152 PELVIC FRACTURE RELATED INJURIES OF THE BLADDER NECK AND THEIR MANAGEMENT

Abstract

INTRODUCTION AND OBJECTIVE: Bladder neck injuries are a well recognised but rare consequence of pelvic fracture related trauma. The authors have been unable to find any reference in the literature to their specific management. This report summarises our experience. METHODS: Since 10/1998 we treated 14 men with bladder neck injuries following pelvic fracture. Two were referred to us for delayed primary repair of the bladder neck injury 7-9 days after trauma. The other 12 patients presented for further treatment 3 months 5 years after trauma having had their initial treatment elsewhere. All the injuries were at or close to the anterior midline and associated with lateral compression fractures. Five were confined to the bladder neck and the bladder and 7 extended into the urethra or were associated with urethral disruption. All had an associated cavity. All had overlapping pubic bone fragments involved in the cavity and the rupture. In two long-standing cases with delayed presentation one had recurrent haematuria and the second had recurrent urinary infection associated with osteitis pubis. All patients underwent resection of the involved bone fragments, excision of the cavity, repair of the bladder neck and reconstruction of the urethra (when necessary). Wherever possible the repair was supplemented with an omental wrap. This was not possible in two cases. Two patients with particularly severe pelvic fracture injuries had a transverse rupture of the bladder neck above the prostate and the membranous urethra below the prostate with a sequestered prostate. We have seen this in children before but not in adults. RESULTS: In one of the two cases when an omental wrap was not possible the cavity recurred. This was in the patient with a delay of five years in presentation. Eight patients required subsequent implantation of an artificial urinary sphincter for sphincter weakness incontinence. The others have an acceptable degree of continence. CONCLUSIONS: We conclude that traumatic bladder neck rupture occurs at or close to the anterior midline of the prostatic urethra in relation to a crush or tear injury as a consequence of overlapping pubic bones in a lateral compression pelvic fracture. The nature of the bladder neck sphincter mechanism means that the bladder neck rupture is held open. These injuries never heal spontaneously and are always associated with a cavity and should therefore be closed early rather than waiting 3 6 moths afterwards as is the case with pelvic fracture urethral injury. A previously unreported form of injury is described.