- Email: [email protected]
Traumatic Rupture of the Bladder and Urethra:1 Report of Cases
TRAUl\t!ATIC RUPTURE OF THE BLADDER AND URETHRA1 REPORT OF CASES W. CALHOUN STIRLING Washington, D. C.
Due to the position of the urinary organs, injury is relatively infrequent as compared to injuries in other parts of the body. However, since the advent of the automobile, injuries to the urinary tract have become more common. This report comprises 7 cases of rupture, 4 being urethral in origin and 3 involving the bladder. All were operated on by me and but one death occurred, that being a case of long standing stricture of the urethra with rupture and extravasation into the scrotum and space of Retzius. The patient was moribund when seen and no hope was offered for recovery even before drainage was established. Of the 7 cases, 4 were the results of automobile or motorcycle accidents, one was from falling astride a buggy wheel, one resulted from a stricture of the urethra and the seventh was due to a blow against the saddle horn while riding horseback. For the sake of brevity these cases are reported collectively. Other causes of trauma to the lower urinary tract include gunshot wounds, blows over the lower abdomen, spontaneous rupture of the urethra from an old stricture, etc. In bladder injuries the peritoneal cavity may be soiled and thus render the prognosis very grave. A study of the cases reported in the literature shows the mortality to be over 75 per cent where the condition is over twenty-four hours' duration. Watson reports a series of cases in which the non-operative treatment was followed by a mortality of 88.7 per cent, whereas early operative treatment has reduced the mortality to approximately 40 per cent. 1 Read before the Virginia, Maryland and District of Columbia Medical Society, Washington, D. C., November 10, 1926.
503
504
W. CALHOUN STIRLING
The diagnosis may be made by obtaining a history of recent trauma to_the urinary tract plus either the presence of blood in the urine or the absence of urine in the bladder on catheterization, or inability to pass a catheter to the bladder in cases of suspected rupture of the urethra. Extravasation of urine into the scrotum or suprapubic region may be seen depending on the site of rupture in relation to the triangular ligament. In borderline cases of suspected vesical rupture a cystoscopic examination may be made to determine if the bladder is ruptured. The exact point of rupture may be thus located also whether or not the peritoneal cavity has been invaded. An x-ray should be made in severe injuries of the bony pelvis, as fracture is not uncommon and may result in a spicule of bone piercing the bladder wall. Two of these cases had severe fracture of the pelvis, with tearing of the bladder by a bony fragment. The treatment of this condition consists of, first, supportive and, secondly, incision and drainage. The first group includes heat, stimulant to the heart together with fluids either under the breast or intravenously and an opiate for the pain. The operative treatment resolves itself into drainage of the peritoneal cavity if involved, a tube in the bladder if the peritoneum is not torn, together with an indwelling catheter in the urethra to drain the bladder through the normal route. In cases where the injury is confined to the urethra and it is impossible to pass a catheter through the site of rupture an external urethrotomy should be done. If extravasation of urine occurs, wide incisions are imperative to prevent extensive sloughing and gangrene. Due to the limited time only the outstanding cases of each group will be briefly reported herewith. CASE REPORTS OF RUPTURE OF THE BLADDER
Case 1. N. G., male, forty years, seen in consultation with Dr. Grimes, May, 1924. Patient was riding horseback and was thrown against the saddle horn. No immediate pain was experienced and but a slight nausea was felt. He continued home and went to bed with very little pain at the time. Several hours later he had a chill followed by a sharp rise jn temperature. His condition gradually grew worse, the
TRAUMATIC RUPTURE OF BLADDER AND URETHRA
505
pain in the suprapubic region increased in severity and some swelling was noted in the scrotum and inguinal region two days later. He was then brought to the hospital where I first saw him in consultation seven days after the accident. At this time he was very toxic, the temperature being 102, pulse 120 and respiration 24. In the left inguinal region, extending from the ilia! crest to the scrotum marked swelling and grayish discoloration of the tissues was seen. Blood was found on catheterization of the bladder but very little urine. The skin on the scrotum was very dark and gangrenous and was sloughing in places. The pre-operative diagnosis was traumatic rupture of the bladder with extensive extravasation of urine. Under ether anesthesia several wide incisions were made in the tumified areas and a drain inserted in the bladder. All the tissues in the bladder region were necrotic and contained a very foul fluid. The post-operative course was slow due to the extensive slough, but the patient was discharged cured four weeks later. Case 2. J. J., male, aged 87, was seen in July, 1926, in consultation with Dr. Louis Mackall. Chief complaint was difficulty in passing the urine together with hematuria. Patient gave a history of falling astride a buggy wheel sixty-five years ago rupturing the urethra at the peno-scrotal junction. An attempt was made at catheterization but it was unsuccessful and an external urethrotomy was done. A tube was left in the perineum for four weeks. This was followed by a permanent perinea! fistula. Since that time patient has been catheterizing himself at daily intervals with a very small silver catheter, followed by boric acid irrigations. He continued his daily occupation until six months ago when he began to notice some blood-tinged urine on catheterization. This grew worse until he was seen in July, 1926. Due to the scar formation about the perinea! fistula only an infant size cystoscope could be introduced into the bladder. A sessile growth was seen on the left lateral wall of the bladder just lateral to the left ureteral orifice. Diagnosis was made of carcinoma of bladder. The bladder was opened supra-pubically under novocaine and the carcinomatous mass examined. It was found to surround a small diverticulum and just at the point where the silver catheter touched the bladder wall laterally. Due to its wide dissemination no attempt was made to resect it, but the tumor was destroyed down to the pedicle with the radio knife. Several doses of x-ray were given later to lessen the bleeding. The patient picked up and regained some strength but died three months later from metastasis. It was felt the cancer was caused by the catheter touching the bladder
506
W. CALHOUN STIRLING
wall at one place over a period of sixty years as the patientfrequently walked about the room with the catheter in the bladder. This is the longest case of which I have any record where daily catheterization was practised. Case 3. Myrtle N., aged nineteen, seen June 5, 1926, in consultation with Dr. W. C. Gwynn. Patient gave a history of being in an automobile accident twelve hours previously and was rendered unconscious by the impact. Does not remember anything previous to her entry in the hospital following the accident. Physical examination shows marked rigidity of abdomen, intense pain on palpation of bladder region. The bladder was catheterized but no urine was obtained, but some blood escaped at this time. Her temperature was 97, pulse 140, respiration 36. An x-ray was made of the chest and pelvis, which shows three ribs to be fractured, also the bony pelvis was found to be fractured with a spicule of bone near the site of rupture of the bladder. A hurried cystoscopic examination was done using averysmallquantityof sterile water. This showed a rent in the bladder near the left ureteral orifice. A diagnosis of intraperitoneal rupture of the bladder was made and immediate drainage of the peritoneum suggested. This was done under gas-oxygen anesthesia. On exposure of the peritoneum it was found to be edematous and contained a dark fluid. It was opened and 1200 cc. of bloody urine removed. Due to her critical condition the rent in the bladder was not closed. Two tube drains were inserted and an indwelling catheter in the urethra. Despite the extensive soiling of the peritoneum no evidence of peritonitis developed following operation and she made an excellent recovery. The convalescence was stormy for several days due to the shock. The pelvic fracture was in excellent alignment so it was immobilized and united very satisfactorily. Patient left hospital four weeks later with bladder healed and no evidence of any cystitis. CASE REPORTS OF RUPTURE OF THE URETHRA
Case 4- John G.,·aged twelve, entered hospital June 18, 1926, seen in consultation with Drs. Joe Rogers and A. M. McDonald. He was in an auto accident and entered the hospital in shock with pain in the bladder region. An attempt was made to pass a catheter to the bladder but only a small amount of blood was obtained. An x-ray showed fracture of the pelvis with a spicule of bone on the inner surface of the iscium. A fluctuant mass was palpable suprapubically. The diagnosis before
TRAUMATIC RUPTURE OF BLADDER AND URETHRA
507
operation was rupture of the bladder neck. Under ether the bladder was exposed and the catheter seen lying beneath the bladder wall in the perivesical space. The rent was found in the posterior urethra and had completely severed the urethra at the entrance to the bladder. The bladder was then opened and a catheter passed through the penis and guided into the bladder with a drain suprapubically. Convalescence was slow but aside from the fractured pelvis was uninterrupted and patient discharged cured. Voiding was normal. Case 5. Jas B. T., aged 28, was seen June, 1925, in consultation with Dr. Brown. Patient gave a history of being in a collision and was thrown on the cross bar of his motorcycle. Following the accident he was unable to void and was brought to the hospital in great pain. Blood was seen issuing from the urethral meatus but an attempt to pass a catheter was unsuccessful. Some bulging was seen in the perineum, so immediate incision and drainage was suggested. An external urethrotomy was done and on opening the urethra it was found to be completely severed at the membranous urethra. The cut edges were approximated by suture and a catheter passed into the bladder through the normal channel. The patient made an uneventful recovery and was discharged, cured two weeks later. Sounds were passed to insure the patency of the urethra.
Lack of time precludes the possibility of reporting the other cases in this group. Six patients were cured, the seventh being moribund when first seen and no hope of a cure was offered at operation as the scrotum had sloughed off and the lower abdomen was necrotic. SUMMARY
1. Early diagnosis and treatment has reduced the mortality from 88.7 per cent to less than 40 per cent in cases of rupture of the bladder. 2. The triad of symptoms, i.e. tumor, bloody urine with inability to void is very suggestive of rupture of the bladder, especially if no urine is obtained on catheterization. 3. Traumatic rupture of the urethra is characterized by inability to pass a catheter to the bladder, blood at the urinary meatus
508
W. CALHOUN STIRLING
with swelling in the perineum. If seen early and drainage is established within twenty-four hours the mortality is very low. 4. All cases of injury to the urethra should be followed up to insure patency of the canal and sounds passed at intervals to insure the caliber of the urethra remaining of ample size.
Due to the position of the urinary organs, injury is relatively infrequent as compared to injuries in other parts of the body. However, since the advent of the automobile, injuries to the urinary tract have become more common. This report comprises 7 cases of rupture, 4 being urethral in origin and 3 involving the bladder. All were operated on by me and but one death occurred, that being a case of long standing stricture of the urethra with rupture and extravasation into the scrotum and space of Retzius. The patient was moribund when seen and no hope was offered for recovery even before drainage was established. Of the 7 cases, 4 were the results of automobile or motorcycle accidents, one was from falling astride a buggy wheel, one resulted from a stricture of the urethra and the seventh was due to a blow against the saddle horn while riding horseback. For the sake of brevity these cases are reported collectively. Other causes of trauma to the lower urinary tract include gunshot wounds, blows over the lower abdomen, spontaneous rupture of the urethra from an old stricture, etc. In bladder injuries the peritoneal cavity may be soiled and thus render the prognosis very grave. A study of the cases reported in the literature shows the mortality to be over 75 per cent where the condition is over twenty-four hours' duration. Watson reports a series of cases in which the non-operative treatment was followed by a mortality of 88.7 per cent, whereas early operative treatment has reduced the mortality to approximately 40 per cent. 1 Read before the Virginia, Maryland and District of Columbia Medical Society, Washington, D. C., November 10, 1926.
503
504
W. CALHOUN STIRLING
The diagnosis may be made by obtaining a history of recent trauma to_the urinary tract plus either the presence of blood in the urine or the absence of urine in the bladder on catheterization, or inability to pass a catheter to the bladder in cases of suspected rupture of the urethra. Extravasation of urine into the scrotum or suprapubic region may be seen depending on the site of rupture in relation to the triangular ligament. In borderline cases of suspected vesical rupture a cystoscopic examination may be made to determine if the bladder is ruptured. The exact point of rupture may be thus located also whether or not the peritoneal cavity has been invaded. An x-ray should be made in severe injuries of the bony pelvis, as fracture is not uncommon and may result in a spicule of bone piercing the bladder wall. Two of these cases had severe fracture of the pelvis, with tearing of the bladder by a bony fragment. The treatment of this condition consists of, first, supportive and, secondly, incision and drainage. The first group includes heat, stimulant to the heart together with fluids either under the breast or intravenously and an opiate for the pain. The operative treatment resolves itself into drainage of the peritoneal cavity if involved, a tube in the bladder if the peritoneum is not torn, together with an indwelling catheter in the urethra to drain the bladder through the normal route. In cases where the injury is confined to the urethra and it is impossible to pass a catheter through the site of rupture an external urethrotomy should be done. If extravasation of urine occurs, wide incisions are imperative to prevent extensive sloughing and gangrene. Due to the limited time only the outstanding cases of each group will be briefly reported herewith. CASE REPORTS OF RUPTURE OF THE BLADDER
Case 1. N. G., male, forty years, seen in consultation with Dr. Grimes, May, 1924. Patient was riding horseback and was thrown against the saddle horn. No immediate pain was experienced and but a slight nausea was felt. He continued home and went to bed with very little pain at the time. Several hours later he had a chill followed by a sharp rise jn temperature. His condition gradually grew worse, the
TRAUMATIC RUPTURE OF BLADDER AND URETHRA
505
pain in the suprapubic region increased in severity and some swelling was noted in the scrotum and inguinal region two days later. He was then brought to the hospital where I first saw him in consultation seven days after the accident. At this time he was very toxic, the temperature being 102, pulse 120 and respiration 24. In the left inguinal region, extending from the ilia! crest to the scrotum marked swelling and grayish discoloration of the tissues was seen. Blood was found on catheterization of the bladder but very little urine. The skin on the scrotum was very dark and gangrenous and was sloughing in places. The pre-operative diagnosis was traumatic rupture of the bladder with extensive extravasation of urine. Under ether anesthesia several wide incisions were made in the tumified areas and a drain inserted in the bladder. All the tissues in the bladder region were necrotic and contained a very foul fluid. The post-operative course was slow due to the extensive slough, but the patient was discharged cured four weeks later. Case 2. J. J., male, aged 87, was seen in July, 1926, in consultation with Dr. Louis Mackall. Chief complaint was difficulty in passing the urine together with hematuria. Patient gave a history of falling astride a buggy wheel sixty-five years ago rupturing the urethra at the peno-scrotal junction. An attempt was made at catheterization but it was unsuccessful and an external urethrotomy was done. A tube was left in the perineum for four weeks. This was followed by a permanent perinea! fistula. Since that time patient has been catheterizing himself at daily intervals with a very small silver catheter, followed by boric acid irrigations. He continued his daily occupation until six months ago when he began to notice some blood-tinged urine on catheterization. This grew worse until he was seen in July, 1926. Due to the scar formation about the perinea! fistula only an infant size cystoscope could be introduced into the bladder. A sessile growth was seen on the left lateral wall of the bladder just lateral to the left ureteral orifice. Diagnosis was made of carcinoma of bladder. The bladder was opened supra-pubically under novocaine and the carcinomatous mass examined. It was found to surround a small diverticulum and just at the point where the silver catheter touched the bladder wall laterally. Due to its wide dissemination no attempt was made to resect it, but the tumor was destroyed down to the pedicle with the radio knife. Several doses of x-ray were given later to lessen the bleeding. The patient picked up and regained some strength but died three months later from metastasis. It was felt the cancer was caused by the catheter touching the bladder
506
W. CALHOUN STIRLING
wall at one place over a period of sixty years as the patientfrequently walked about the room with the catheter in the bladder. This is the longest case of which I have any record where daily catheterization was practised. Case 3. Myrtle N., aged nineteen, seen June 5, 1926, in consultation with Dr. W. C. Gwynn. Patient gave a history of being in an automobile accident twelve hours previously and was rendered unconscious by the impact. Does not remember anything previous to her entry in the hospital following the accident. Physical examination shows marked rigidity of abdomen, intense pain on palpation of bladder region. The bladder was catheterized but no urine was obtained, but some blood escaped at this time. Her temperature was 97, pulse 140, respiration 36. An x-ray was made of the chest and pelvis, which shows three ribs to be fractured, also the bony pelvis was found to be fractured with a spicule of bone near the site of rupture of the bladder. A hurried cystoscopic examination was done using averysmallquantityof sterile water. This showed a rent in the bladder near the left ureteral orifice. A diagnosis of intraperitoneal rupture of the bladder was made and immediate drainage of the peritoneum suggested. This was done under gas-oxygen anesthesia. On exposure of the peritoneum it was found to be edematous and contained a dark fluid. It was opened and 1200 cc. of bloody urine removed. Due to her critical condition the rent in the bladder was not closed. Two tube drains were inserted and an indwelling catheter in the urethra. Despite the extensive soiling of the peritoneum no evidence of peritonitis developed following operation and she made an excellent recovery. The convalescence was stormy for several days due to the shock. The pelvic fracture was in excellent alignment so it was immobilized and united very satisfactorily. Patient left hospital four weeks later with bladder healed and no evidence of any cystitis. CASE REPORTS OF RUPTURE OF THE URETHRA
Case 4- John G.,·aged twelve, entered hospital June 18, 1926, seen in consultation with Drs. Joe Rogers and A. M. McDonald. He was in an auto accident and entered the hospital in shock with pain in the bladder region. An attempt was made to pass a catheter to the bladder but only a small amount of blood was obtained. An x-ray showed fracture of the pelvis with a spicule of bone on the inner surface of the iscium. A fluctuant mass was palpable suprapubically. The diagnosis before
TRAUMATIC RUPTURE OF BLADDER AND URETHRA
507
operation was rupture of the bladder neck. Under ether the bladder was exposed and the catheter seen lying beneath the bladder wall in the perivesical space. The rent was found in the posterior urethra and had completely severed the urethra at the entrance to the bladder. The bladder was then opened and a catheter passed through the penis and guided into the bladder with a drain suprapubically. Convalescence was slow but aside from the fractured pelvis was uninterrupted and patient discharged cured. Voiding was normal. Case 5. Jas B. T., aged 28, was seen June, 1925, in consultation with Dr. Brown. Patient gave a history of being in a collision and was thrown on the cross bar of his motorcycle. Following the accident he was unable to void and was brought to the hospital in great pain. Blood was seen issuing from the urethral meatus but an attempt to pass a catheter was unsuccessful. Some bulging was seen in the perineum, so immediate incision and drainage was suggested. An external urethrotomy was done and on opening the urethra it was found to be completely severed at the membranous urethra. The cut edges were approximated by suture and a catheter passed into the bladder through the normal channel. The patient made an uneventful recovery and was discharged, cured two weeks later. Sounds were passed to insure the patency of the urethra.
Lack of time precludes the possibility of reporting the other cases in this group. Six patients were cured, the seventh being moribund when first seen and no hope of a cure was offered at operation as the scrotum had sloughed off and the lower abdomen was necrotic. SUMMARY
1. Early diagnosis and treatment has reduced the mortality from 88.7 per cent to less than 40 per cent in cases of rupture of the bladder. 2. The triad of symptoms, i.e. tumor, bloody urine with inability to void is very suggestive of rupture of the bladder, especially if no urine is obtained on catheterization. 3. Traumatic rupture of the urethra is characterized by inability to pass a catheter to the bladder, blood at the urinary meatus
508
W. CALHOUN STIRLING
with swelling in the perineum. If seen early and drainage is established within twenty-four hours the mortality is very low. 4. All cases of injury to the urethra should be followed up to insure patency of the canal and sounds passed at intervals to insure the caliber of the urethra remaining of ample size.