CHAPTER XXVI
Wounds of the Urinary Bladder (155Casualties)
Leon M. Michels, M. D.
There were 155 wounds of the urinary bladder (4.9 percent) in the 3,154abdominal injuries in this series (table 86). One hundred and thirty-four weremultivisceral; some portion of the intestinal tract as well as the bladder waswounded in every one of these cases.
TABLE 86.-Essential data in 155 wounds ofurinary 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 |
| 155 | 4.91 | 100.0 | 46 | 29.7 |
NATURE OF THE INJURY;
The most frequent sites of entry of missiles causing wounds ofthe bladder were the buttocks and the anterior abdominal wall. Each of thesesites was penetrated 56 times. Other sites of entry were the thigh, hip,perineum, back, flank, and, in one instance, the midaxilla. The missiles wereretained in the body in about two-thirds of the cases. Thirty-five wounds werecaused by bullets, seventy-one by shell fragments, and three by blunt trauma. Inthe 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 uponcomplicating intra-abdominal wounds and the amount of intra-abdominal orretroperitoneal hemorrhage. Discharge of urine through the abdominal wound wasobserved in 6 cases, and hematuria was present in 150 cases. Both
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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 wasbased partly on inferences derived from the nature of the wound. The path of themissile, as determined by an alinement of wounds of entrance and exit, or by thelocation of the wound of entrance in relation to the roentgenologic position ofthe retained foreign body (bodies), was the most important diagnosticconsideration. A possible injury of the bladder always had to be borne in mindin fractures of the bony pelvis, as well as in occasional instances of abdominalinjury following pressure or blast.
Although hematuria and the existence of a urinary fistula pointed to injuryof the urinary tract, their absence by no means warranted the conclusion that ithad not occurred. Filling the bladder with some solution for diagnostic purposeswas not regarded as good practice. If the organ had been punctured, additionalcontaminated material was likely to escape into the peritoneal cavity, and, moreimportant, extravasation of fluid could occur retroperitoneally andinfraperitoneally. Another contraindication to this practice was the fact that the majority of the patients had other abdominal lesions. Sincelaparotomy was required in all cases, nothing was lost, and the patient's safetywas enhanced, by delaying instillation of saline solution through a urethralcatheter until the abdomen was opened and conditions could be ascertained andcontrolled. 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 vesicalwounds were found at autopsy. The three other patients developed urinaryfistulas, through wounds in the thigh, rectum, and abdomen. All were subjectedto cystostomy, with satisfactory results.
In one case, a suspected injury to the bladder could not be demonstrated atoperation, but an indwelling catheter was nevertheless introduced. When it wasremoved, 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 bladderinjuries, laparotomy was required, regardless of the vesical wound. It wastherefore easy to inspect the intraperitoneal portion of the bladder and carryout such repairs as were necessary. After the peritoneum had been closed andsuprapubic cystostomy performed, the extraperitoneal portion of the bladder wasinspected, and whatever surgery might be required in that area was carried out.
The bladder injury, as already noted, was not identified at operation in 6cases. Seven patients died in the course of operation. In 10 other cases therewas 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 thewound, and penicillin, when it became available, was occasionally used in thesame manner. After operation, all patients received a sulfonamide drug by mouthor by vein, penicillin by the intramuscular route, or both agents incombination.
POSTOPERATIVE COMPLICATIONS
In spite of the high frequency of other intra-abdominal injuries, recordedpostoperative complications were not numerous in this series of bladderinjuries. Atelectasis occurred in 3 cases, and wound infection in 3.Evisceration occurred later in one of the infections. Fecal fistulas developedin 2 cases. Other single recorded complications included pneumonia, cardiacfailure, urinary fistula, secondary hemorrhage, pyelitis, epididymitis, andsubphrenic abscess. An abscess of unspecified location occurred in one case andpyrexia of undetermined origin in another. There was no instance of infection ofthe paravesical tissues in any of the surviving patients in the period (1 to 20days) in which they were followed in forward hospitals, and there was only oneinstance of retroperitoneal cellulitis among the patients who died.
FACTORS OF MORTALITY
In analyzing the case fatality rate in these 155 wounds of the bladder, itmust be borne in mind that 134 of them were multivisceral. Furthermore, inpractically all the multiple injuries, the other wounds presented greatertechnical problems and were of far more serious import than wounds of thebladder. This was particularly true of wounds of the pelvic blood vessels andwounds of the intestinal tract; an intestinal injury was present in everymultivisceral wound (table 87).
All 46 deaths (tables 86, 87, and 88) occurred in patients with other intra?abdominalinjuries, the case fatality rate rising as the number of other visceral injuriesincreased. The existence of the bladder wound apparently increased the riskassociated with the other injuries. The case fatality rate for 353 univisceralinjuries of the ileum and jejunum, for instance, was 13.9 percent (table 50). Inthe 40 cases in which a bladder injury was associated with the intestinalinjury, the rate was 22.5 percent. The case fatality rate for 251 univisceralinjuries of the colon was 22.7 percent (table 55). When a bladder injury wasassociated with the intestinal injury, the rate rose to 42.9 percent. On theother hand, none of the 21 casualties with univisceral lesions of the bladderdied, which makes the case fatality rate 34.3 percent (46 deaths) in the 134multivisceral cases.
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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 fatalitiesin abdominal injuries. The shock-mortality relationship followed the expectedpattern; namely, the greater the degree of shock when the patients were firstseen, the higher the case fatality rate. The rate was 8 percent in patients notin shock, 25 percent in patients in moderate shock, and 63 percent in patientsin severe shock.
TABLE 88.-Primary cause of death in relationto 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 |
| 15 | 3 | 10 | 4 | 6 | 1 | 3 | 42 |
1Exclusive of 4 deaths in which the causes are notknown and which occurred, respectively, at operation and on the second day, thethird day, and between the sixth and eighth days after operation.
2Miscellaneous causes included gas gangrene in 3 cases, a heartlesion and retroperitoneal cellulitis in 1 case each, and (probably) ananesthetic cause in 2 cases.
