With a launched Anururia, the patient needs emergency hospitalization into the urological department. The most common cause of such anuria is the presence of a stone in the kidney or a ureter. In case of pain in the lumbar region, the appointment of antispasmodic and painkillers is shown.

Emergency care for kidney injury

Emergency assistance in the pre-hospital stage with signs of traumatic shock and internal bleeding is reduced to anti-deposit measures and to the introduction of hemostatics (adroxonium, vikasol), as well as cardiovascular funds. With isolated damage to the kidney, subcapsular therapeutic measures on site are reduced to the introduction of spasmolitics, and sometimes priedol and other narcotic drugs, cardiovascular preparations. These events can be continued in ambulance. With severe damage to the kidney with ruptures, its bleeding continues. Need to begin drip administration The bloodstream and anti-shock solutions that need to continue in the hospital where hemotransfusion is possible.

In the hospital, the surgical tactics is twofold. It depends on the severity of injury. During subcapsular damage, conservative therapy (hemostatic and antibacterial drugs), a strict bed regime is prescribed for 3 weeks. When the kidney breaks, an emergency surgery is made, the volume of which depends on the degree of damage (nephrectomy, resection of the lower pole, primary seam).

The main task of the ambulance is to deliver the victim to the hospital in a timely manner where there is urology department. During transportation, anti-deposit measures are held.

Emergency assistance in injuries of bladder

The provision of first medical assistance begins immediately with anti-deposit and hemostatic activities. They can continue during the transportation of the patient. The main task of the ambulance and emergency care is fast delivery of a patient in a surgical hospital duty or better in such an institution where there is a duty urological service. It is very important to correctly diagnose, as it immediately focuses on the duty officer of the receiving rest to conduct emergency diagnostic and therapeutic measures. The main diagnostic method conducted in the hospital is ascending cystography with the introduction contrast substance in the cavity bladder. At the same time, the radiographs are clearly visible to it in the abdominal cavity or in an octoral fiber. Treatment of breaks and bladder damage Operative: embedding wounds of the bladder, the imposition of opicostostomas, drainage of the pelvis. With intraperitoneal damage, the operation begins with laparotomy and audit of the organs abdominal cavity.

Emergency assistance in the injury of the urethra

Based clinical symptoms and objective research There are all possibilities to diagnose the damage to the urethra. The introduction of the catheter in the urethra is completely contraindicated. Therapeutic measures are aimed at combating shock and internal bleeding. They should begin immediately and not stop during transportation. Before transporting for a long distance, especially with difficult road conditions, it is advisable to produce capillary bladder puncture.

The main task of the ambulance and emergency care is urgent delivery of the victim in the hospital, where there is a surgical or urological department.

With severe pelvic injuries and multiple body damage, patients are transported on a shield into a traumatology department. In the hospital, the method of choice is epicistostomy. With timely delivery of the patient and successful anti-depository therapy in young and middle age in the absence of multiple damage and concomitant diseases, a primary plastic surgery is possible, which is carried out after removing from shock during the first 1 to 2 days. To do this, it is necessary to produce special urological studies: an excretory urography and urethrography.

With open damage (injuries) an aseptic bandage is superimposed. Persons with damage to the bones of the pelvis must be laid on seats with a roller under the legs bent. With hematuria without signs of internal bleeding and shock, it is possible to transport patients sitting, with profuse hematuria with severe anemization and a drop in blood pressure - on stretchers. With pain and shock, anti-shock events are held.

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First aid for injury of bladder

Emergency Assistance for Anuria

With a launched Anururia, the patient needs emergency hospitalization into the urological department. The most common cause of such anuria is the presence of a stone in the kidney or a ureter. In case of pain in the lumbar region, the appointment of antispasmodic and painkillers is shown.

Emergency care for kidney injury

Rendering emergency care at the cooking stage in signs traumatic shock And internal bleeding is reduced to anti-deposit measures and to the introduction of hemostatics (adroxonium, vikasol), as well as cardiovascular funds. With isolated damage to the kidney, subcapsular therapeutic measures on site are reduced to the introduction of spasmolitics, and sometimes priedol and other narcotic drugsCardiovascular preparations. These events can be continued in ambulance. With severe damage to the kidney with ruptures, its bleeding continues. It is necessary to start the drip administration of blood-cutting and anti-shock solutions, which must be continued in the hospital, where hemotransfusion is possible.

In the hospital, the surgical tactics is twofold. It depends on the severity of injury. When subcapsular damage, conservative therapy (hemostatic and antibacterial drugs) is carried out, a strict bed mode is assigned for 3 weeks. When the kidney breaks, an emergency surgery is made, the volume of which depends on the degree of damage (nephrectomy, resection of the lower pole, primary seam).

The main task of an ambulance is to deliver the victim to the hospital in a timely manner, where there is a urological department. During transportation, anti-deposit measures are held.

Emergency assistance in injuries of bladder

The provision of first medical assistance begins immediately with anti-deposit and hemostatic activities. They can continue during the transportation of the patient. The main task of the ambulance and emergency care is fast delivery of a patient in a surgical hospital duty or better in such an institution where there is a duty urological service. It is very important to make a diagnosis correctly, since it immediately orients the duty officer of the reception rest for emergency diagnostic and medical events. The main diagnostic method conducted in the hospital is an upward cystography with the introduction of a contrast agent into the urinary bubble cavity. At the same time, the radiographs are clearly visible to it in the abdominal cavity or in an octoral fiber. Treatment of breaks and bladder damage Operative: embedding wounds of the bladder, the imposition of opicostostomas, drainage of the pelvis. With intraperitoneal damage, the operation begins with laparotomy and audit of the abdominal organs.

Emergency assistance in the injury of the urethra

Based on clinical symptoms and an objective study, there are all possibilities to diagnose the damage to the urethra. The introduction of the catheter in the urethra is completely contraindicated. Therapeutic measures are aimed at combating shock and internal bleeding. They should begin immediately and not stop during transportation. Before transporting for a long distance, especially with difficult road conditions, it is advisable to produce capillary bladder puncture.

The main task of the ambulance and emergency care is urgent delivery of the victim in the hospital, where there is a surgical or urological department.

With severe pelvic injuries and multiple body damage, patients are transported on a shield into a traumatology department. In the hospital, the method of choice is epicistostomy. With timely delivery of the patient and successful anti-depository therapy in young and middle age in the absence of multiple damage and concomitant diseases, a primary plastic surgery is possible, which is carried out after removing from shock during the first 1 to 2 days. To do this, it is necessary to produce special urological studies: an excretory urography and urethrography.

With open damage (injuries) an aseptic bandage is superimposed. Persons with damage to the bones of the pelvis must be laid on seats with a roller under the legs bent. With hematuria without signs of internal bleeding and shock, it is possible to transport patients sitting, with profuse hematuria with severe anemization and a drop in blood pressure - on stretchers. With pain and shock, anti-shock events are held.

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Bubble injury symptoms and treatment

Urinary bladder damage most often turn out to result in fractures of pelvic bones, which occur during a car accident, falling, blows or household injury. Injuries can be closed and open, inside and extremistically. Moreover, in 80% of cases, damage arise as a result of closed injuries. But the open injuries of the bladder are much more dangerous, as they are complicated by damage to neighboring organs and the entertainment of various infections.

Treatment of bladder injury

First aid in the treatment of injury of the bladder

Here are some valuable advice on the provision of prefigure assistance to the injury from the injury of the bladder:

In the presence of a wound, an aseptic dressing is required.

Put the injured on the back, lifting the head and laying the rollers under the knees. Provide full peace. In signs of traumatic shock, it is necessary to put it on the back at an angle of 45 ° so that the pelvis is raised in relation to the head.

On the low part Belly put a cold, and he warm to the most injured.

Urgently deliver it to the hospital for treatment.

Due to the strongest pain in the bladder region, which the victim is experiencing, pain shock arises. Therefore, the provision of medical care must be started with anti-shock events and surgical processing of the wound, which will provide an opportunity to determine the nature of the injury and the amount of operational intervention.

Treatment of injuries of the bladder - exceptionally operational. Only light minor damage do not require surgical intervention. In this case, it is carried out antibacterial therapy, and, if necessary, the catheter is installed.

Symptoms of bladder injury

Basic symptoms of bladder injury

With closed injury of the bladder begins internal bleeding, the victim feels strong pain At the bottom of the abdomen, it is not able to empty the bladder independently, blood appears in the urine, the bloating is observed.

With an open injuries of the bladder, such symptoms are observed: the pain is at the bottom of the abdomen, which gradually spreads throughout the abdomen or to the crotch area, frequent, but unsuccessful urination urge, leakage from the wound of urine with blood intake.

With an extra-bubble injury of the bladder, the symptoms are as follows: blood in the urine, the pain at the bottom of the abdomen, the tensions of the muscles above the pubic and in the iliac areas, which does not disappear with the empty bladder.

With intraperitoneal urinary bubble breaks, urination disorders are observed, blood release or bloody urine, then signs of peritonitis appear.

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Bubble injuries

With closed injuries of the bladder, in the case of its incomplete break, a cold compress is prescribed to the bottom of the abdomen, a strict bed regime, anti-inflammatory drugs and hemostaticities for 7 to 8 days. A two-way catheter is installed in the bladder. In the case of a complete break of the bladder, operational treatment is assigned. With intraperitoneal gaps, laparotomy is prescribed, which includes stitching the bladder wall defect, draining the abdominal cavity and cystostomy. With an extra-bubble break, the breaking of the urinary bubble break is made through cystomomic access, in addition, the drainage of the small pelvis on the Boylaski is prescribed (in the case of urinary infiltration of the small pelvic fiber). With urinary bubble injuries, surgical treatment should be urgent. In case of intraperitoneal break, laparotomy is produced with breaking breaking, and with extra-breadless - cystostomomy with ears cystostomomic breaking access. Drainage of a small pelvis on Bulya is carried out according to the testimony. There are closed and open injuries of the bladder. Among the closed, the bladder wall injury is distinguished, the separation of the urethra, full, incomplete and two-stage gap. More than three quarters of cases fall on extra-bruteral gaps, which are almost always accompanied by the fractures of the pelvic bones (with intraperitoneal gaps such fractures are rarely found). Intraperitoneal urinary bubble breaks in 70 - 80% of cases occur in persons who are in a state of alcohol intoxication. In peacetime, open injuries of the bladder are more often crushing and rezany wounds, in wartime - firearms. Open injuries of the bladder are divided into intra and extra-bubble, through, mixed and blind. They manifest themselves pain in the stomach, shock, symptoms of urinary peritonitis, urinary infiltration, urination disorder, tenesms, hematuria, separation from the wound of urine.

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The amount of assistance in damage to the organs of the urogenital system at the stages of medical evacuation

With closed kidney damage first medical Help Includes anti-deposit measures, the introduction of antibiotics, bladder catheterization with acute urine delay.

Qualified medical care. With mass arrival victims with closed injury The kidneys are sent to the hospital compartment for conservative treatment (hemostatic agents, infusion therapy, analgesics, anti-inflammatory drugs). Conservative treatment is carried out in cases where the overall state of the wounded satisfactory, there is no profuse hematuria, the symptoms of the continued internal bleeding and increasing accumulatory urehematomes. Indications for surgical treatment are combined damage to the abdominal organs, continuing internal bleeding, increasing uroghematoma, profuse hematuria (with a large number of blood clots).

The kidney is removed in cases of scammers of renal parenchyma, with deep bursts of the body of the kidney penetrating into the lochcan, as well as damage to the renal leg vessels.

Under the kidney gunshot wounds, the first medical assistance includes correction and replacement of the bandage, anti-deposit measures, the introduction of antibiotics and tetanus antecisin when wounded, bladder catheterization with acute urine delay.

Qualified medical care. With open kidney damage, the wounded with signs of continuing internal bleeding and profuse of hematuria are immediately sent to the operating room, with a shock II-C degree without signs of bleeding - into the anti-school chamber, agonizing in hospital chambers, all the other wounded with possible damage to the kidneys - in the operating room first .

Operational intervention starts with laparotomy, eliminate damage abdominal organs, inspect the kidney and produce the necessary operation. The revision of the damaged kidney needs to be carried out after the overpaid of the turnstile on the vascular leg. After removal of the kidney or other operation, the contraperture in the lumbar region is applied and the wound drain through it. Rear leaflet of peritoneum over remote kidney is sewn.

An indication to nephrectomy serve: the prospect of all the renal parenchyma, multiple and single deep kidney breaks, penetrating into the jelly, the prospect of one of the ends of the kidney with deep cracks reaching the gate of the kidney or lochank. Nephrectomy is shown in damage to the renal leg.

Before removing damaged kidneys, it is necessary to find out the presence of a second kidney, which is achieved by a preoperative insignible urography or ultrasound examination, as well as the kidney palpation during the audit of the abdominal cavity. The presence and function of the second kidney can be mounted as follows: pin up the ureter damaged kidneys, 5 ml of 0.4% indigorine solution is administered intravenously and in 5-10 minutes it is determined in the urine obtained by the catheterization of the bladder.

From organizing operations, the kidney wounds and resection of its ends are used. Surgical treatment of wound kidneys is made by economical excision of the well-metered pavens of parenchyma with removal foreign languages and blood bumps, thoroughly flashing bleeding vessels. To stop bleeding on the vascular leg, there is a temporary soft clamp for a period of no more than 10 minutes. Renal wound is better to sew using P-shaped seams.

Recreation of the ends of the kidney is more expedient to perform a ligature method. Easying of wound kidney, ligatural resection of its ends must be combined with the imposition of nephrosty. The drainage of the retroperitoneal space is carried out through the lumbar region with the dismissal of 2-3 tubes. The wound of the lumbar region is embedded to drainage.

Injuries of ureters when providing a qualified surgical care During operation, it is rarely diagnosed. In case of detection of the ureter's injury, the latter is stitched on a fine polychlorvinyl tube, which one of its end is excreted through the renal puree and the parenchyma to the outside through the lumbar region together with the octopic and incoming drainage. If there is an internal stent in the surgeon, the wound in the ureter wound is advisable after installing the stent. With a significant ureteral defect (over 5 cm), its central end is sewn into the skin, and the ureter is intubated with a polychlorvinyl tube. Reconstructive operations are performed in a specialized hospital for wounded in the chest, belly, pelvis.

Specialized urological assistance in closed damage and gunshot wounds of the kidney includes the execution of deferred operational interventions, reconstructive-restorative operations, treatment of complications (supplies, fistula, pyelonephritis, the narrowing of urinary tract) and eliminating the manifestations of renal failure.

When the bladder is injected, the first medical assistance includes a temporary stopping of bleeding, anesthesia, intravenous infusion of polyglyukin, heartbreaks, the introduction of antibiotics and tetanus antecisin. In the case of relent of the bladder, its catheterization or capillary puncture is made. Wounded with damage to the bladder in the first place are evacuated, in the lying position.

Qualified medical care. Wounded with bladdment bladder are subject to surgical treatment. With continuing bleeding and shock, anti-shock events are carried out in the operating room, which are wounded immediately after receipt. The operation is urgent.

With intraperitoneal injuries of the bladder, extra laparotomy is made. The wound of the bladder is invented by a two-row seam using a resinking material. Extraperitonization is performed. The abdominal cavity, after removing the spilled urine is washed with saline. The bladder is drained with cystostomas, and the olive space is through an operating wound with several tubes.

The technique of imposition of a supraid uropement fistula is as follows. On the median line between the navel and the Lone, a cut is made of 10-12 cm long, cut the skin, fiber and aponeurosis, push the straight and pyramid muscles. Duffally, in the proximal direction is separated from the bubble of the prepaulous fiber together with the forehead of the peritoneum. On the wall of the bubble, the top of the tip is superimposed by two piercing seams, for which the bubble is tightened into the wound. Isolating the peritone and fiber with tampons, dissect the bubble between stretched ligatures. After making sure that the bubble is opened, a drainage tube is introduced into it with a lumen diameter of at least 9 mm. The end of the tube introduced into the bubble must be sliced \u200b\u200b(cutting edges rounded), an opening is made on the side wall equal to the diameter of the lumen of the tube. The tube is administered first to the bottom of the bubble, then delayed by 1.5-2 cm and sewn to the wound bubble ketgutoy thread.

The wall of the bubble is sewn by two-row suture resicking threads. A rubber grader is introduced into the preposter tissue. Wound is stirred in layers, and one of the skin seams additionally fix the drainage tube.

With extrably wounded wounds of the bladder wounds, available for sewing, are squeezed by two-row ketgutov (Viklovy) seams; Wounds in the area of \u200b\u200bthe bladder neck and the bottom are cut from the mucosa of the ketguet; If it is impossible to embroil the edges of the Russian Academy of Sciences, it is brought off with a ketgut, drifts are injured outside. Urine dilution from the bladder is carried out with the help of cystostomomas and a urethral catheter. With extra-breech damage, the drainage of the pelvic fiber is not only through the front abdominal wall, but also through the crotch. To do this, after stagging the wall of the bladder from the wounds of the abdominal wall, the Corncang stupidly pass from the octolopusary fiber to the crotch through the locking hole (according to I.V. Buyalsky-Mac-Worter) or under the Lona joint on the side of the urethra (according to P. A. Kupriovov), Above the end of the Corncang cut the skin and the reverse movement is introduced a captured drainage tube.

If the drainage of the pelvic fiber was not fulfilled during the primary intervention, with the development of urinary illuminations, the pelvic thazic cell is a typical access to I. V. Buyalsky-Mac-Worter. Wounded laid on the back with bent in the knees and allotted in tazobed Susta foot. The cut of a length of 8-9 cm is performed on the front-inner surface of the thigh, parallel to the femoral and crotchy fold and below it for 2-3 cm. Stupidly smell the thrust muscles of the thigh and fit the pelvic locking hole. In the downward branch of the pubic bone in the course of the fibers dissect the outer locking muscle and the locking membrane. Spreading muscle fibers with Corncang, penetrate into a straight-turn hole. Stupidly spreading the muscle, lifting the back pass, fall into the preposter fiber where the blood and urine accumulate. The presence of 2-3 tubes in pre-space provides drainage of the pelvic fiber, the prevention and treatment of urinary illuminations, thrombophlebitis and other dangerous complications.

When providing specialized surgical assistance, complications developed after injury to the bladder are treated. Intraperitoneal damage is complicated by peritonitis, abdominal abscesses. Outstretcho damage can lead to the formation of urinary infiltration, urinary and purulent illuminations with the transition to phlegmon pelvic and retroperitoneal fiber. Subsequently, osteomyelitis of the bones of the pelvis, thrombophlebitis, cystitis, pyelonephritis, Wrostsisis can occur.

Success in the treatment of damage to urethra depends on the correctly selected tactics and consistent implementation of therapeutic measures. The amount of assistance at the stages of medical evacuation at closed damage is the same as the injuries of the urethra.

The first medical assistance is reduced to the prevention and control of shock and bleeding, the introduction of antibiotics, tetanus anatoxine. When urine delay, the urinary bubble puncture is performed.

Qualified medical care. The victim continues anti-shock events. The dilution of urine (excluding bruises and tangent wounds without damage to the mucous) is made by imposing cystostomas. Perform surgical processing Wounds, hematomas and urinary cutieles drain. With damage to the rear urethra plug fiber Drainaged by I. V. Buyalsky-Mac-Worter or P. A. Kupriyanov. If the surgeon has the corresponding skills, it is advisable to perform a tunneling of urethra with a silicone tube with a diameter of 5-6 mm. Primary seam urethra is strictly prohibited. The recovery of urethra is carried out in a long time after final scarring and eliminate inflammatory phenomena. The polychlorvinyl soft catheter can only be installed in the case of its free, non-violent conduct of the urethra in the bladder. Closed injuries in the form of an injury or an incomplete break of the vestra wall without significant urethrorragia, with the preserved ability to urinate and satisfactory condition, are treated with conservative (spasmolitis, tranquilizers; during urethrorrhigis - vikasol, calcium chloride; sodium ethalate; antibiotics with a preventive purpose). If the damage of the urethra is accompanied by a urine delay, a soft catheter is installed for 4-5 days or perform a gravy puncture of the bladder. Damage in the form of a complete break, the interruption of either the scramble of the wall of the urethra is treated operational way.

Specialized urological assistance consists in surgical processing of wounds according to indications, imposing a supraid blade, wide drainage of fiber of pelvic, perineum and scrotum, operations to restore the intake of urethra, treatment of wound infectious complications. Plastic operations are performed after special studies, allowing to judge the degree and nature of damage to the urethra. Primary seam is possible only when the hanging part of the urethra is injured without a large diastasis of the ends. Restoration front department The urethres are advisable to carry out by imposing secondary seams, and when the rear section is damaged - with good condition of the wounded - immediately after receipt or after the scarring and liquidation of inflammation. With serious condition, the operation is postponed at a later date.

Operations of the intake of urethral intake are made with an obligatory dilution of urine through a supraid urinate fistula.

In case of damage to the scrotum, the first medical care includes, stopping the ongoing bleeding from the edges of the wound by ligating the vessels, the introduction of antibiotics, tetanus anatoksin, further anti-shock therapy.

Qualified and specialized medical care was wounded with damage to the scrotum and its organs, it comes down to the primary surgical treatment of the wound, during which only clearly non-visual tissues are removed, stop bleeding. Depending on the type of damage, surgical processing of Russian wounds, its appendage, seed rope. When separating the scrotum, the testicles are immersed under the skin of the hips. Indications to the removal of eggs are its complete scoke or separation of the seed rope. With multiple tears of eggs, its fragments are washed with a 0.25-0.5% solution of novocaine with the addition of an antibiotic and crosslinked with rare ketgutov (Viklikov) seams. All operations are completed by the drainage of the wound.

With injuries, the scrotum is carried out conservative treatment. The presence of intravaginal hematoma is an indication to surgical intervention.

With wounds of penis, qualified medical care includes primary surgical treatment of the wound, which comes down to final stop Bleeding, economical excision of clearly non-visual fabrics, tissue infiltration by antibiotic solution. For riping wounds Skin flaps do not excine, and by imposing guide seams cover their defect. Damage to the cavernous bodies feed with a ketgut with a seizure of a protein shell in the transverse direction. In the presence of combined damage to the urine channel, the urine-bubble fistula is applied.

With the provision of specialized medical care They produce economical surgical treatment of wounds and plastic surgery on the substitution of extensive skin defects in early dates or after cleansing wounds from necrotic tissues and the appearance of granulation. Operational treatment of violated functions of cavernous bodies and operations to restore the penis are carried out after the elimination of all inflammatory phenomena in the scar. The suppression of erections arising from the operation on the sexual term is achieved by the appointment of drugs, estrogen, bromine preparations and neuroleptic mixtures.

Military field surgery instructions

4315 0

Damage to ureter

Damage to the ureter are the most rare damage to the urinary tract with external injury. With a stupid injury, a gap in the place of extracting the ureter from the pelvis (or a little lower) as a result of re-installing or separating the lower end of the ureter fixed to the bladder triangle. With penetrating injury, the ureteral contusion is possible, as well as its partial or complete gap.

Contusion may occur when a gunshot injection, if the bullet passed next to the ureter, which leads to damage to the vessels of the ureter wall, including bleeding or thrombosis. The revision of the wound shows that the bullet went past the ureter, while his wall looks intact or slightly damaged. In the event of a thrombosis of vessels in the ureter wall, necrosis is subsequently observed with the formation of the blade.

Bladder damage

In children, the bladder is an intraabdominal organ, in adults it is located significantly lower and is surrounded by pelvic bones, which protects it from the most severe damage during the injury of the abdomen and pelvis. The bladder damage occupies the second place in the frequency after the kidney injury and are usually combined with the fracture of the bones of the pelvis.

Blast bladder bruise

Under the injury of the bladder understands the disorder of the intention of its wall with hemorrhage. The cystogram of the contours of the bubble is not changed. With a fracture of pelvic bones, there is often an extensive hematoma inside the bone pores, which leads to a bubble displacement or upwards or to the side. Treatment in such cases is conservative, since the violation is permitted without deformation of the wall of the bubble.

Intraperous urinary bubble break

This damage is the result of an abdominal injury or pelvis at the moment when the bubble is filled with urine; At the same time, the bubble dome takes place with urine flowing into the abdominal cavity. The cystogram marks the extravasation of contrast along the colon and between the intestinal loops. A revision of the abdominal cavity with the elimination of the urinary bubble dome break is necessary.

Outfrequent urinary bubble break

On the cystogram, the pelvic pelvis side wall is determined and below the bubble. It is most advisable to obtain a radiograph after washing the bladder if the extravasation takes place mainly behind the bubble and on a cystogram with a filled bubble the picture is unclear. Until recently, in such cases, an exploration was made to eliminate the extraperitoneal break. However, with a single extra-bruteral break and small extravasia, drainage (only) of the bladder through the catheter is successfully used. The catheter is left at 14 days; Before removing it is re-cystography.

Damage to urethra

There are distinguished damage to the rear (prostato-membrane) and the front (bulbous and spongy) part of the urethra.

Damage to the back of the urethra

Damage to the rear ventilation of the urethra is usually associated with a pelvic fracture, while damage to the front department is the result of a direct strike (a drop on sharp items with widely spaced legs, a dip). When finger rectal studies and inspection of the perineum, the crotch hematoma is found or highly mixed prostate gland, which indicates a complete break of the urethra. Inspection of the perineum detects a classic "butterfly cracker" caused by a hematoma, which is limited to the attachment of wide fascia.

In the case of a complete break in the back of the urethra, conflicting opinions are expressed regarding the feasibility of primary restoration of the integrity of the urethra with a supersturo cystostomy; Some clinicians are limited to the tombstone cystostomy. With primary restoration of the integrity of the urethra, the bladder is left open, and the urethra is sewn using the "Railway Coupling Technique" (two clutched probe are used to stretch the foley catheter in the bladder). When tightening the catheter, the ends of the torn urethra come closer.

The healing of the urethra occurs within a few weeks. If only cystostomy is used. That hematoma pelvis is solved, allowing the prostate gland to take a normal position. In both methods, the urethra is healing, but with the formation of stricture; The frequency of impotence and incontinence of urine in both cases is the same.

Breed Urethra

In such cases, blood is noted from the outer opening of the urethra, while the urethrogram remains normal. The injury injury is treated conservatively using a catheter (or without it).

Partial rupture of urethra

A limited extravagation of contrast is found on the urethrogram at the place of damage to the passage of a contrast agent in the bladder. In the treatment of partial breaks, either only urethral catheterization is applied (carried out by a urologist), or catheterization in combination with a grazing cystostomy. Healing occurs within a few weeks.

Full rupture of urethra

On the urethrogram, a significant extravasation of contrast is determined at the place of damage in the absence of a contrast agent in the bladder. Such damage is eliminated surgically In front of the urethra: It is perfect drainage through a catheter, an epicistostomtom is applied to the urine lead, and a small urethral expander is used to immobilize the anastomosis area.

Damage to genital organs

Eggs

The mobility of the testicles, the reduction of the muscle raising the testicle, and the presence of a durable egg capsule contribute to infrequent damage to the testicles during car accidents. The straight blow to the pressing of the egg to the Lonnoy articulation leads to damage - bruises or rupture. In both cases, the bag of the vaginal shell is filled with blood (hematocele), which leads to the appearance of extensive and intense shiny swelling of the scrotum. Early audit with the evacuation of blood clots and the ears of the tear of eggs contributes to a more rapid normalization of the function of the egg, which is observed in conservative treatment; At the same time, such complications are noted less often as hematoma infection and egg atrophy.

The devoid of the interior of the egg should be covered by the remaining skin, even if the reconstruction occurs a voltage in the seam overlay zone. Usually, the scrotum acquires its almost normal dimensions after a few months.

Penis

Injuries caused by membership include damage to the vacuum cleaner and cut the blade. With the help of a vacuum cleaner, extensive damages are applied in the field of penis head, as well as urethra, in which excision of dead tissues and reconstruction are needed. The cuts of the blade varies from surface wounds of a pre-compusual bag until a complete amputation of the head of the penis. With amputation of the penis, replantation or local reconstruction of the outer opening of the urethra is produced. With the distal part of the penis, the good condition of the tissues and the duration of ischemia is less than 18 h preferably replantation.

The traumatic rupture of the cavernous body or a penis fracture arises with a strong impact of a member in a state of erection about a solid subject (LON-MODE or pellery bottom of the sexual partner), as well as when applying a direct strike on a member or with excessive bending. At this moment, the creative sound is heard, then pain in the penis appears; The swelling rapidly increases, the skin color changes, the penis of the penis changes. With such damage, an immediate operation is needed with the removal of blood clot and the restoration of the intake of the damaged protein shell of the cavernous body.

Restoration of the skin lost during separation or due to burn is carried out by transplanting split flap on the purified and uninfected wound of the penis. The cut off the skin should not be sewn to the previous place, because it is inevitably infected and necrotizes; Subsequently, it has to delete it.

Damage to the penis occurs and when the skin squeezes the suspension bag in the zipper of the trousers. Manipulation on the snake for the purpose of skin extraction is usually long and painful. In this case, it is better to use nippers for the separation of the middle link (or a lock) of the snake, which will allow to release the imprinted skin. Turnstile pennal syndrome due to compression or squeezing, such as hair, ring, steel washer or metal nut, manifested early occurrence Pain and edema head. The squeezing object must be removed or dissected.

Summary

Injury organs gOOD SYSTEM Significantly complicates the treatment of patients with multiple damage. ONP doctor should be good to know the radiological methods that help when determining damage, as well as possible treatment options. The use of CT scanning when estimating retroperitoneal damage is becoming more widely distributed, ousting HVV. However, in cases where a quick assessment of the kidney function is required, intravenous pyelography is still indispensable.

A. S. Kess, K. S. Smith

The bladder is an important organ of the urinary system. Any damage can lead to serious health consequences. Therefore, it is necessary to remember the first signs of injury and features of therapy.

Features of injury of bladder

Under the injury of the bladder means any violation of the integrity of its wall. This happens as a result of external influence. Such damage is hardly transferred to the victims and may have critical consequences. Therefore, when the first symptoms are discovered, it is necessary to immediately seek help from specialists.

This body is not protected, so even a blow to a small force in the stomach can lead to his damage. Recovery will require a lot of time. Treatment will be carried out in a hospital.

Classification of damage

Depending on the location of the damaged area, all injuries of the bladder can be divided into several categories:

1. Intra-brass. Such damage is more often due to the fact that the bladder at the time of injury was filled. In this case, the contents are bottled on the abdominal cavity.
2. Ovenly. These damage occur in fractures of pelvic bones. It does not hit urine into the abdominal cavity.
3. Combined. If, with a fracture of the pelvic bones, the bladder was filled, and its damage occurred immediately on several sites, then the urine is poured on the abdominal cavity.

If we consider all injuries from the point of view of the injury, then the following types can be distinguished:

1. Closed injury. At the same time, the injury and breaking of the skin and nearby tissues occurs. Internal organs are not in contact with the external environment.
2. Open injury. It is characterized by damage to the skin and the contact of the organs with external factors.

Classify the injuries of the bladder can also be gravity. In this case, the following groups are distinguished:

1. Complete rupture of the organ.
2. Incomplete rupture of the body.
3. Injury. Such damage does not imply a violation of the integrity of the bladder.

In some cases, not only the bladder itself is damaged, but also nearby organs. Based on this characteristic, injuries are divided into several categories:

1. Isolated. The bladder itself is damaged exclusively.
2. Combined. At the same time with bladder Nearby organs are injured.

The treatment program will be developed by a specialist based on the type and features of the injury. At the same time, the patient will have to spend a certain time in the hospital.

How does the disease manifest?

In order to properly decide on the treatment method, it is necessary to pay attention to the symptoms that accompany the problem. Among them are distinguished:

1. Pain feelings at the bottom of the abdomen.
2. Loss of urination capabilities.
3. Detection of blood impurities in the urine.
4. Frequent urge to the toilet, but at the same time urination does not occur. A small amount of blood may be released.
5. Signs of internal bleeding are found, for example, drop in blood pressure, leather pale, rapid heartbeat.
6. There are signs of developing peritonitis. This phenomenon occurs when urine gets into the abdominal cavity. These symptoms include: pain sensations that destroy only in a semi-side position, an increase in body temperature, an increased tone of the muscles of the abdominal cavity, attacks of vomiting and nausea, bloating.
7. If the injury is extra-abrasion, then swelling can appear in the lower abdomen, as well as the formation skin Pokrov In this zone.

When such symptoms appear, it is necessary to have a survey as soon as possible and proceed with treatment. Delegation in such a situation threatens with serious consequences.

The main causes of injury

You can get injury to the bladder in the following situations:

1. When falling from a height for any subject.
2. While hitting a knife or gunshot wound.
3. With too sharp jump. This often happens if the bladder during the jump was crowded.
4. When the blow fell into the lower part of the abdomen.
5. When conducting a bladder catheterization procedure. When the tube is introduced into the organ in order to ensure a full-fledged urine outflow, damage to the walls of the bubble is possible.
6. During the bunning of the urethra. This procedure involves the expansion of the channel by introducing metal pins into it.
7. Operational intervention in the fractures of the bones of a small pelvis.
8. The cause of injury may also become illness: prostate adenoma, narrowing of the urethra, prostate cancer.

Often, injuries occur in a state of alcoholic intoxication. At the same time, urinary urinary is dulled.

Basic diagnostic techniques

To form an accurate diagnosis, a specialist conducts several diagnostic measures. They include:

1. Inspection of the patient and collection of anamnesis. The doctor polls the victim for complaints, obtaining such injuries earlier, the use of any medicinal preparations.
2. General blood analysis. Allows determine the presence of bleeding, the level of hemoglobin and red blood cells is determined.
3. Analysis of urine. During the study, the presence of erythrocytes in the sample is revealed.
4. Ultrasound. A study is carried out not only by the bladder, but also the kidneys. This allows you to estimate the size and structure of the body, to identify the presence of blood clots, violation of urine passage. In addition to this, an ultrasound of all abdominal cavity can be carried out. It helps to detect the hemorrhage into the abdominal cavity.
5. Retrograde cystography. In the bladder injected a special substance that is brightly manifested on a radiographic picture. The pictures will be clearly visible features of damage and the state of pelvic bones.
6. Urography. The victim is introduced the drug, which falls into the kidneys. After that, a radiographic study is carried out. This technique allows you to determine the location of the injury, as well as the degree of its gravity.
7. MRI. This method is characterized by increased accuracy. It allows you to study the bladder in various projections. Due to this, it is possible to find out the nature of damage, severity, as well as injuries of nearby organs.
8. Laparoscopy. In the bottom of the abdomen are made small cuts. The probe with the camera is introduced through them. Such a survey makes it possible to determine the presence of bleeding and its intensity, the location of the wound and the presence of related damage.
9. CT scan. This is a radiographic research method that allows you to get a three-dimensional image. With it, it is possible to accurately determine the nature of damage, the degree of gravity, the intensity of bleeding.

The choice of a specific technique is carried out on the basis of the existing in medical institution Equipment, patient's body features.

Rules of treatment

Modern medicine offers the following therapeutic techniques:

1. Medical treatment. The use of drugs is permissible only with light damage: injury or a small bubble wall. Prescribed hemostatic and anti-inflammatory drugs, antibiotics. In the presence of strong pain sensations prescribe painkillers. In this case, the patient must adhere to the beddown.
2. Washing the bladder with a laparoscopic method or through a cut.
3. Cystostomy. This procedure is applied to men. A small rubber tube is installed in the bladder, providing urine outflows.

When spreading urine into the abdominal cavity, drainage will be required. A specific treatment technique is selected based on the severity of damage.

What complications may be accompanied by injury?

In severe cases, complications of the disease can develop. Among them are distinguished:

1. URVROPSIS Open wound Can be infected with microorganisms. As a result, the inflammatory process is launched.
2. Shock state due to abundant blood loss. This is manifested in loss of consciousness, rapid heartbeat, superficial breathing, falling blood pressure.
3. Purulent process in the bladder.
4. Osteomyelitis. This is inflammation of pelvic bones.
5. Education fistula. Next to the bladder takes place blood and urine. It provokes the destruction of the body wall. As a result, a channel is formed through which urine can flow into the abdominal cavity.
6. Peritonitis. Appears when urine getting into the abdominal cavity.

With the emergence of such consequences, an additional complex of medical measures will be required. The program is developed by the attending specialist based on the features of the disease.

How to prevent injury?

In order to avoid severe health consequences, you must follow the following recommendations:

1. Determine and treat prostate diseases in a timely manner.
2. Try to avoid traumatic situations.
3. Abandon the bad habits, especially from the use of alcoholic beverages.
4. Regularly monitor the level of the prostatospecific antigen. Its concentration increases with diseases of the prostate gland.

If the injury is still occurred, for three months after the end of treatment, it is necessary to observe the urologist.

Timely diagnosis I. proper therapy Injuries will help to avoid serious health consequences. At the first alarming signs, please contact the doctor.

Spontaneous urinary bubble breaks are described, damaged to tool Research: cystolitripsy, tour and hydraulic tension in order to increase the tank.

In the rupture mechanism, the nature and force of the injury impact, the degree of filling the bladder urine. A sudden increase in intravenous pressure is transmitted with the same force to all the walls of the bladder containing urine. At the same time, its side walls, surrounded by bones, and the base of the bubble, adjacent to the pelvic diaphragm, counteract the increased intravenous pressure, while the least protected and most thinned part of the bubble facing the abdominal cavity is broken. Intraperitoneal bursts of the wall of the bubble arising from this mechanism are distributed from the inside of the dust: first the mucous membrane, then the submissible and muscular layer, Last but the peritoneum.

In a number of observations, the peritoneum remained intact, leading to the subvershit spread of the contents of the bladder. To the similar hydrodynamic rupture, the compression of a crowded bladder can be resolved by each other fragments of the pelvic ring with its fractures without direct injuries of the bubble wall with bone fragments.

An additional influence factor The tension of the pubic-bubble bonds when the fumbles of pubic bones and the pubic articulation are like this discontinuity is more often an extra-fristed bladder separation. Finally, damage to the bladder near his neck cause displaced fragments of pubic and sedan bones, although during operation they are rarely detected in the wound bladder wound.

This fact explains the elasticity of the pelvic ring, as a result of which bone fragments, wounding the bladder at the time of injury, can subsequently leave the wound channel. Not all fractures of the pelvic bones, even with a violation of the continuity of the pelvic ring, are accompanied by the urinary bubble bursts. Apparently, for its damage, it is necessary to have a sufficient amount of urine that contributes to the close arrangement of the walls to the pelvis bones and a smaller bubble offset at the time of injury.

There are bruises, incomplete bursts of the wall of the bubble (urine is not poured beyond its limits) and full gaps with urine plot into surrounding fabrics or abdominal cavity. The incomplete gap turns into a full result of inflammatory and necrotic changes in the wound, overflowing the bubble of the urine and increasing the intravenous pressure at the moment of urination. Such a mechanism leads to a two-stage rupture.

Symptoms of closed damage and injuries of the bladder

Closed injuries of the bladder are characterized by a combination of symptoms of damage to the bladder itself, signs of damage to other organs and bones of the pelvis, manifestations of early and late complications Injuries. Hematuria, urination disorders, pain at the bottom of the belly of OLS of the gossip area with a primary examination of a patient with anama injury allow you to suspect the bladder damage.

In case of isolated damage, pain occurs in a suplocked area. Violation of urination and hematuria. Urination disorders during bladder damage different. The nature of the disorder is associated with the degree of emptying of the bladder through the wound hole in the surrounding fabrics or in the abdominal cavity. With injuries and incomplete breaks of the bladder, rapid, painful urination occurs, is an acute urination delay.

Sometimes with light damage to urination remains normal. Full breakdowns are characterized by the absence of independent urination at frequent and painful urges, however, in contrast to the urination delay, it is determined above the pubic tympanite. With extrabreast damage, it is soon replaced by a growing point that does not have clear boundaries, with intraperitoneal breaks, the tympanite is combined with the presence of free fluid in the abdominal cavity. When breaking the bladder against the background of fruitless urges on urination, it is sometimes possible to release a few drops of blood, a long lack of urination and urges to it.

An important symptom of the injury of the bladder is hematuria, the intensity of which depends on the damage and its localization. With bruises, external and internal incomplete, intraperitoneal gaps of macrohematuria are short-lived, or even absent, while with significant gaps in the neck and the urochpinal triangle, it is pronounced. Nevertheless, the isolated urinary bubble breaks are extremely rarely accompanied by significant blood loss and shock.

In case of intraperitoneal breaks of the bladder, peritoneal symptoms are developing slowly, growing gradually (within 2-3 days), expressed weakly and non-permanent, which is often the cause of late diagnosis of urinary peritonitis.

Initially localized pain in the suprapic area acquire a spilled nature, the partares of the intestines are joined, the bloating of the abdomen, the latency of the chair and gases, nausea, vomiting. After a cleansing enema, there are a chair and gases depart. The belly participates in breathing, the tension of the muscles of the abdominal wall and pain in the palpation of the abdomen is insignificant or moderately expressed peritoneal symptoms expressed weakly, for a long time The intestinal peristalsis is listened.

A day later, the patient's condition deteriorates, signs of intoxication are joined, leukocytosis, azotemia develop. Inituating in the abdominal cavity of the infected urine leads to an earlier appearance of a painting of a spilled peritonitis, however, at the same time, a clinic of dynamic intestinal obstruction, accompanied by a sharp blowing of the intestine. In the absence of anamnestic information about injury such clinical picture Registration as food poisoning.

With extrabreast damage after a few hours after injury, the hematurium intensity decreases, however, the frequency and painfulness of urinary urges increases. In the above-blocking and inguinal areas, the skin solidity and subcutaneous fiber appears in the form of testing swelling. The condition of the victim is gradually deteriorating due to the increasing urinary intoxication and the development of the pelvic phlegmon or abscess, as evidenced by heat Bodies, in laboratory tests - neutrophilic leukocytosis with a shift to the left, hypochromic anemia, an increase in residual nitrogen, urea and creatinine in blood serum.

In 50-80% of observations, victims with combined bladder damage are in a state of collapse and shock, significantly changing the nature of clinical manifestations and impellent diagnosis. The insulated fractures of the bones of the pelvis with an octatic hematoma can also manifest themselves with pain, disurium, tension and soreness when palpation of the front abdominal wall, gas delay, chairs and urine. These symptoms are probably associated with irritation by the hematoma of parietal peritoneum, squeezing the neck of the bladder.

Suspicion of bladder damage Indication to special studies, allowing to confirm the fact of damage to the bladder, determine its appearance and plan the therapeutic tactics.

Complications of closed injuries and injuries of the bladder

Complications of the injury of the bladder most often occur due to late diagnosis of damage or late treatment.

Complications of bladder damage:

• growing urogenoma:
• phlegmon pelvis;
• localized abscesses;
• urinary peritonitis;
• adhesive intestinal obstruction;
• sepsis.

In case of damage to the neck of the bladder, the vagina, the rectum, urinary fistulas, strictures are developing without timely elimination. Subsequently, it may be necessary to carry out plastic operations.

The extensive trauma of the sacrum, sacral roots or pelvic nerves leads to the dignity of the bladder and impaired the function of urination. If the cause of the urinary bubble dysfunction is innervation violation, then for some time you may need catheterization. In some serious damage to the sacral plexus, urination disorder can be stable due to a decrease in the tone of the muscles of the bladder and its neurogenic dysfunction.

Complications for injections and incomplete breaks of the bladder are rarely arising: hematuria, urinary tract infection, reducing the volume of the bladder, less often the formation of the pseudodivanticulus of the bladder.

Diagnostics of closed damage and injuries of the bladder

The diagnosis of closed injuries of the bladder is based on the analysis of the circumstances and the mechanism of injury, the data of physical research, laboratory and radial methods diagnostics.

At the pre-hospital stage, the diagnosis of bladder damage is difficult: only 20-25% of victims are sent to hospitals with a properly established diagnosis, where the recognition of extra-brute breaks does not cause special difficulties. High frequency combinations of bladder damage with pelvic bone fractures alarms doctors, and in the presence of appropriate complaints, urinary disorders, blood in the urine there is a need for additional ultrasonographic and x-ray studiesAllowing in the early stages to establish the correct diagnosis and perform operational treatment in the first hours after hospitalization.

It is very different about the diagnosis of intraperitoneal gaps. A typical picture of intraperitoneal damage occurs about 50% of victims, and therefore observing the patients is delayed. Clinical signs of injury (severe general condition; frequent pulse, bloating, the presence of a free fluid in the abdominal cavity, the symptoms of irritation of peritoneum, impairment of urination and other signs) are missing or expressed weakly against the background of shock and blood loss.

Absades, bruises and other signs of injury in the abdomen and pelvis, refinement of the damage mechanism, assessing the condition of the patient and the degree of filling of the bladder help to suspect its damage. Palpation through the rectum determine the presence of its damage, hematoma and blades of bone fractures, hovering bubble-recycling folds.

When examining the patient, it is necessary to pay attention to the abdins and subcutaneous hematomas of the anterior abdominal wall, the hematoma on the perineum and the inner surface of the thighs. It is necessary to visually evaluate urine color.

The most characteristic symptoms of bladder damage - macrohematuria (82%) and abdominal pain during palpation (62%). Other symptoms of the injury of the bladder - microhematuria, the impossibility of urination, hematoma in a suplocked region, the tension of the muscles of the anterior abdominal wall, arterial hypotension, reduced diurea.

If the patient is in a state of alcoholic intoxication, the above symptoms are not manifested immediately. With intact urinary diaphragm, urine shades are limited to the pelvic area. In the case of rupture of the upper fascia of the urinary diaphragm, urine infiltrates the scrotum, crotch and abdominal wall. When the bottom fascia breaks the pelvic diaphragm urine infiltrates penis and / or thigh.

The simplest, affordable and not requiring high qualification and special equipment method of diagnosing bladder damage - diagnostic catheterization, performed as a gently soft catheter, in the absence of signs of damage to the urethra.

Signs indicating damage to the bladder:

• no or a small amount of urine in the urinary bubble in a patient who has not flipped into a long time:
• a large amount of urine, significantly exceeding the physiological tank of the bladder;
• blood adherence to the urine (it is necessary to eliminate the renal origin of the hematuria);
• discrepancy between the volumes of the fluid introduced and deposited according to the catheter (positive symptom of Zeldovich);
• the released fluid (urine and exudate mixture) contains up to 70-80 g / l of protein.

To identify free blood and urine in the abdominal cavity in recent years, ultrasound, laparoscopy and laparocentsis (diagnostic puncture of the front abdominal wall) are widely used. The catheter introduced into the abdominal cavity alternately direct under the hypochondrium, in the iliac areas and the cavity of the pelvis, removing the contents of the abdominal cavity syringe. When obtaining blood, liquid with an admixture of yellow, intestinal content or urine diagnose damage internal organs and perform urgent laparotomy. In the case when the liquid does not flow into the abdominal cavity, 400-500 ml of physiological sodium chloride physiological solution is introduced, then suck and examined for blood, diastases and urine. The negative result of the laparcente allows to refrain from laparotomy.

To detect a small amount of urine in the wound separated and intraperitoneal liquid obtained during laparcense or during the operation, the presence of substances selectively concentrating in the urine and its indicators are determined. The most suitable endogenous substance ammonia, the concentration of which in the urine is thousands of times greater than in the blood and other biological fluids.

The method of determining urine in the fluid under study to 5 ml of the fluid under study is added 5 ml of a 10% solution of trichloroacetic acid (for precipitation of the protein), stirred and filtered through a paper filter. A 3-5 ml of a 10% solution of caustic potassium (con) and 0.5 ml of non-salary reagent is poured into a clear and colorless filtrate for octic. If the fluid test contains more than 0.5-1% of urine, it acquires an orange color, purre and drops a brown colors, which is regarded as damage to the urine authorities. In the absence of urine in the fluid under study, it remains transparent weakly yellow color.

Ultrasound, bladder catheterization and abdominal cavity puncture - the most acceptable methods of diagnosing bladder damage in urgent help.

The same methods are the main diagnostic techniques at the stage of providing qualified surgical assistance that does not have in the equipment of radiographic equipment.

The diagnostic value of cystoscopy during the breakdowns of the bladder is limited by the complexity of laying the patient to the urological chair (shock, fractures of the pelvic bones), the impossibility of filling the bladder during breaks, intense hematuria that impedes the inspection due to poor visibility. In this regard, striving to perform cystoscopy in suspected damage to the bladder should not be. It can be used on final stageIf clinical and radiological data do not confirm, but also not exclude with sufficient reliability, the presence of damage, and the patient's condition allows cistoscopy.

Necessarily conduct laboratory study blood to assess the severity of blood loss (hemoglobin level, hematocrit and erythrocytes) and urine. High level The electrolytes, creatinine and urea serum causes suspicion of intraperous urinary bubble gap (urine enters the abdominal cavity, urinary ascites and absorbed peritoneum).

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Macro Hematuria

Macro Hematuria is a permanent and most important, but not unambiguous symptom accompanying all kinds of bladder damage. Numerous studies show that macrohematurium at a fracture of the hip strictly correlates with the presence of a bladder break. During the urinary bubble break, Macro Hematuria occurs in 97-100%, and the fracture of the hip is 85-93% of observations. The simultaneous presence of these two states is a strict indication for cystography.

Isolated hematuria without any information about the injury of the lower urinary tract It is not an indication for cystography. Additional factors allowing to suspect the bladder damage - arterial hypotension, reduced hematocrit, the general difficult condition of the patient and the accumulation of fluid in the pelvic cavity. If the injury of bones of the pelvis is not accompanied by macrohematuria, then the likelihood of serious damage to the bladder cut is reduced.

For urethrorragia, before conducting cystography, it is necessary to carry out retro hay urethrography in order to identify possible damage to the urethra.

Microhematuria

The combination of the fracture of the pelvic ring and microhematuria testifies to the damage to the urinary tract, however, if general Analysis urine is less than 25 red blood cells in sight with a large increase in the microscope, the probability of breaking the bladder is small. All patients with a gap of the bladder detect hematuria - more than 50 red blood cells in sight with a large increase.

Cystography is advisable if, according to urine research, with a large increase in the number of erythrocytes exceeds 35-50 and even 200 in sight.

Caution should be treated in childhoodBecause according to studies in the detection of 20 red blood cells in the field of view, with a large increase in cystography, you can miss up to 25% of the bladder breaks.

Overview radiography allows you to identify bone fractures, free liquid and gas in the abdominal cavity.

Excretory urography with descending cystography in most of the bladder injuries, especially complicated by shock, is little informative due to the fact. that the concentration of the contrast agent is insufficient to identify urine pillars. The use of an excretory urography during the injuries of the bladder and the urethra in 64-84% of observations gives a falsely negative result, as a result of which its use for diagnostics is inappropriate. The usual cystograph of phase during standard excretory urography does not allow to eliminate damage to the bladder.

Cystography

Retrograde cystography is the "Gold Standard" diagnosis of bladder damage to reveal the urinary bubble. spend differential diagnosis Between intra and extrearsitic breaks, establish the presence and localization of the pillars. In addition to high informativeness, the method is safe, it does not waste the condition of the victim; It does not cause complications from the contrasting agent into the abdominal cavity or an olive fiber - when the discontinuation of the cystography is detected, there is an operational intervention with the drainage of the abdominal cavity or the drainage of the pillars. Conducting retrograde cystography It is advisable to combine with sample Ya.B. Zeldovich.

In order to ensure high informative studies on a catheter in the bladder, at least 300 ml of a 10-15% solution of a contrast water-soluble substance are slowly injected by 1-2% novocaine solution with antibiotic wide spectrum actions. Perform a series of X-ray shots of the bladder in frontal (front-hand) and sagittal (oblique) projections. Be sure to take a picture after emptying the bladder to clarify the localization and nature of the spread of increments in the olivepuster and retroperitoneal tissue, which increases the efficiency of the study by 13%.

The main X-ray sign of the bladder damage is the presence of (increments) of a contrast substance beyond its limits, indirect - strain and shifting it up or to the side. Indirect signs are more often observed with extra-bustitoneal tear and octopusual hematomas.

Characteristic direct radiographic signs of intraperitoneal break - clear side limits, a concave and uneven upper surface of the bladder due to the overlap of the bubble shadow of the emissions of the contrast. With intraperitoneal gaps, the loops of the intestine are contrasted: a straight-turn-bubble (straight-turn-and-and-iron) recess. The shadows of the contrast agent, which sprinkled into the abdominal cavity, is well contacted due to their location between the loop of the intestine.

Signs of extra-bubble breaking fuzzy bladder contour, vagueness: X-ray-contrast pillars into an octopusing tissue in the form of individual bands (flame languages, divergent rays) with a small cloud-like shade - medium; A continuous dimming without clear contours - large gaps.

All pillars, as a rule, are below the top edge / Ossa Acetabulum.

In case of non-compliance with the above rules, there is a possibility of obtaining false result. The data of the cystography is based on the classification of bladder damage under the Protocol of the European Association of Urologov (2006).

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Ultrasound procedure

The use of ultrasound in order to diagnose the bladder damage is not recommended as a routine study method due to the fact that its role in identifying bladder damage is small.

Ultrasound allows you to detect free liquid in the abdominal cavity, liquid formation (urehemate) in a small pelvic cell, blood clot in the urinary bubble cavity or the lack of visualization of the bladder when filling it on the catheter. The use of ultrasound is currently limited due to the fact that patients with polytrampus are more often conducted by CT - more informative diagnostic method.

CT scan

Despite the fact that CT is the method of choice for studying stupid and penetrating the injuries of the abdomen and hips, nevertheless its routine use is inexpedient even with a complete bladder, since it is impossible to retper the urine from the transudate. For this reason, in order to diagnose the bladder damage, CTs are carried out in combination with retrograde contrasting of the bladder - CT cystic.

CT cystography makes it possible to diagnose the bladder damage with an accuracy of 95% and the specificity of 100% in 82% of observations, the CT data is fully coincided with the data obtained during the operation. In the diagnosis of intraperitoneal damage to the bladder, KT-cystography is sensitive in 78% and is 99% specifically. When conducting CT cysgography, performing additional scanning after emptying the bladder does not increase the sensitivity of the method.

Thus, the CT with the contrasting of the bladder and retrograde cystography in terms of the diagnosis of bladder damage to the same informativeness, but the use of CT provides the possibility of diagnosing also combined injuries of the abdominal organs, which undoubtedly increases the diagnostic value of this research method.

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Angiography

Magnetic resonance imaging

MRI in the diagnosis of bladder injuries are used mainly to diagnose combined damage to the urethra.

In case of clinical signs of damage to the abdominal organs, the final diagnosis of the type of injury of the bladder is carried out during its revision during the operation. After the revision of all abdominal organs, the integrity of the bladder is checked. Through the wound of the bubble, with sufficient sizes, it is conducted by the revision of all walls to exception also and extretic gaps.

Treatment of complete closed damage is always operational. Best results observe when early timing Operational intervention. Before operational intervention Ori injuries of the bladder The primary task is to stabilize the general condition of the patient.

In many patients with a closed extraperitoneal gap of the bladder, its catheterization is effective, even if there is extravasation of urine for peritoneum or in the area of \u200b\u200bexternal genital organs.

According to Corriere and Sandlera studies, 39 patients with a gap of the bladder are cured solely due to its drainage and a good result is marked in all observations. Cass, cured 18 patients with an extraperitoneal gap of the bladder only one drainage, observed complications only in 4 observations.

According to some authors, preferably transurethral drainage of the bladder, leading to a smaller level of complications. The urethral catheter, left for a period of 10 days to 3 weeks. Remove after cystography.

With small extra-bubble injuries of the bladder arising in endoorological operations, conservative treatment is possible against the background of the bladder drainage within 10 days. By this time, 85% of the observations of the bladder damage will be healed independently.

Indications for surgical treatment of extrably terrestrial stupid injury:

• damage to the neck of the bladder;
• bone fragments in the thickness of the bladder and reducing the wall of the bladder between bone fragments;
• the impossibility of adequate drainage of the bladder urethral catheter (the formation of a bunch, continuing bleeding);
• related damage to the vagina or rectum.

Practice shows that the earlier the operational intervention is performed with similar intra and extra-bubble damage, the better the results.

The goal of the operation is the urinary bubble revision, the embedding of its defects with a single-row seam with the use of absorbable suture material, the urinary assignment by imposing epicistostomas and drainage of the parasic urinary pillars and the small pelvic fiber urehemate.

With intraperitoneal damage, median laparotomy produce. Abdominal cavity is thoroughly dried. The wound of the bladder erupts single or double-row seams by ketgutov or synthetic absorbable threads. After stitching the wall of the bladder wall, the seam is tested. In the abdominal cavity, a thin polychlorvinyl drainage is left.

For the introduction of antibiotics and abdominal cavity, it is sutured to the place of the drainage. With difficulty in the discovery of the bubble wall during the operation and for checking the sealant of the seam at the end of the operation on the bladder, the introduction of a 1% solution of methylene blue or 0.4% solution of indigormina in the urinary bubble is used in the bladder in the bladder. If the injury of the wound bladder is hampered, it is carried out by extperperitiousonization.

Outperitoneal, easily accessible urinary bubble breaks are cut by a resattime material with a two-or single-row seam. When localizing damage in the bottom and neck of the bladder, due to their inaccessibility, the imposition of submersible seams from its cavity is possible. Drainages derived from the outside of the wound to the wound opening, depending on the localization of the wound through suplocked access: however, preferably through the crotch on the pyrius or a locking hole along the Boyl-Mac-Wargeru. Then the catheter is fixed to the thigh with tension per day and remove it no earlier than 7 days.

When the bladder neck is separated from the urethra, stitching of the separated parts is almost impossible due to the technical difficulties of the imposition of seams in this area and the developed urine infiltration by the time of operational intervention. To restore the passability of the urination channel and the prevention of the formation of a striking of a large length after the evacuation of urogooma in the bladder through the urethra, a catheter is carried out.

Then, retreating at 0.5-1.5 cm from the edge of the wound of the cervical cervical of the bubble, impose 1-2 ketguette ligatures on the right and left, while flashing the bladder depring and prostate capsule near the urethra's hole. The ligatures are gradually tied, bring the bladder to bring together and eliminate the diastasis between the cervical bubble and the proximal end of the urethra. The bladder is fixed in its anatomical bed. The bladder and the urban space drain with silicone (chlorvinyl) tubes.

The urethral catheter retains up to 4-6 days. If it is impossible to impose a folee catheter, the cylinder of which is filled with a liquid and tension for the catheter approach the cervix to the prostate, apply the seams between them in easily accessible places and fix the catheter with tension to the thigh. With a serious condition of the patient and the protracted intervention, the mapping of the bladder neck with the urethra is delayed at a later date, and the operation finish with cystostomy and the drainage of the spaspuspoto space.

The bladder is drained with any of its gaps using predominantly epitistus, and the drainage tube is better to install as close as possible to the top of the bubble.

The tube is fixed with a ketgut to the bladder wall, after the bubble wound eats below the tube, the stroma region is laid to the aponeurosis of direct muscles. The high arrangement of the drainage tube warns the development of osteomyelitis of pubic bones. Only in some cases, with a small damage to the bubble in women, the absence of peritonitis and urinary chains, the tightness of the bubble wound seamlessness, is permissible to drainage using a constant catheter for 7-10 days.

In the postoperative period, it is advisable to actively remove urine using siphon drainage, devices for draining UDR-500, vibro-waiter. Stationary vacuum suns. If necessary, the bladder washing with antibacterial solutions entering the intake irrigator of the two-section drainage or an additional capillary tube installed through suprocessing access. Improving the outcomes of closed bladder damage is determined early diagnosis and timely operational intervention. Mortality in a number of institutions managed to reduce up to 3-14%. Cause of the death of victims -
Multiple severe damage, shock, blood loss, spilled peritonitis and workpiece.

With an extremely serious condition of the patient, cystostomy is carried out and drained the olive phosphus tissue. Reconstructive operation is performed after stabilizing the patient's condition.

Patients with a fracture pelvis reducing operation on the bladder must be carried out to intraosnial fixation of fragments.

In the postoperative period, antibiotics of a wide range of action, hemostatic preparations, analgesics are prescribed. In the overwhelming majority of cases, when using such a method of treating damage, complete healing occurs in time, not exceeding 3 weeks.

Intraperous urinary bubble break - absolute Indication to emergency operation; Contraindication is only the agonal state of the patient. With suspected combined damage to the abdominal organs, it is advisable to include an abdominal surgeon in the operating brigade.

Operational access - Lower Urgent Laparotomy. After opening the abdominal cavity, the organs conduct a thorough audit in order to eliminate their combined damage. If there are such damage, the abdominal stage of the operation is first performed.

The urinary bubble breaks is usually observed in the region of the transitional fold of the peritoneum. With the difficulty of detecting the bubble break site, it is advisable to use intravenous administration of a 0.4% indigoline solution or a 1% solution of methylene blue, staining urine into blue and facilitating the identification of bladder damage.

After detection of damage to the wall of the bladder, the epicistostomy is performed, and the gap is stitched by a two-row joint using a absorbable material. Sometimes the bladder is further drained to the urethral catheter, 1-2 days are adjusted to the constant washing of the bladder with solutions of antiseptics.

In the absence of combined damage to the abdominal organs, the operation is completed by sanitation and drainage. Drainage tubes are installed through contraceptive cuts into the cavity of the small pelvis and on the right and left side canals of the abdominal cavity. With a spilled peritonitis, a nasogasostinal intestinal intubation is performed.

In the postoperative period, antibacterial, hemostatic, anti-inflammatory, infusion therapy, intestinal stimulation and correction of homoseostasis disorders.

The duration of the drainage of the abdominal cavity and the bladder is determined individually depending on the characteristics of the flow postoperative period. At the same time focus on the indicators of intoxication, the duration of hematuria, the presence of infectious-inflammatory complications.