Surgical Repair of Bladder Injuries
We use a continuous 2/0 Vicryl suture (i.e., absorbable) and close the bladder in two layers. In the first layer, ensure that any bleeding vessels in the cut edge of the bladder are ligated with the suture.
Whenever the urinary tract has been opened and then closed, it is a sensible precaution to leave a drain in place. It is inevitable
5. TRAUMATIC UROLOGICAL EMERGENCIES 109
that the closure will not be completely watertight, and as a consequence urine will leak through the suture line for a few days. A drain removes this and can prevent the consequences of a urine collection (a urinoma) becoming infected.
POSTERIOR URETHRAL INJURIES
As discussed above, these are essentially an injury that occurs following pelvic fracture, and specifically fracture of the pubic rami. In the emergency situation their management consists of diversion of the flow of urine past the injury, by suprapubic catheterization (see above).
ANTERIOR URETHRAL INJURIES
These injuries are rare. The majority occur as a result of a straddle injury in boys or men. For example, while riding a bicycle and suddenly applying the brakes, the perineum comes into forcible contact with the crossbar of the bicycle. The bulbar urethra is crushed between the crossbar and the pubic bone. Other mechanisms include direct injuries to the penis, penile fractures (Marsh et al. 1999), inflating a catheter balloon in the anterior urethra (Sellett 1971), and penetrating injuries by gunshot wounds.
Making the Diagnosis
In cases with these types of injuries, you should have a high index of suspicion that an anterior urethral injury has occurred. The patient may complain of blood at the end of the penis, difficulty in passing urine, or frank haematuria. A haematoma may develop around the site of the rupture. There may be swelling of the penis as a consequence of extravasation of urine into the peri-urethral tissues. If Buck's fascia has been ruptured, urine and blood may track into the scrotum, causing swelling and a characteristic 'butterfly-wing' pattern of bruising, which reflects the extent to which the bruising may spread as a consequence of the anatomical attachments of Colles' fascia (see below) (Fig. 5.22).