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2. Discussion
ileus and intraabdominal abscess formation [8]. Blad-
der rupture is most commonly seen in combination
with a pelvic fracture (70±95%) and occurs in 4±15%
of cases of pelvic fracture [6]. Extraperitoneal ruptures
(50±85%) are more common than intraperitoneal rup-
tures (15±45%) and rarely (0±12%) they occur in com-
bination [9].
Urethral injury occurs in 5±10% of cases of pelvic
fracture and is more likely to occur with anterior dis-
ruption of the pelvic ring occurring in 20% of unilat-
eral and 50% of bilateral symphyseal fractures [5].
The male urethra is divided anatomically into an-
terior (distal) and posterior (proximal) parts. The pos-
terior urethra composed of membranous and prostatic
segments is classically damaged during pelvic fractures
in which shearing forces are applied to the prostato-
membranous junction. Trauma to the posterior urethra
therefore typically occurs in patients with multiple
injuries some of which may require urgent attention.
The diagnosis in men is usually not dicult and it
would be suspected by the history and con®rmed by
abdominal and digital rectal examination, as discussed,
and documentation on retrograde urethrography.
There are, however, several pitfalls [13]. There is poor
correlation between the amount of urethral bleeding
and the severity of the injury as a total transection of
the urethra may result in little bleeding whereas a
mucosal contusion or a small partial tear may be ac-
companied by torrential bleeding. A high riding pros-
tate also does not always indicate a ruptured urethra
as the posterior urethra can stretch quite considerably
without disruption of its wall. A pelvic haematoma
may also obliterate the outline of the prostate and it
may be assumed that the prostate has been displaced
upward and out of reach even though it is not far
from its normal position. Retrograde urethrography is
the cornerstone of diagnosis of posterior urethral
injury and should demonstrate the presence or absence
of urethral injury. Inherent dangers of diagnostic
catheterisation should also be highlighted as a partial
rupture may well be converted into a complete rup-
ture, or a catheter passed freely into the peri-prostatic
region (Case 5) through the injured urethra and intro-
duce infection into a previously sterile haematoma. If
the urethral catheter cannot be easily inserted at the
®rst attempt or if there is a high suspicion of urethral
injury as mentioned previously, many would insert a
supra-pubic catheter and perform a de®nitive urethro-
scopy at 10±12 days post injury. Although beyond the
scope of this paper the primary goal of treatment of
urethral injuries should be that of achieving urinary
continence and minimising stricture formation as well
as sexual impotence [7].
Classically intraperitoneal ruptures consist of a hori-
zontal tear in the dome of the bladder, which is cov-
ered by peritoneum and is believed to occur when the
bladder is full as a result of a blow delivered to the
lower abdomen; the dome being the weakest point of
the bladder. Extraperitoneal ruptures are usually as-
sociated with pelvic fractures and usually involve the
anterolateral aspect. These can result from direct pen-
etration by bony spicules (76%) or disruption of the
ligamentous attachments between the bladder and the
pelvis or a bursting type similar to the intraperitoneal
rupture [2]. It should be mentioned that although pri-
mary bladder repair and suprapubic catheter place-
ment is generally accepted as the best treatment for
intraperitoneal bladder rupture [10], extraperitoneal
bladder ruptures may be treated with catheter drai-
nage. This may occur if the urine clears promptly, the
catheter drains well and the bladder neck is not
involved in the injury; otherwise formal repair is man-
datory [11].
In the literature Retrograde Cystography has an ac-
curacy rate ranging from 85 to 100% [6,8,9,11,12].
False negatives have been shown to occur with in-
adequate distension of the bladder where the volume
of contrast infused is less than 250 ml, and when a
post washout ®lm has not been performed. It has been
postulated that without adequate distension the natu-
ral elasticity of the vesical musculature the buering
action of the perivesical tissues or extravesical ¯uid or
haematoma may allow for closure at the site of perfor-
ation. Unless a post washout ®lm is performed extra-
vasated contrast maybe masked by a distended bladder
®lled with contrast media and thus lead to a false
negative result.
3. Recommendations
1. Any patient with a pelvic fracture should be
assumed to have a genitourinary injury until proven
otherwise.
2. High energy shearing injuries and transverse or
pubic ramus fractures should increase this suspicion.
3. Retrograde combined urethrocystograms may
require up to 450 ml of contrast to demonstrate a
leak and true oblique with post washout ®lms must
be performed.
Bladder rupture is uncommon and accounts for less
than 2% of abdominal injuries requiring surgical
repair [6]. It is the associated injuries, which are re-
sponsible for most of the deaths. Mortality rates in the
literature range from 11 to 44% [1] but a delay in the
diagnosis of more than 24 h increases morbidity and
mortality [1,6]. Patients present with abdominal pain
and distension and can suer from prolonged paralytic
4. The passage of a catheter in the resuscitation room