Pelvic Hematoma Research Articles

Open pelvic fractures with vaginal laceration: an unusual clinical feature

A 71-year-old female was admitted to casualty having been struck by a van while crossing a road. Examination revealed bleeding per vaginam and although she had no external injuries, palpable subcutaneous emphysema in the lower abdomen was detected. Roentgenograms con®rmed bilateral fractured ribs, a closed fracture of the right humerus, an extra capsular fracture of the right femur and a complex fracture of the pelvis with central dislocation of the left hip and bilateral superior and inferior pubic rami fractures. There was no evidence of a pneumothorax. A computerised tomographic scan (CT) scan of the patient's abdomen and pelvis, at 1 h post admission, showed extensive subcutaneous and intrapelvic emphysema (Figs. 1 and 2). Bowel perforation was suspected and an emergency laparotomy was performed after haemodynamic stabilisation. During the operation retroperitoneal and pelvic haematomas were noted but there was no evidence of bowel injury. Sigmoidoscopy was normal and a formal vaginal examination, deferred due to pain until general anaesthesia, revealed a vaginal tear in the right lateral wall measuring approx. 7 cm. This was repaired. The patient's orthopaedic injuries including the pelvic fracture were internally ®xed at a later date and she made a full recovery eventually.

Magnetic resonance imaging of postpartum pelvic hematomas: early experience in diagnosis and treatment planning

The purpose of this study was to determine the utility of magnetic resonance imaging (MRI) in detecting and localizing clinically non-apparent postpartum pelvic hematomas, and to describe the therapeutic implications of MRI in these patients. MRI examinations were performed on seven women with pelvic pain and/or fullness following difficult vaginal deliveries. None had clinically evident hematomas, and none were scheduled for surgery. Hematomas in the pelvis were identified with conventional T 1-weighted, and conventional and fast spin echo T 2-weighted sequences. Intravenous contrast was not used. Pelvic hematomas were identified in contiguity with the vagina, cervix, and bladder, within the broad ligament, and in the presacral space. In two patients, hematomas were confined to the perivaginal and pericervical regions. In three patients, perivaginal hematomas extended between the double layers of the broad ligaments. In one patient, a perivaginal hematoma extended into the perivesical space. In one patient, a hematoma was identified only within the presacral space. Based on MRI as the only contributory imaging study, five patients were treated successfully with invasive means and two patients were managed successfully with conservative means. MRI successfully detects and localizes postpartum hematomas, information that often is unavailable from the clinical examination. This information facilitates decisions regarding the need for intervention and the appropriate type of procedure when intervention is necessary for this potentially life-threatening problem. We advocate the use of MRI to evaluate patients at risk for postpartum hemorrhage following difficult vaginal deliveries.

The excision of uterine fibroids by vaginal myomectomy: a prospective study

Objective: To evaluate the clinical effectiveness and safety of the excision of uterine fibroids by vaginal myomectomy. Design: Prospective study. Setting: A gynecology department of a university teaching hospital. Patient(s): Women with menorrhagia, pelvic pain, symptoms of pressure, or subfertility attributable to moderate-sized uterine fibroids who otherwise would have required abdominal or laparoscopic myomectomy. Intervention(s): Vaginal myomectomy. Main Outcome Measure(s): The feasibility of vaginal surgery, operative complications, postoperative recovery, and relief of symptoms. Result(s): Myomectomy was completed vaginally in 32 (91.4%) of 35 patients and none required hysterectomy. The overall operating time was 78 minutes, the estimated operative blood loss was 313 mL, and the mean postoperative hospital stay was 4 days. Pelvic hematomas developed in 4 patients, and one colpotomy required resuture. Seventy-four percent of the women reported relief of their symptoms at 3 months’ follow-up. Three patients have had full-term pregnancies since the operation. Conclusion(s): Myomectomy can be performed by the vaginal route in selected cases with low morbidity and a good short-term success rate. Unlike open myomectomy, it requires no skin incision, and unlike laparoscopic myomectomy, it can be used in patients who have numerous, relatively large, and intramural fibroids.

Retenção urinária aguda por extenso hematoma pelvico após herniorrafia inguinal

The authors report a rare case of a patient with urinary retention following an inguinal herniorraphy, due to extrinsic compression of the bladder by an extensive pelvic hematoma, diagnosed by cystourethrogram and pelvic computadorized tomography. A medical treatment was provided by vesical catheterization for seven days. After this period of time, the hematoma had disappeared and the patient recovered to spontaneous miction.

Subepithelial pelvic hematoma of the kidney clinically mimicking cancer: report of six cases and review of the literature

Objectives. Renal pelvic subepithelial hematoma is a rare but significant clinical mimic of neoplasm. Investigation and treatment of this diagnostic problem are uncertain. Methods. We add 6 patients with this entity to the 15 previously published cases. All 6 were clinically suspected of having cancer, and 5 underwent nephrectomy. Results. The most common clinical findings are gross hematuria (19 of 21 cases) and acute onset of flank pain (13 of 21 cases). Intravenous urogram usually reveals a filling defect at the ureteropelvic junction. Pathologic findings include massive subepithelial and peripelvic hemorrhage, hydronephrosis, cortical infarcts, and renomegaly. Two of our patients have previously undescribed clinical associations, including one who was 2 weeks postpartum and another with ureteropelvic junction obstruction. In addition, our patient with obstruction is the first with subepithelial hematoma to be treated successfully with pyeloplasty. Conclusions. Subepithelial pelvic hematoma may be effectively treated with pyeloplasty or partial nephrectomy if distinguished from cancer preoperatively. Awareness of this rare entity may allow preoperative identification, but this has not been possible to date.

MRI appearance of the pelvis in the post cesarean-section patient

Fever in the post-cesarean section patient may indicate the presence of a potentially life-threatening complication, including abscess, ovarian vein thrombosis, and uterine dehiscence. Imaging findings are often utilized to ascertain the presence or absence of such complications. Familiarity with the normal findings in the post-operative period is essential in making this determination. The purpose of this investigation is to describe the MRI appearance of the post-cesarean section pelvis. Over a 67-month period, 50 patients with persistent low-grade fevers following c-section were referred for MR imaging. Imaging was performed 3–10 days post-operatively. Axial T 1-weighted and T 2-weighted images were acquired in addition to sagittal T 2-weighted images. Coronal images were obtained in some cases. Clinical correlation was obtained through the patients charts, confirming discharge of the patients in stable condition. The uterine incision site usually demonstrated findings consistent with subacute hematoma. The anterior uterine myometrium demonstrated enlargement relative to the posterior uterine wall. Bladder flap hematomas were seen in 64% of cases. Three cases (6%) demonstrated parametrial edema and none of these patients demonstrated ovarian vein thrombosis. Two cases of pelvic hematoma were noted. The normal post-c-section incision site may demonstrate increased or decreased signal intensity on T 2-weighted images and intact endometrial and serosal layers mitigate against the diagnosis of incisional dehiscence. Bladder flap hematomas occurred in slightly more than half the cases. Parametrial edema and pelvic hematoma can be seen as post-surgical changes.

BLADDER ENTRAPMENT DURING INTERNAL FIXATION OF A PELVIC FRACTURE

A 30-year-old white man was admitted to the emergency room after a motor vehicle accident for left lateral shock. At presentation the patient was hemodynamically stable but he required intubation for light coma. Clinical examination demonstrated extensive ecchymoses over the left side of the body, left lower quadrant guarding and left pulmonary hypoventilation. After ruling out urethral injury catheter placement yielded clear urine and urinalysis was negative. Radiographic evaluation showed a ruptured left diaphragm, fractures of the left hemipelvis (ischiopubic segment, acetabulum and iliac crest), peritoneal effusion and moderate cerebral edema. Emergency laparotomy revealed splenic laceration and diaphragmatic dome rupture, which were repaired. Pelvic hematoma that was also discovered a t exploration remained undisturbed. Initial orthopedic management involved traction of the lower left leg. By day 15 of the hospital course, the patient had recovered neurological function and the acetabular fracture was internally fixed. At the completion of surgery moderate hematuria had developed, which was treated with continuous bladder lavage through a double lumen urethral catheter. Excretory urography with the catheter clamped showed bladder compression by an intrapelvic hematoma. Hematuria worsened 2 days later, requiring endoscopic clot evacuation with the patient under general anesthesia. Bladder inspection at the time was unrevealing due to hematuria and inflammation. To determine the bleeding source retrograde cystography was performed, which suggested incarceration of the left lateral bladder wall at the site of the acetabular fracture (fig. 1). This diagnosis was confirmed by pelvic computerized tomography (CT) (fig. 2). At repeat surgery the pelvic hematoma was evacuated and longitudinal cystotomy was performed. This procedure permitted the localization of invagination of the cystic mucosa, where the bladder wall was incarcerated in the left acetabular osseous defect. The bladder was freed from the fracture site, and a small bleeding branch of the obturator artery was noted, explaining the massive hematuria. Hemostasis was achieved by arterial dissection, clamping with verified hemostasis and then ligature at the involved branch of the left hypogastric artery. The bladder was closed in 2 layers with placement of an indwelling urethral catheter. Convalescence was uneventful.

Spontaneous pelvic hematoma simulating neoplasm: case report and literature review.

Spontaneous hematomas are rare and can present with acute or chronic symptoms. Our patient presented with deep vein thrombosis of the lower extremity associated with a spontaneous pelvic hematoma. This lesion was radiologically and clinically indistinguishable from a soft-tissue neoplasm. The case of a spontaneous pelvic neoplasm in an otherwise healthy young man is presented and the literature reviewed regarding issues of differential diagnosis and clinical management.

POSTERIOR SAGITTAL APPROACH FOR MANAGEMENT OF A TRAUMATIC URETHRAL STRICTURE

No AccessJournal of UrologyPediatric Urology1 Oct 1998POSTERIOR SAGITTAL APPROACH FOR MANAGEMENT OF A TRAUMATIC URETHRAL STRICTURE RANJIV MATHEWS, RICHARD I. SILVER, CHARLES PAIDAS, and STEVEN DOCIMO RANJIV MATHEWSRANJIV MATHEWS More articles by this author , RICHARD I. SILVERRICHARD I. SILVER More articles by this author , CHARLES PAIDASCHARLES PAIDAS More articles by this author , and STEVEN DOCIMOSTEVEN DOCIMO More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(01)62595-3AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "POSTERIOR SAGITTAL APPROACH FOR MANAGEMENT OF A TRAUMATIC URETHRAL STRICTURE." The Journal of Urology, 160(4), pp. 1475–1476 References 1 : Rectum and Anus in Surgery of Infants and Children: Scientific Principles and Practice.. Edited by . Philadelphia: Lippincott-Raven1997: 1323. Google Scholar 2 : Posterior sagittal anorectoplasty: primary repair of a rectovaginal fistula in an adult: report of a case. Dis. Colon Rectum1997; 40: 1119. Google Scholar 3 : Posterior sagittal anorectoplasty in adults. Brit. J. Surg.1994; 81: 601. Google Scholar 4 : Repair of posttraumatic stenosis of the urethra through a posterior sagittal approach. J. Ped. Surg.1992; 27: 1465. Google Scholar 5 : Complex urethral reconstruction. Urol. Clin. N. Amer.1994; 21: 567. Google Scholar From the Division of Pediatric Urology, Brady Urological Institute and Division of Pediatric Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland© 1998 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 160Issue 4October 1998Page: 1475-1476 Advertisement Copyright & Permissions© 1998 by American Urological Association, Inc.MetricsAuthor Information RANJIV MATHEWS More articles by this author RICHARD I. SILVER More articles by this author CHARLES PAIDAS More articles by this author STEVEN DOCIMO More articles by this author Expand All Advertisement PDF downloadLoading ...

Is colostomy always necessary in the treatment of open pelvic fractures?

Wound management in open pelvic fractures has used fecal diversion, debridement, and closure by secondary intention to prevent pelvic sepsis. Colostomy care and takedown adds to the morbidity and resource utilization of this approach. We reviewed our experience to determine if a selective approach to fecal diversion based on wound location was possible. Retrospective analysis of patients admitted to a Level I trauma center during an 8-year period. Fractures were classified as open if the fracture was in continuity with the wound. Wounds were classified as perineal if they involved the rectum, ischiorectal fossa, or genitalia, and as nonperineal if they involved the pubis anteriorly, iliac crest, or anterior thigh. Pelvic sepsis was defined as cellulitis, fasciitis, or infection of a pelvic hematoma. Diversion consisted of loop or end colostomy. Eighteen patients with open fractures were identified. Four died from closed head injury and blood loss. The remaining 14 were treated as follows. Five patients with perineal wounds had diversion of their fecal stream. Their Injury Severity Score was 34 +/- 8.3 and their Revised Trauma Score was 7.69 +/- 0.15. No patient developed pelvic sepsis. Nine patients with nonperineal wounds did not undergo diversion. Their Injury Severity Score was 28.6 +/- 5.3 and their Revised Trauma Score was 7.36 +/- 0.45. No patients developed pelvic sepsis in the nondiverted group. No patients with anterior wounds and an intact fecal stream developed pelvic sepsis. Colostomy may not be necessary in all patients with open pelvic fracture. Protocols using fecal diversion based on wound location appear to be safe and may decrease resource utilization and subsequent morbidity related to colostomy closure.

Thromboembolic Complication Rate after Radical Retropubic Prostatectomy

Objectives. The impact of routine ultrasonography for diagnosis and rapid treatment of pelvic lymphoceles and hematomas on the rate of thromboembolic complications was studied. Methods: From June 1987 to December 1995, 508 patients underwent radical retropubic prostatectomy with low-dose heparin prophylaxis at our medical institution. Beginning with patient 321, routine pelvic ultrasonography was started on each patient on postoperative day 1 for diagnosis of lymphoceles and hematomas. The rate of thromboembolic complications in patients 321–508 was compared with that in patients 1–320 (without routine ultrasonography). Results: In patients 1–320, a total of 20 (6.2%) symptomatic thromboembolic complications occurred: five (1.6%) pulmonary emboli and 15 (4.7%) cases of deep venous thrombosis. In patients 321–508, the total rate of thromboembolic complications was significantly reduced (p = 0.049): only 4 patients (2.1%) had thromboembolic events (1 pulmonary embolism and 3 cases of deep venous thrombosis): all but 1 of the complications were associated with small hematomas, which were first negative on routine pelvic ultrasonography but positive on CT scan only done when clinical suspicion of symptoms occurred or during open surgery and showed compression of the iliac vein. Conclusions: Pelvic lymphoceles and hematomas seem to be important cofactors in the pathophysiology of thromboembolic complications after radical retropubic prostatectomy. Most lymphoceles and hematomas can be diagnosed with pelvic ultrasonography although small hematomas can be overseen with pelvic ultrasonography. Surgeons should become more aware of these postoperative complications particularly in patients on heparin prophylaxis.

Obstructive uropathy caused by massive pelvic haematoma: a report of two cases

Obstructive uropathy caused by massive pelvic haematoma: a report of two cases

Removal of adnexal masses by operative laparoscopy during pregnancy

We evaluated the outcomes of pregnancies in nine women who underwent removal of an adnexal mass by operative laparoscopy during pregnancy. These patients, who would otherwise have undergone exploratory laparotomy, were treated by diagnostic and operative laparoscopy using the carbon dioxide laser and electrocoagulation. Gestational ages ranged from 12 to 22 weeks (mean 15 wks). Indications for the surgery were persistent complex or enlarged adnexal mass (7), painful adnexal mass (1), and acute abdomen and intraabdominal hemorrhage (1). Procedures performed were ovarian cystectomy (7), paratubal cyst removal (1), and evacuation of pelvic hematoma (1). Operating time ranged from 55 to 150 minutes (mean 101 min). Peritoneal washings were always obtained. No tocolytics were used during or after surgery. Normal fetal heart tones were auscultated postoperatively in the recovery room. There were no complications secondary to the surgery. Six women delivered at term with weight appropriate for gestational age (AGA). One patient had premature rupture of membranes at 31 weeks' with delivery of a viable AGA infant by emergency cesarean section. Two patients' pregnancies at 26 and 29 weeks are progressing normally. Operative laparoscopy for certain pelvic pathology may be performed safely with no complications to the pregnancy.

A randomized trial of open versus closed vaginal vault in the prevention of postoperative morbidity after abdominal hysterectomy

OBJECTIVE: Our purpose was to evaluate the effects of two surgical techniques, closed vaginal vault with two layers of continuous 3-0 polyglactin suture versus open vaginal vault with a locking 3-0 polyglactin suture, after abdominal hysterectomy. STUDY DESIGN: A prospective, randomized trial was performed. During the hospital stay and 4 to 8 weeks after the operation patients were observed for evidence of morbidity. RESULTS: Of the 273 evaluable subjects, 141 had the vaginal vault left open whereas 132 were closed. Ten (7.1%) and eight patients (6.1%) had infections at the operative site (pelvis or abdominal wound) ( p = 0.92). A urinary tract infection was diagnosed in three 2.1%) and in four subjects (3.0%) ( p = 0.46). A pelvic hematoma developed in two patients of each group ( p = 0.66). Vault granulations were recorded in 11% and 12% of subjects ( p = 0.97). CONCLUSION: This study failed to show some benefit in favor of either of the two surgical policies. A careful surgical technique and antibiotic prophylaxis seem to remain the most important factors in the prevention of postoperative morbidity.

Magnetic resonance characteristics of intrapelvic haematomas

Although haematomas in the female pelvis are not rare, their magnetic resonance (MR) appearance has not been well characterized. Accordingly, we analysed the MR appearances of various stages of haematomas in the female pelvis. A retrospective analysis of 35 haematomas in 28 patients sequentially imaged with a 1.5 T MR unit was performed. The time interval between the insult and MR imaging was determined and the appearances of the haematoma were evaluated. The results were compared with those in the central nervous system. The evolution of haematomas in the pelvis appeared similar to that of haematomas in the brain, and four stages (acute, early subacute, late subacute and chronic) were identified according to the signal intensity pattern on T1 and T2 weighted images. Pelvic haematomas differed from intracranial haematomas in the following features: (1) The speed of evolving pelvic haematomas was gradual. (2) In the centre of acute haematomas, slightly hyperintense areas were seen on both sequences, suggesting residual oxyhaemoglobin. (3) Haematomas evaluated in the early subacute stage had complex appearances. (4) In older haematomas, central intermediate signal intensity areas, presumably due to diamagnetic hemichromes, became predominant on T1 weighted images. In conclusion, although the evolution of a pelvic haematoma is similar to that of a brain haematoma, its speed is gradual and MR appearances are somewhat different due to environmental differences.

Postradical orchiectomy hemorrhage: Should an alteration in staging strategy for testicular cancer be considered?

We report 3 cases of postradical orchiectomy hemorrhage from separate institutions. The retroperitoneal and pelvic hematoma formed as a complication of orchiectomy can be misinterpreted to represent metastatic disease on postoperative staging computed tomography scans. As a result of inaccurate information obtained from these evaluations, significant alterations in patient management will result. Prevention and early recognition of this complication are crucial if unnecessary treatment is to be avoided.

The outcome of placenta accreta in Kuwait (1981-1993).

To study the demographic characteristics of patients with placenta accreta and to identify the clinical features, maternal and neonatal complications of this condition. Sixteen cases of placenta accreta were identified in the Maternity Hospital of Kuwait during the period January 1981 to July 1993. Medical records were reviewed regarding past obstetric history, type of placenta, clinical presentation, maternal and fetal outcome. The rate of placenta accreta was found to be 98 per 1,000,000 deliveries. Emergency hysterectomy was needed in 87.5% of cases. There was one maternal death (6.25%) and three perinatal deaths (18.75%). Hemorrhage was the major presenting symptom either externally and antenatally in previa accreta or postpartum in accreta of the upper segment or internally in the same cases. The major postoperative complications were coagulopathy, urinary injury, pelvic hematoma and abscess, in addition to cardiac arrest. These complications, when considered separately, were not affected by a previous history of uterine scarring. Placenta accreta is a major cause of obstetric hemorrhage and has an adverse effect on maternal and neonatal outcome. It ought to be considered a possibility in patients with previous uterine scarring, placenta previa or retained placenta. It will remain a growing problem in the developing countries due to the rising incidence of previous multiple cesarean sections. Unfortunately the latter do not deter women in this part of the world from insisting upon having big families and refusing tubal ligation.

The rehabilitative management of the traumatic brain injury patient with associated femoral neuropathy

The initial diagnoses of associated injuries in patients with traumatic brain injury (TBI) are often overlooked because of the priority given to life-sustaining measures. Pelvic and abdominal injuries comprise less than 5% each of the concurrent injuries associated with TBI and multiple trauma. This report describes a 32-year-old man who sustained a moderate TBI with facial, pelvic, and extremity fractures secondary to a fall. His hospital course was complicated by sepsis, acute renal failure, and retroperitoneal hemorrhage. Admitted to the rehabilitation service 6 weeks after the fall, the patient was found to have a previously undiagnosed profound quadriceps muscle weakness. A diagnosis of femoral neuropathy was confirmed by electrodiagnostic studies and was attributed to compression by pelvic hematomas. Rehabilitation management included use of a solid ankle cushion heel (SACH) wedge, a functional knee brace, a progressive ambulation program, neuromuscular stimulation, and patient and family education with an emphasis on safety. The patient progressed rapidly with his rehabilitation program, improving from moderate assistance in all skills to independence in 3 weeks. This case illustrates the importance of the physiatrist's role in the early detection of associated injuries in patients with multiple trauma and TBI; it also illustrates some of the rehabilitation techniques that may be employed to aid a patient with a femoral neuropathy to regain junctional ability.

Associated injuries in patients with blunt chest trauma: detection by abdominal roentgenograms after aortography.

To determine the value of abdominal roentgenograms after aortography for detecting additional organ injuries, we retrospectively evaluated the abdominal and pelvic roentgenograms after aortography of 170 trauma patients who underwent arch aortography to detect aortic rupture. In 160 (94%) of 170 patients, the results of arch studies were normal. Ten (6%) of 170 patients had aortic rupture (8 patients) or rupture of a major vessel (2 patients). Thirty-one (18%) of 170 patients had associated injuries demonstrated by the roentgenograms taken after aortography, including pelvic or femoral fractures (13%), pelvic hematomas (5.8%), renal injuries (1.1%), and bladder ruptures (2.9%). We conclude that abdominal and pelvic pain roentgenograms should be part of a routine arch aortography performed for blunt chest trauma to detect additional organ injuries that frequently accompany injuries from motor vehicle crashes.

Using a vaginal tube to separate the uterus from the vagina during laparoscopic hysterectomy

Hysterectomy performed totally by laparoscopy has few advocates because separating the cervix from the vagina is difficult. This technical difficulty can be overcome by placing a wide-bore plastic tube in the vagina to expose the cervico-vaginal junction and stretch the vaginal fornices. The stretched vagina falls away from the cervix as diathermy cuts over the tube rim. The tube guides the incision, and the plastic protects any adjacent structures. The most convenient external diameter is between 4-5 cm. Made from smooth, electrically-inert plastic, the tube's opposite distal end has a valve that maintains the pneumoperitoneum. We have used it in 73 cases, and the only associated complication has been one vault pelvic hematoma.