今日の臨床サポート

膀胱損傷

著者: 羽賀宣博 福岡大学医学部 腎泌尿器外科学講座

監修: 中川昌之 公益財団法人 慈愛会 今村総合病院 泌尿器科顧問

著者校正/監修レビュー済:2021/05/12
参考ガイドライン:
患者向け説明資料

概要・推奨   

  1. 膀胱損傷を起こしている患者は他臓器損傷を起こしていることが多い。したがって、全身状態が不良の患者は膀胱損傷の診断、治療より救命を優先させる。
  1. 膀胱造影は造影剤を注入する前、造影剤充満時、造影剤排出後の3枚必ず撮影する
  1. CT膀胱造影では、膀胱内に注入する造影剤は、生理食塩水で薄めて使用するCT画像のハレーションの予防のため)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
羽賀宣博 : 未申告[2021年]
監修:中川昌之 : 研究費・助成金など(武田薬品工業株式会社)[2021年]

改訂のポイント:
  1. 定期レビューを行い、膀胱修復術の治療適応や膀胱瘻カテーテル留置の可否に関して、加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 膀胱は骨盤内に存在するため、外傷から守られた場所にあるが、交通事故や落下などで骨盤骨折を起こし際に、膀胱損傷が発症しうる[1]。また膀胱充満時に下腹部に強い圧迫を受けた際にも、骨盤骨折がなくても発症することがある。その場合、比較的脆弱な膀胱頂部が破裂しやすい。その他、切創や医原性に発症することもある。医原性としては、経尿道的手術、婦人科手術、大腸切除術等の骨盤内手術中に起きやすい。小児では、骨盤骨は発達・成長の途中であるため、成人と比較すると鈍的膀胱損傷を受けやすい[2]
  1. 膀胱損傷は尿が腹膜外に溢流するか(<図表>)、腹膜内に溢流するか(<図表><図表><図表>)で分けられる。
  1. 症状は下腹部痛や下腹部の圧痛、排尿困難、肉眼的・顕微鏡的血尿である。
 
腹膜外膀胱損傷

膀胱造影(a、b):造影剤が不規則な形態を示している(矢印)、骨盤骨折も認められる(白矢印)。
CT膀胱造影(c):膀胱損傷のため造影剤が膀胱前腔に存在している(矢印)。

 
腹膜内膀胱損傷

膀胱造影:造影剤が腸管の周囲に及び、腸管の形態が描出される(矢印)。膀胱周囲に血腫が存在するため膀胱が圧排されている(H)。また骨盤骨折も認められる(開放矢印)。

 
腹膜内膀胱損傷

膀胱造影:造影剤が膀胱から腹膜内に溢流して、右上行結腸の形態を描出している(矢印)。

 
腹膜内膀胱損傷

CT膀胱造影:造影剤が腸管周囲に認められる。

 
  1. 病歴と症状で膀胱損傷が疑われれば、ただちに適切な医療機関に紹介して評価を行うべきである。
  1. 診断は尿道からカテーテルを挿入し造影を行う膀胱造影か、造影剤を膀胱に注入した後にCTを行うCT膀胱造影が診断能力に優れる。
  1. 治療は腹膜外への溢流であれば、留置カテーテルで保存的に経過を観察する。腹膜外溢流でも鈍的損傷で膀胱損傷以外の臓器損傷が疑われれば、膀胱の修復、さらに膀胱以外の損傷部の修復を行う[1][3][4]。切創、腹膜内溢流であればただちに損傷部の修復を行う[1][4]
問診・診察のポイント  
  1. 健常な成人が何の誘因もなく膀胱外への尿溢流を来すことは考えにくく、まず外傷を受けたのか、受けた場合どのような外傷を受けたのか、症状発症時の状況を問診する。

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文献 

著者: Matthew J Coppola, Joshua Moskovitz
雑誌名: Emerg Med Clin North Am. 2019 Nov;37(4):611-635. doi: 10.1016/j.emc.2019.07.003.
Abstract/Text Genitourinary trauma often occurs concomitantly with other abdominopelvic trauma, but nevertheless is important to master in diagnosis, management, and treatment. There are subtleties to diagnosis and important steps that should not be missed to properly manage patients.

Copyright © 2019 Elsevier Inc. All rights reserved.
PMID 31563198  Emerg Med Clin North Am. 2019 Nov;37(4):611-635. doi: 1・・・
著者: Christopher M Deibert, Benjamin A Spencer
雑誌名: J Urol. 2011 Jul;186(1):151-5. doi: 10.1016/j.juro.2011.03.002. Epub 2011 May 14.
Abstract/Text PURPOSE: The bladder is the most commonly injured genitourinary organ from blunt pelvic trauma. In this study we describe traumatic bladder injuries in the United States, their management and association with mortality.
MATERIALS AND METHODS: We queried the 2002 to 2006 National Trauma Data Bank for all subjects with bladder injury. Demographics, mechanism of injury, coexisting injuries, type of bladder injury, and operative interventions for bladder and other abdominal trauma are described. Multivariate logistic regression analysis was used to examine the relationship between bladder injury and in-hospital mortality.
RESULTS: Of 8,565 subjects with bladder trauma 46% had pelvic fracture and 15% had 2 or more intra-abdominal injuries. Of these subjects 54% underwent bladder surgery, including 76% with intraperitoneal injury and 51% with surgical repair of other abdominal organs. On multivariate analysis operative bladder repair reduced the likelihood of in-hospital mortality by 59%. Greater likelihood of death was seen in African-American and Native American patients, and those with pelvic injuries, triage to higher acuity care, penetrating trauma and multiple abdominal injuries.
CONCLUSIONS: We demonstrated that surgical repair provides a significant survival advantage for subjects with bladder trauma. With 76% of intraperitoneal bladder injuries being repaired, there appears to be underuse of a lifesaving procedure. Additional studies to refine indications for bladder repair are warranted.

Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
PMID 21575961  J Urol. 2011 Jul;186(1):151-5. doi: 10.1016/j.juro.2011・・・
著者: Peter V Quagliano, Sean M Delair, Ajai K Malhotra
雑誌名: J Trauma. 2006 Aug;61(2):410-21; discussion 421-2. doi: 10.1097/01.ta.0000229940.36556.bf.
Abstract/Text BACKGROUND: This study was designed to evaluate prospectively the accuracy of computed tomography (CT) cystography for the detection of bladder rupture, performed concurrently with screening abdominal/pelvic CT, in patients at risk for blunt bladder injury. The study also aimed to validate our proposed method of performing CT cystography, which was designed to minimize the time and effort required to image the bladder.
METHODS: CT cystography was performed on patients at risk for blunt bladder injury. Retrograde filling of the bladder with dilute iodinated contrast material was performed before routine abdominal/pelvic CT scanning, performed with oral and intravenous contrast. Conventional cystography, when performed, followed CT cystography.
RESULTS: CT cystography, followed by conventional cystography, was performed in 212 patients, among whom 19 had bladder rupture. The CT cystography sensitivity and specificity for bladder rupture in these patients was 95% and 100%, respectively; for conventional cystography, sensitivity and specificity were 95% and 100%, respectively. CT cystography was performed without conventional cystography in 283 patients, among whom 27 had bladder rupture. The sensitivity and specificity of CT cystography for bladder rupture in these patients were both 100%.
CONCLUSIONS: CT cystography is equivalent to conventional cystography for detecting the presence or absence of blunt bladder injury. CT cystography can be performed as an integral part of the CT screening undergone by many blunt trauma patients and, in the vast majority of these patients, it can alleviate the need for a separate conventional cystogram.

PMID 16917459  J Trauma. 2006 Aug;61(2):410-21; discussion 421-2. doi:・・・
著者: Parvati Ramchandani, Philip Michael Buckler
雑誌名: AJR Am J Roentgenol. 2009 Jun;192(6):1514-23. doi: 10.2214/AJR.09.2470.
Abstract/Text OBJECTIVE: Blunt and penetrating abdominal trauma can cause significant injury to the genitourinary organs, and radiologic imaging plays a critical role both in diagnosing these injuries and in determining the management. In this article, we describe and illustrate the spectrum of injuries that can occur in the genitourinary system in order to facilitate accurate and rapid recognition of the significant injuries.
CONCLUSION: Imaging plays a crucial role in the evaluation of the genitourinary tract in a patient who has suffered either blunt or penetrating trauma because multiorgan injury is common in such patients. Contrast-enhanced CT is the primary imaging technique used to evaluate the upper and lower urinary tract for trauma. Cystography and urethrography remain useful techniques in the initial evaluation and follow-up of trauma to the urinary bladder and urethra.

PMID 19457813  AJR Am J Roentgenol. 2009 Jun;192(6):1514-23. doi: 10.2・・・
著者: C Bent, T Iyngkaran, N Power, M Matson, T Hajdinjak, N Buchholz, T Fotheringham
雑誌名: Clin Radiol. 2008 Dec;63(12):1361-71. doi: 10.1016/j.crad.2008.03.011. Epub 2008 Jun 26.
Abstract/Text Blunt renal trauma is the third most common injury in abdominal trauma following splenic and hepatic injuries, respectively. In the majority, such injuries are associated with other abdominal organ injuries. As urological injuries are not usually life-threatening, and clinical signs and symptoms are non-specific, diagnosis is often delayed. We present a practical approach to the diagnosis and management of these injuries based on our experience in a busy inner city trauma hospital with a review of the current evidence-based practice. Diagnostic imaging signs are illustrated.

PMID 18996268  Clin Radiol. 2008 Dec;63(12):1361-71. doi: 10.1016/j.cr・・・
著者: Reynaldo G Gomez, Lily Ceballos, Michael Coburn, Joseph N Corriere, Christopher M Dixon, Bernard Lobel, Jack McAninch
雑誌名: BJU Int. 2004 Jul;94(1):27-32. doi: 10.1111/j.1464-410X.2004.04896.x.
Abstract/Text
PMID 15217426  BJU Int. 2004 Jul;94(1):27-32. doi: 10.1111/j.1464-410X・・・
著者: A J Deck, S Shaves, L Talner, J R Porter
雑誌名: J Urol. 2000 Jul;164(1):43-6.
Abstract/Text PURPOSE: We present our experience with computerized tomography (CT) cystography for diagnosing bladder rupture in patients with blunt abdominal and pelvic trauma, and compare the results of CT cystography with those of surgical exploration.
MATERIALS AND METHODS: We identified all patients with blunt trauma diagnosed with bladder rupture from 1992 to September 1998. We reviewed the radiology computerized information system for all CT cystography performed to evaluate blunt trauma during the same period. We also reviewed the medical records and pertinent radiographic studies of patients with bladder rupture who underwent CT cystography as part of the hospital admission evaluation. Operative and radiographic findings were compared.
RESULTS: CT cystography was performed in 316 patients as part of the initial evaluation of blunt trauma. Of the 44 patients with the ultimate diagnosis of bladder rupture CT cystography revealed bladder rupture in 42, while 23 of the 28 (82%) who underwent formal bladder exploration had operative findings that exactly matched the CT cystography interpretation in terms of the presence and type of rupture. In the 316 patients CT cystography detected bladder rupture with an overall sensitivity and specificity of 95% and 100%, respectively. For intraperitoneal rupture sensitivity was 78% and specificity was 99%.
CONCLUSIONS: CT cystography provides expedient evaluation of bladder rupture due to blunt trauma and has accuracy comparable to that reported for plain film cystography. We recommend CT cystography over plain film cystography in patients undergoing CT for other injuries associated with blunt trauma.

PMID 10840421  J Urol. 2000 Jul;164(1):43-6.
著者: Marc A Bjurlin, Richard J Fantus, Michele M Mellett, Sandra M Goble
雑誌名: J Trauma. 2009 Nov;67(5):1033-9. doi: 10.1097/TA.0b013e3181bb8d6c.
Abstract/Text BACKGROUND: Pelvic fractures from blunt force trauma place the bladder and urethra at risk for injury, often resulting in significant complications. We sought to compare morbidity, mortality, and health care resource utilization in patients with and without genitourinary injuries (GUI) associated with pelvic fractures.
METHODS: In this retrospective study of patients with blunt force pelvic fractures, the incidence of GUI, initial emergency department data, mechanism of injury, morbidity, health care resource utilization, associated injuries, discharge disposition, and mortality were investigated using chi tests for categorical variables and Student's t test for continuous variables comparing pelvic fractures with and without GUI. Multiple logistic regression analysis was used to detect significant predictors of mortality.
RESULTS: Of the 31,380 patients with pelvic fractures, 1,444 had GUI. Men more commonly sustained pelvic fractures with GUI than women (66.14% vs. 33.86%). The incidence of urogenital, bladder, and urethral injuries for men and women was 5.34%, 3.41%, 1.54%, and 3.62%, 3.37%, 0.15%, respectively. Patients with GUI remained hospitalized longer (median 10 vs. 6 d, p < 0.001), had more intensive care unit stay days (median 3 vs. 1 d, p < 0.001), were less often discharged home (31.02% vs. 42.82%), and had an increased mortality rate (13.99% vs. 8.08%, p < 0.001) when compared with patients without GUI. Motor vehicle collisions were the most common mechanism of injury for all pelvic fractures. Spleen and liver were the most commonly injured abdominal organs associated with pelvic fractures as a whole. Pelvic fractures with GUI were more likely to result in associated injuries of the bowel, and reproductive organs. Although GUI was not found to be an independent predictor of mortality, age >or=65 years, initial systolic blood pressure in the emergency department 0 mm Hg to 90 mm Hg, Injury Severity Score >or=25, Glasgow coma score of CONCLUSION: Patients sustaining a pelvic fracture with GUI have an increase in morbidity. Although GUI was not an independent predictor of mortality, patients who sustained a pelvic fracture with GUI had a greater number of concomitant injuries resulting in an increase in overall mortality compared with those without an associated GUI.

PMID 19901665  J Trauma. 2009 Nov;67(5):1033-9. doi: 10.1097/TA.0b013e・・・
著者: Nicolaas Lumen, Franklin E Kuehhas, Nenad Djakovic, Noam D Kitrey, Efraim Serafetinidis, Davendra M Sharma, Duncan J Summerton
雑誌名: Eur Urol. 2015 May;67(5):925-9. doi: 10.1016/j.eururo.2014.12.035. Epub 2015 Jan 6.
Abstract/Text CONTEXT: The most recent European Association of Urology (EAU) guidelines on urologic trauma were published in 2014.
OBJECTIVE: To present a summary of the 2014 version of the EAU guidelines on urologic trauma of the lower urinary tract with an emphasis on diagnosis and treatment.
EVIDENCE ACQUISITION: The EAU Trauma Panel reviewed the English-language literature via a Medline search for lower urinary tract injury (LUTI) up to November 2013. The focus was on newer publications and reviews, although older key references could be included.
EVIDENCE SYNTHESIS: A full version of the guidelines is available in print (EAU Guidelines 2014 edition, ISBN/EAN 978-90-79754-65-6) and online (www.uroweb.org). Blunt trauma is the main cause of LUTI. The preferred diagnostic modality for bladder and urethral injury is cystography and urethrography, respectively. In the treatment of bladder injuries, it is important to distinguish between extra- and intraperitoneal ruptures. Treatment of male anterior urethral injuries depends on the cause (blunt vs penetrating vs penile-fracture-related injury). Blunt posterior urethral injuries can be corrected by immediate/early endoscopic realignment. If this is not possible, such injuries are managed by suprapubic urinary diversion and deferred (>3 mo) urethroplasty. Treatment of female urethral injuries depends on the location of the injury and is usually surgical.
CONCLUSIONS: Correct treatment of LUTIs is important to minimise long-term urinary symptoms and sexual dysfunction. This review performed by the EAU trauma panel summarises the current management of LUTIs.
PATIENT SUMMARY: Patients with trauma to the lower urinary tract benefit from accurate diagnosis and appropriate treatment according to the nature and severity of their injury.

Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
PMID 25576009  Eur Urol. 2015 May;67(5):925-9. doi: 10.1016/j.eururo.2・・・
著者: Hossein Tezval, Mohammad Tezval, Christoph von Klot, Thomas R Herrmann, Klaus Dresing, Udo Jonas, Martin Burchardt
雑誌名: World J Urol. 2007 Apr;25(2):177-84. doi: 10.1007/s00345-007-0154-y. Epub 2007 Mar 10.
Abstract/Text This article mainly reviews urinary tract injuries in patients with multiple trauma. Approximately 10% of all traumatic injuries resulting from an external force will involve the genitourinary system. The article discusses mechanisms of injury, diagnosis, and therapeutical approaches for renal, ureteral, bladder, and urethral trauma. Due to the complexity of such injuries--despite several attempts to provide a standard strategy in trauma patients with urinary tract involvement--an individual and patient-specific-therapeutic approach is mandatory in most cases. However, the availability of classified guidelines may help the surgeon to reach the most accurate decision. Because of the similarity of American and European guidelines on urological trauma, this article adapts injury severity scales and classification from the American Association for the Surgery of Trauma.

PMID 17351781  World J Urol. 2007 Apr;25(2):177-84. doi: 10.1007/s0034・・・

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