to its anterior and partly to its lateral walls, extending as far as the finger could reach. All other physical signs were negative. His temperature was 37.5°0., pulse 96, and respiration 24. The leukocyte count was 11,000 with 70 per cent polymorphonuclears. Plain x-ray films disclosed an old fracture of the neck of the femur and of the left inferior ramus of the pubis. A urethrogram showed the opaque medium filling a very irregular and tortuous posterior urethra, not emptying into the bladder but into an area 2 cm. in diameter, on its left side and on a level with the upper border of the pubis, approximately half way between the internal and external sphincter. The urological diagnosis was fracture of the left ramus of the pubis and rupture of the posterior urethra with chronic periurethritis and periurethral abscess. An attempt to pass a filiform failed but with this manipulation the infective process flared up within 24 hours. The pain became constant, the fever and pulse rate shot up, and the leukocyte count went up to 14,000. Sulfathiazole did not 1 Read at annual meeting, South Central Section, American Urological Association, Oklahoma City, Okla., September 25, 1942. 307
308
ALFONSO E. GUERRA
improve matters, and with a modified preoperative diagnosis of acute periurethritis a cystostomy was performed. All anatomical planes down to the bladder consisted of hard fibrous tissue. The peritoneum was adherent to this mass and was barely stripped back sufficiently to incise the bladder. This organ was found to be somewhat ovoid in shape, rigid, inelastic, uncollapsible, of about 100 cc in capacity, its walls imparting to the examining finger the sensation of a hard smooth cartilaginous cavity lined with velvet. A fragment of bone an inch long was discovered freely loose inside. The bladder neck was funnel-shaped and undilatable. To its left was found a jagged opening about half a centimeter in diameter and of unknown depth. A No. 12 F rubber catheter was passed down the bladder neck and out through the meatus, tying the two extremes over the pubis. The abscess seen in the urethrogram was drained through the retropubic space, yielding about 15 cc of purulent material. A Pezzer sound and a cigarette drain were left in place, and the wound was closed in the usual manner. All symptoms and signs of acute infection quickly subsided. Subsequent cystoscopic examinations through the cystostomy opening showed the jagged hole becoming smaller and the bladder acquiring some degree of distensibility. It was found impossible to dilate the posterior urethra beyond No. 12 F caliber. The catheter and the Pezzer sounds were removed after about 6 weeks and within a few days the patient was back where he started; that is, passing small amounts of urine frequently although with less difficulty and pain, some of the urine escaping through a small fistula where the cigarette drain had been placed to drain off the periurethral abscess. Several urethrograms were taken and all gave the same results; the opaque substance followed the path of least resistance past the external sphincter, into the posterior urethra, into the abscess, and then slowly into the bladder. There was no evidence that the internal sphincter could yield to the pressure of the instillation. The size of the abscess varied directly with the amount of substance pushed into it. Our iµterpretation of the findings was this: We had before us a bladder encased in hard fibrous tissue. This was the result of organization of previous acute pericystitis and periurethritis, leaving that organ with no ability to discharge its contents by contraction and with a rigid bladder neck unable to yield to hydrostatic pressure. As the ureters continued to pump urine, the intracystic pressure increased only to be transmitted through a fistula into an abscess cavity which had distensibility, elastic recoil, and control by the external sphincter. Pain was the sign of overdiste:p_tion and intra-abdominal pressure the means of emptying it. Nature had accidentally provided the patient with an organ having the function of storing and expelling urine as a supplement to a useless bladder. Four possible solutions were considered: To leave it alone, condemning the patient to permanent frequency, ascending pyelonephritis, and probable acute exacerbation of the local infection; to drain the abscess through perineal section, leaving a permanent urinary fistula and no urinary control; to transplant the ureters and resect bladder and all infected tissue, a risky procedure in view of the
PELVIC FRACTURE AND BLADDER PERFORATION
309
adherence of the peritoneum to the pericystic :fibrosis; to leave a permanent cystostomy, an easy but unpleasant way out of the difficulty. Case histories presented at medical meetings attempt to show what has been found and what has been done. We present this one because we believe the :findings are unusual, as stated previously, a bladder encased in post-inflammatory cartilaginous-like tissues, and an accidental formation of a cavity with bladderlike function. But we do not show what has been done, rather ask what should be done. Monterrey, Mexico.