|SYMPOSIUM ON PELVIC TRAUMA
|Year : 2014 | Volume
| Issue : 1 | Page : 29-32
Pelvic fracture and urogenital injuries
Ashwani Kumar Dalal1, Tej Prakash Sinha2, Debajyoti Mohanty1
1 Department of General Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Department of Trauma and Emergency Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
|Date of Web Publication||6-Jun-2014|
Ashwani Kumar Dalal
Department of General Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Pelvic injuries occur in major crash accidents. Injury to the bladder and membranous urethra are the commonest associated urogenital injuries. More and more urethral injuries are being managed conservatively in the acute phase for fear of hemorrhage and infection, which may result in late sequel of urethral injuries. The definitive surgery can be delayed in favor of simple.
Keywords: Pelvic fracture, bladder injury, urethral injury, cystostomy, urethrography
|How to cite this article:|
Dalal AK, Sinha TP, Mohanty D. Pelvic fracture and urogenital injuries. J Orthop Traumatol Rehabil 2014;7:29-32
|How to cite this URL:|
Dalal AK, Sinha TP, Mohanty D. Pelvic fracture and urogenital injuries. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 May 26];7:29-32. Available from: http://www.jotr.in/text.asp?2014/7/1/29/134008
| Introduction|| |
Pelvic ring injuries are usually encountered in major crash high-energy scenes and are challenging clinical problems in which an urgent multidisciplinary approach is required. Pelvic fractures are reportedly the third most common cause of death in motor vehicle crashes, ranked only after central nervous system and chest injuries. 
Early mortality is usually associated with hemorrhage from both pelvic and extrapelvic sources or severe closed head injury, whereas late mortality is secondary to sepsis or multiple system organ failure. Nonoperative methods of managing hemorrhage have gained favor in recent experience. Rupture of the urinary bladder and avulsion of the membranous urethra in males are among the integral risks in pelvic trauma. In pelvic trauma, it is always essential to exclude bladder and urethral injuries if patient has not voided urine after injury, and if there is blood at the tip of urethra.
The overall incidence of pelvic ring injuries has been reported to range between 3% and 8% of all skeletal injuries. The majority of pelvic ring injuries is caused by blunt trauma and is most commonly encountered after motor vehicle crashes. This is, in particular, true for the younger population, whereas pelvic injuries in elderly patients more often result from falls. ,
The overall mortality rates with pelvic ring injuries ranged from 3% to 20%. ,,,,,,,,,,,,,,,,,,
The incidence of urogenital injury ranges from 23% to 57%. ,,,, Urethral and vaginal injuries are the most common injuries. , Vaginal lacerations result from either penetration of a bony fragment or from indirect forces from diastasis of the symphysis pubis.
Injuries to the cervix, uterus, and ovaries are rare. , Bladder rupture occurs in up to 10% of pelvic fractures. The incidence of rectal injury ranges from 17% to 64% dependent upon type of fracture. ,,,, Bowel entrapment is rare.  Pelvic injury is commonly associated with concomitant intrathoracic and or intraabdominal injury. 
| Detection and management of injuries to the lower urinary tract|| |
Injury to the genitourinary organs should be suspected in patients with pelvic fracture if the patient has suprapubic pain and tenderness, perineal ecchymosis, laceration, and/or tenderness, hematuria, is unable to void or if there is bloody urethral discharge, blood, or periprostatic hematoma discovered on digital rectal examination. Injury is confirmed by radiographic study, which is conducted as follows: In acute setting, when urethral disruption is suspected, retrograde urethrogram is performed first [Figure 1]a and b. Posterior urethral disruptions can be managed acutely by realignment of the urethra over a urethral catheter or by placement of a suprapubic catheter for bladder drainage only. Catheterization is often recommended as the first diagnostic step after the injury is suspected; however, it should be discouraged if urethrography is not available. Since catheterization may introduce infection in to the pelvic hematoma and may add to the trauma of injured urethra and may fail to reveal the presence of incomplete urethral injury. If the urethra is demonstrated to be intact, a catheter is inserted in to the bladder and a cystourethrogram is performed by instillation of approximately 300 cc of contrast media. A postevacuation film is also obtained. Measurement of fluid instilled and fluid returned should be made. Intravenous pyelogram is obtained to evaluate the upper urinary tract. Gross hematuria discovered after spontaneous voiding or after insertion of a Foley catheter is the most common sign of bladder injury. Computed tomography cystogram with distended bladder and postemptying views has replaced the traditional retrograde cystourethrogram for the diagnosis of bladder injury.
|Figure 1: (a) Retrograde urethrogram showing normal urethra (b) Retrograde urethrogram showing extravasation of contrast suggestive of urethral rupture|
Click here to view
The bladder may be injured by perforation by displaced spicules of bone or sudden compression, resulting in bursting due to a rise in intravesical pressure. Hemorrhage from the ruptured bladder is rarely a problem in terms of blood loss, although clots may obstruct the catheter which is used to drain the bladder, thereby complicate management. Extravasation of urine is a major problem in injuries to the bladder. Extravasation of sterile urine for a brief time, however, induces little inflammatory response in the retroperitoneum or the peritoneal cavity. Therefore, rupture of the bladder is not a catastrophic event if it is recognized early.
Regardless of how a suprapubic cystostomy is placed, it is always advisable to distend the bladder during localization of the surgical site. This affords the physician the best opportunity to find the bladder quickly and avoid bowel injury. It is better performing percutaneous cystostomy as high as possible so that pelvic reconstructive surgeries can be done safely at a later date.
Early "direct" bladder repairs are easily performed at the time of anterior pelvic open reduction and internal fixation.  This approach of primary bladder injury repair at the time of pelvic fixation avoids missing entrapment of viscera such as bowel within the symphysis pubis diastasis at the same time it needs team approach and required skill for good outcome.
With prompt recognition and appropriate treatment the outcome should be good. Chronic sequels are rare. The customary treatment in practice of most urologists has been operative repair and postoperative catheter drainage. However, recent experience reported from several centers suggests that many of these patients can be successfully treated without surgery if the bladder is drained by way of an indwelling catherer.  Selection of patients for a nonoperative treatment is a matter of judgment. At present, nonoperative treatment is advised, except in patients who have only minimal extravasation and do not require abdominal surgery for other reasons. Intraperitoneal rupture of the bladder is an indication for abdominal exploration and suture repair of the bladder. Laparoscopic bladder repair has been reported, but there are not enough data available to analyze the real value of this approach.
Injuries to membranous urethra are a more difficult problem because of the prevalence of the late complications. The mechanism of this injury is based on the following anatomical considerations: The urogenital diaphragm is firmly attached to the pubic rami. The prostate is fixed to the pubis by the puboprostatic ligament. When the central portion of the pubis is displaced, traction is exerted on the urethra which, at this point is thin and delicate. The injury usually occurs at the junction of the membranous and bulbar urethra. Aside from the fact that the patient is unable to void, the injury poses no immediate problem but still the primary concern, in the patient with pelvic fracture urethral distraction injury is, resuscitation of the patient to preserve life because of associated injuries. Extravasation of urine is minimal because of the competence of the bladder neck. Late sequel is frequent; however, strictures are common. Sexual impotence is reported to occur in 30% of patients who sustain the injury. 
Divert urine away from the site of injury, preserve the residual sphincter mechanism at the bladder neck, and avoiding jeopardizing sexual function. If suprapubic cystostomy approach is chosen, the distraction defect between the two ends of the urethra often scars and becomes fibrotic, blocking the urethra and bladder emptying. Once fibrosis has stabilized, the patient can undergo posterior urethroplasty. In most cases, this procedure can be performed via a perineal approach in a single-stage surgery. The results of this single-stage perineal urethroplasty are excellent and a patent urethra can be reestablished in the majority of men who undergo surgery. ,,
Urethral injury is not confined to male patients only. In women with suspected pubic bone fractures, vaginal examination to examine the urethra for blood or laceration is necessary. The physical examination, although valuable, is not foolproof. A significant proportion of patients found to have urethral injury will not have positive physical findings.
There are many techniques which are used for primary realignment, these include the following:
- Simple passage of a catheter across the defect. This maneuver will be possible only in few cases and in partial ruptures only.
- Endoscopically assisted catheter realignment using flexible, rigid endoscopes, and biplanar fluoroscopy.
- Use of interlocking sounds (''railroading'' or magnetic catheters to place the catheter. This is an open surgical technique used for posterior urethral injury, where the sound is passed per urethra from below as well as through the bladder urethra is aligned and repaired over a catheter.
- Pelvic hematoma evacuation and dissection of the prostatic apex (with or without suture anastomosis) over a catheter.
- Catheter traction or perineal traction sutures to pull the prostate back to its normal location.
- Traumatic posterior urethral injury and early realignment using magnetic urethral catheters.
Hadjizacharia et al.,  showed that patients undergoing immediate endoscopic early spontaneous voiding compared with patients undergoing delayed repair and had a significantly decreased rate of stricture formation. Data are also clear that early realignment of the disrupted urethra in men and early definitive repair of the injured urethra in women are both associated with improved long-term sexual function.  For these reasons, early, expeditious diagnosis, and realignment of urethral disruptions with avoidance of suprapubic catheterization are preferred. Injury to the bladder neck in association with a disrupted prostatic urethra is a particularly troublesome rare injury that can lead to chronic incontinence if not identified early and has recently been successfully managed with implantation of an artificial sphincter.  Two or 3 weeks after injury a cystogram is done by instillation of contrast media into the bladder via the suprapubic cystostomy tube. If urethral injury was incomplete, urethra may heal spontaneously and the patient may be able to void; in which case, the cystostomy is removed and subsequent examinations are scheduled to monitor for the development of stricture. In most patients, complete loss of the continuity of the urethra will be found. In this event, repair of the defect is electively scheduled 3-6 months after injury. The prostate may remain displaced so that the subsequent repair is difficult because of the distance between the ends of the divided urethra. This is an unusual occurrence. In most cases, the prostate returns to its normal anatomic position with reabsorption of the pelvic hematoma. Patients who receive cystostomy alone as initial treatment experience delay in full recovery, because of the need for subsequent diagnostic evaluation and, in most cases, surgical repair of the urethra.
Advantages of this approach are many; however, in some circumstances, early surgical requirements are simplified. This is in particular advantage in multiple injury patients. Diagnostic uncertainties, anesthesia risks, and risks involved in elective surgery may be increased by the presence of associated injuries. Cystostomy may be performed without invading the hematoma and delay definitive repair until the hematoma is resolved.
| Perineal injury and open pelvic fracture|| |
Open pelvic fracture is a particularly troublesome problem to deal with because the associated perineal laceration may involve the anus, rectum, vagina, and urethra and direct communication with the pelvic fracture site can lead to early decompression of the pelvic hematoma and exsanguinations or contamination of the pelvic hematoma, leading to sepsis and multiple organ failure. Moreover, later contamination of the fracture site or pelvic hematoma is possible because of transmural laceration of the vagina or rectum or faecal soiling of the laceration when bowel activity resumes.
Careful digital rectal examination with selective sigmoidoscopy (either rigid or flexible) will often disclose the extent of injury and allow an estimate of the risk for contamination and faecal soilage.
Vaginal lacerations should be repaired. When injured, the anal sphincter complex should be reapproximated to the degree possible. Large complex wounds should undergo daily debridement and pulse irrigation in the operating room until bedside dressing changes can be tolerated. Diverting colostomy may be necessary to prevent septic complications and when indicated should be performed within 48 h of injury. Open pelvic fractures with lacerations in the groin or pubic area carry a much lower risk of fecal soilage and colostomy will usually not be needed in this situation.
| Summary|| |
The results of management of bladder injuries associated with pelvic fractures should be good if the condition is recognized early. Late sequels are rare in this injury as compared with injuries of the membranous urethra in males. Controversy surrounds the question of nonoperative management of the injuries of the bladder. The feasibility of delayed repair of injuries of membranous urethra has been well-established. Impotence is an important consideration, since reports indicate that it occurs with greater frequency when early repair is attempted. The definitive repair should be delayed by simple cystostomy.
| References|| |
|1.||Dalinka MK, Arger P, Coleman B. CT in pelvic trauma. Orthop Clin North Am 1985;16:471-80. |
|2.||Tscherne H, Pohlemann T. Becken und Azetabulum. Berlin: Springer Verlag; 1998. |
|3.||Wubben RC. Mortality rate of pelvic fracture patients. Wis Med J 1996;95:702-4. |
|4.||O'brien DP, Luchette FA, Pereira SJ, Lim E, Seeskin CS, James L, et al. Pelvic fracture in the elderly is associated with increased mortality. Surgery 2002;132:710-4. |
|5.||Rommens PM, Hessman MH. Staged reconstruction of pelvic ring disruption: Differences in morbidity, mortality, radiologic results, and functional outcomes between B1, B2/B3, and C-type lesions. J Orthop Trauma 2002;16:92-8. |
|6.||Gustavo Parreira J, Coimbra R, Rasslan S, Oliveira A, Fregoneze M, Mercadante M. The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures. Injury 2000;31:677-82. |
|7.||Allen CF, Goslar PW, Barry M, Christiansen T. Management guidelines for hypotensive pelvic fracture patients. Am Surg 2000;66:735-8. |
|8.||Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Velmahos G, Chan L. Pelvic fractures: Epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002;195:1-10. |
|9.||Riemer BL, Butterfield SL, Diamond DL, Young JC, Raves JJ, Cottington E, et al. Acute mortality associated with injuries to the pelvic ring: The role of early patient mobilization and external fixation. J Trauma 1993;35:671-5. |
|10.||Rothenberger D, Velasco R, Strate R, Fischer RP, Perry JF Jr. Open pelvic fracture: A lethal injury. J Trauma 1978;18:184-7. |
|11.||Mucha P Jr, Farnell MB. Analysis of pelvic fracture management. J Trauma 1984;24:379-86. |
|12.||Chong KH, DeCoster T, Osler T, Robinson B. Pelvic fractures and mortality. Iowa Orthop J 1997;17:110-4. |
|13.||Poole GV, Ward EF, Muakkassa FF, Hsu HS, Griswold JA, Rhodes RS. Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries. Ann Surg 1991;213:532-8. |
|14.||Eastridge BJ, Burgess AR. Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695-700. |
|15.||Van Veen IH, Van Leeuwen AA, Van Popta T, Van Luyt PA, Bode PJ, Van Vugt AB. Unstable pelvic fractures: A retrospective analysis. Injury 1995;26:81-5. |
|16.||Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, et al. Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma 1990;30:848-56. |
|17.||Fox MA, Mangiante EC, Fabian TC, Voeller GR, Kudsk KA. Pelvic fractures: An analysis of factors affecting prehospital triage and patient outcome. South Med J 1990;83:785-8. |
|18.||Ismail N, Bellemare JF, Mollitt DL, DiScala C, Koeppel B, Tepas JJ 3 rd . Death from pelvic fracture: Children are different. J Pediatr Surg 1996;31:82-5. |
|19.||Davidson BS, Simmons GT, Williamson PR, Buerk CA. Pelvic fractures associated with open perineal wounds: A survivable injury. J Trauma 1993;35:36-9. |
|20.||Torode I, Zieg D. Pelvic fractures in children. J Pediatr Orthop 1985;5:76-84. |
|21.||Hadjizacharia P, Inaba K, Teixeira PG, Kokorowski P, Demetriades D, Best C. Evaluation of immediate endoscopic realignment as modality for traumatic urethral injuries. J Trauma 2008;64:1443-9. |
|22.||Naam NH, Brown WH, Hurd R, Burdge RE, Kaminski DL. Major pelvic fractures. Arch Surg 1983;118:610-6. |
|23.||Gilliland MD, Ward RE, Barton RM, Miller PW, Duke JH. Factors affecting mortality in pelvic fractures. J Trauma 1982;22:691-3. |
|24.||Ferrera PC, Hill DA. Good outcomes of open pelvic fractures. Injury 1999;30:187-90. |
|25.||Hanson PB, Milne JC, Chapman MW. Open fractures of the pelvis. Review of 43 cases. J Bone Joint Surg Br 1991;73:325-9. |
|26.||Ben-Menachem Y, Coldwell DM, Young JW, Burgess AR. Hemorrhage associated with pelvic fractures: Causes, diagnosis, and emergent management. AJR Am J Roentgenol 1991;157:1005-14. |
|27.||Fleming WH, Bowen JC 3 rd . Control of hemorrhage in pelvic crush injuries. J Trauma 1973;13:567-70. |
|28.||Dyer GS, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury 2006;37:602-13. |
|29.||Sinnott R, Rhodes M, Brader A. Open pelvic fracture: An injury for trauma centers. Am J Surg 1992;163:283-7. |
|30.||Smith RJ. Avulsion of the nongravid uterus due to pelvic fracture. South Med J 1989;82:70-3. |
|31.||Lunt HR. Entrapment of bowel within fractures of the pelvis. Injury 1970;2:121-6. |
|32.||Reiff DA, McGwin G Jr, Metzger J, Windham ST, Doss M, Rue LW 3 rd . Identifying injuries and motor vehicle collision characteristics that together are suggestive of diaphragmatic rupture. J Trauma 2002;53:1139-45. |
|33.||Routt ML, Simonian PT, Defalco AJ, Miller J, Clarke T. Internal fixation in pelvic fractures and primary repairs of associated genitourinary disruptions: A team approach. J Trauma 1996;40:784-90. |
|34.||Robards VL, Haglund RV, Lubin EN, Leach JR. Treatment of rupture of the bladder. J Urol 1976;116:178-9. |
|35.||Gibson GR. Impotence following fractured pelvis and ruptured urethera. Br J Urol 1970;42;86-8. |