The most significant symptoms are a desire to urinate and inability to do more than perhaps expel a few drops of bloody fluid. Of course the passage of any blood or bloody urine will suggest the occurrence of such an injury. Patients are usually unable to stand upright, and also show a strong tendency to flexion of the thighs. The introduction of a catheter and the withdrawal of bloody urine do not necessarily settle the question as to whether there has been any possible laceration. Some surgeons have taught that normal urine is comparatively harmless and that it is no more likely to produce infection than the catheter used for diagnostic purposes; but this is not safe teaching today. A clean metal instrument is of no more danger than a clean probe under other circumstances. Weir has suggested a valuable test, consisting of removal of all the urine possible, after which a measured quantity of sterile fluid is injected. If on using a catheter again this be all recovered it may be assumed that the bladder is not ruptured, otherwise the contrary. If hours after the injury a catheter be used and no urine secured, this fact will be most suggestive. The cystoscope is usually disappointing, since a bladder so injured cannot often be satisfactorily examined.
Another class of serious injury to the bladder includes the perforations, such as may be effected by gunshot or stab wounds, or, as in one case of my own, where a lad sat down upon an iron spike, about three-quarters of an inch square and nearly six inches in length. The point of the spike entered the anus, and the consequence of the injury was a perforation of the anterior wall of the rectum and the posterior wall of the bladder, with injury to its anterior wall without complete perforation. Prompt operation saved this case, as it will most such instances, although it was shown that a piece of his trousers had been carried into and left in the bladder. I opened the abdomen above the pubis, to be sure that the peritoneum was not injured, and then drained by a tube passed into the anus and out just above the pubis, after removing the piece of cloth. Prompt recovery followed.
The bladder may also be injured by rude manipulation of instruments, especially the metal catheter, by one unaccustomed to using it, or when serious difficulties are offered by prostatic enlargement.
Treatment.
—Diagnosis or even serious suspicion of such injuries to the bladder as above described require either perineal or abdominal section, the choice of the procedure being based upon circumstances. If there be reason to suspect intraperitoneal extravasation, then the abdomen should be opened, carefully cleaned, the bladder rent sought and sutured, the mucosa being first closed with hardened gut, while the peritoneal aspect may be sutured with silk or thread. The bladder should be drained, at least by retention of a catheter, passed if necessary by perineal section, and the abdomen drained. In the female drainage may be made through the cul-de-sac. If there be urinary extravasation behind the perineum, then perineal section should be made, and the bladder, thus freely opened, should be drained with a sufficiently large tube; while in the female it will probably be sufficient to dilate the urethra and insert a tube of sufficient size. It is not always easy to discover an opening placed posteriorly in the bladder wall, and after a wide exposure, with emptying and cleansing of the pelvis, it may be of great assistance to place the patient in the Trendelenburg position. Under rare circumstances the rent may be so placed as to justify a suprapubic drainage of the bladder.
FOREIGN BODIES IN THE BLADDER.
Foreign bodies other than calculi occur in the bladder in consequence of both accident and of design. The former are, e. g., represented by pieces of broken catheter, while the latter are materials introduced from without in consequence of sexual perversion, during intoxication, or from some other vicious tendency. The latter occur more often in girls and women, the former more often in men. In such a collection of cases as was made by Poulet (Foreign Bodies in Surgery) almost every imaginable object that could be introduced into the bladder is mentioned. Some of these have slipped in accidentally after external manipulation, as in masturbation, and some have been deliberately introduced. Perhaps as common an object as any is the ordinary hairpin. It is the short urethra of women which is made the much more frequent resort for such practices than the long urethra of men, in which latter foreign bodies are often entangled or arrested before they reach the bladder.
Any object allowed to remain in the bladder will serve as a nidus for the formation of a calculus, which will form in time, and it may result that not until the removal of the calculus and examination of its interior structure will the original foreign body be found.
All objects of this kind should be removed as early as possible after their introduction. Such removal may be easy and accomplished by dilatation of the female urethra, with or without the use of the cystoscope; or the bladder may require to be opened, either above the pubis, through the perineum, or through the vagina, in order that the object in question may be extracted.