Buck S Fascia Rupture

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Figure 12-2. Calculi (kidney stones). (A) Photograph of calcium oxalate calculi shows that these kidney stones are colorless, octahedral-shaped crystals that look like small squares crossed by intersecting diagonal lines. These are the most common (80%) type of kidney stone. (B) Photograph of magnesium ammonium sulfate (struvite or triple phosphate) calculi shows that these kidney stones are colorless, rectangular, prism-shaped crystals. These are the second most common (15%) type of kidney stone. (C) Photograph of uric acid calculi shows that these kidney stones are yellow or red-brown, diamond or rhombic prism-shaped crystals. These are the third most common (5%) type of kidney stone. (D) Photograph of cystine calculi shows that these kidney stones are colorless, refractive, and hexagonal-shaped crystals. These are the least common (1%) type of kidney stone. (A—D reprinted with permission from Graff L: A Handbook of Routine Urinalysis. Philadelphia, JB Lippincott, 1983, pp 93, 144, 151, 173.)

a. Calcium oxalate calculi are radiopaque and, by urinalysis, are colorless ootahe-dral-shaped crystals that look like small squares crossed by intersecting diagonal lines. They are the most common (40%) type of kidney stone and form when the urine is at an acid (< 6.0) or neutral pH (7.0). They are associated with: absorptive hypercalcemia, vitamin D intoxication, hyperparathyroidism, milk-alkali syndrome, and renal tubular acidosis (all of which cause hypercalcemia), ethylene glycol poisoning, diabetes, and liver disease.

b. Magnesium ammonium sulfate (struvite) or triple phosphate calculi are radiopaque and, by urinalysis, are colorless, rectangular, prism-shaped crystals. They are the second most common (15%) type of kidney stone and form when the urine is at an alkaline pH (> 7.4). They usually form staghorn calculi. They are associated with urinary tract infections caused by urea-splitting bacteria (e.g., Proteus vulgaris, Providencia species, Pseudomonas species, Klebsiella species, Staphylococcus species).

c. Uric acid calculi are radiolucent and, by urinalysis, are yellow or red-brown, diamond or rhombic prism-shaped crystals. They are the third most common (5%) type of kidney stone and form when the urine is at an acid pH (< 6.0). Thoy are associated with gout, leukemia, Lesch-Nyhan syndrome, and myeloproliferative disorders.

d. Cystine calculi are faintly radiopaque. They are flat, yellow, and hexagonal. They are the least common (1%) type of kidney stone and form when the urine is at an acid pH (< 6.0). Cystine calculi are caused by cystinuria, an autosomal recessive disorder that results in defective renal tubular reabsorption of the amino acids cystine, ornithine, arginine, and lysine.

III. URINARY BLADDER (Figure 12-3)

A. Surfaces

1. Posterior surface (fundus, or base). In males, the posterior surface of the bladder is related to the rectovesical pouch, rectum, seminal vesicles, and ampulla of the ductus deferens. In females, the posterior surface is related to the anterior wall of the vagina.

2. Anterior surface. In both males and females, the anterior surface is related to the pubic symphysis and retropubic space of Retzius.

3. Superior surface. In males, the superior surface is related to the peritoneal cavity. In females, this surface is related to the vesicouterine pouch (peritoneal cavity) and uterus.

4. Apex. In both males and females, the apex is related to the median umbilical ligament, or urachus (a remnant of the allantois in the fetus); the two medial umbilical ligaments (remnants of the right and left umbilical arteries in the fetus); and the two lateral umbilical ligaments, which are elevations formed by the right and left inferior epigastric arteries and veins.

5. Neck. In males, the neck of the bladder is related to the prostate gland and prostatic urethra. In females, it is related to the urogenital diaphragm.

B. Internal structure. The mucosal lining is composed of transitional epithelium. The walls are composed of a layer of smooth muscle (detrusor muscle). The trigone of the bladder is located on the posterior surface of the bladder, and its limits are defined superiorly by the openings of the ureters and inferiorly by the urethra.

C. Clinical considerations

1. Location. In infants, the empty bladder lies within the abdominal cavity. In

Fundus Bladder Ductus Deferens

Figure 12-3. (A) Sagittal section through the male pelvis showing the various anatomic relations of the urinary bladder. D- ductus deferens; P = prostate gland; PC = peritoneal cavity (shaded)] PS = pubic symphysis bone; R = rectum; RA = rectus abdominis muscle; RPS= retropubic space of Retzius; RV = rectovesical pouch; SV = seminal vesicle; U = urachus; UG = urogenital diaphragm. (B) Sagittal section through the female pelvis showing the various anatomic relations of the urinary bladder. These anatomic relations are important because clinical vignette questions may discuss urinary bladder pathology and ask what surrounding structures are affected. RUP= rectouterine pouch of Douglas; UT = uterus; U = urachus; V = vagina; VUP = vesicouterine pouch.

Rectovesical Pouch

adults, the empty bladder lies within the minor pelvis. As the adult bladder fills, it rises out of the minor pelvis, above the pelvic inlet, and may extend as high as the umbilicus. In acute retention of urine, a needle may be passed through the anterior abdominal wall (skin superficial fascia (Camper and Scarpa) linea alba transversalis fascia extraperitoneal fat -> bladder wall) without entering the peritoneal cavity to remove the urine from the bladder (suprapubic cystostomy).

adults, the empty bladder lies within the minor pelvis. As the adult bladder fills, it rises out of the minor pelvis, above the pelvic inlet, and may extend as high as the umbilicus. In acute retention of urine, a needle may be passed through the anterior abdominal wall (skin superficial fascia (Camper and Scarpa) linea alba transversalis fascia extraperitoneal fat -> bladder wall) without entering the peritoneal cavity to remove the urine from the bladder (suprapubic cystostomy).

2. Urine leakage as a result of trauma (Figure 12-4)

a. Rupture of the superior wall (dome), usually caused by compression on a full bladder, results in intraperitoneal extravasation of urine within the peritoneal cavity.

b. Rupture of the anterior wall, usually caused by a fractured pelvis (e.g., as a result of a car accident) that punctures the bladder, results in extraperitoneal extravasation of urine within the retropubic space of Retzius.

c. Rupture of the urethra above the urogenital diaphragm, usually caused by a fractured pelvis or improper insertion of a catheter, causes extraperitoneal extravasation of urine within the retropubic space of Retzius.

d. Rupture of the urethra just below the urogenital diaphragm is the most common type of urine leakage injury. It usually is caused by a straddle injury (e.g., falling against a bicycle crossbar) that results in extraperitoneal extravasa

Skin (layer 1)

Superficial fascia — (Camper and Scarpa) (layer 2)

External oblique muscle (Layer 3)

Superficial fascia — (Camper and Scarpa) (layer 2)

External oblique muscle (Layer 3)

Scarpa Vitamin

Deep fascia of Buck

Skin (layer 1)

Superficial perineal space

Figure 12-4. The five areas of trauma that cause urine leakage. 1 = Rupture of the superior wall of the urinary bladder results in extravasation of urine into the peritoneal cavity (PC). 2 = Rupture of the anterior wall of the urinary bladder results in extravasation of urine into the retropubic space of Retzius (RPS). 3 = Rupture of the urethra above the urogenital diaphragm (UG) results in extravasation of urine into the retropubic space of Retzius. 4 = Rupture of the urethra below the urogenital diaphragm results in extravasation of urine into the superficial perineal space. Note that extravasated urine within the superficial perineal space can extend into the scrotal, penile, and anterior abdominal wall areas. 5 = Rupture of the penile urethra results in extravasation of urine beneath the deep fascia of Buck and will remain confined to the penis. PS = pubic symphysis; dots = urine.

Deep fascia of Buck

Skin (layer 1)

Colles fascia and dartos muscle (layer 2)

External spermatic fascia (layer 3)

Superficial perineal space

Figure 12-4. The five areas of trauma that cause urine leakage. 1 = Rupture of the superior wall of the urinary bladder results in extravasation of urine into the peritoneal cavity (PC). 2 = Rupture of the anterior wall of the urinary bladder results in extravasation of urine into the retropubic space of Retzius (RPS). 3 = Rupture of the urethra above the urogenital diaphragm (UG) results in extravasation of urine into the retropubic space of Retzius. 4 = Rupture of the urethra below the urogenital diaphragm results in extravasation of urine into the superficial perineal space. Note that extravasated urine within the superficial perineal space can extend into the scrotal, penile, and anterior abdominal wall areas. 5 = Rupture of the penile urethra results in extravasation of urine beneath the deep fascia of Buck and will remain confined to the penis. PS = pubic symphysis; dots = urine.

tion of urine within the superficial perineal space and extending into the scrotal, penile, and anterior abdominal wall areas (urine does not extend into the thigh region or anal triangle). The superficial perineal space is located between Colles fascia and the dartos muscle (layer 2; see Figure 6-4) and the external spermatic fascia (layer 3; see Figure 6-4). Clinical findings include: blood at the urethral meatus, ecchymosis, painful swelling of the scrotal and perineal areas, and tender enlargement in the suprapubic region as a result of a full bladder, e. Rupture of the penile urethra, caused by a crushing injury to the penis, results in extraperitoneal extravasation of urine beneath the deep fascia of Buck. If the deep fascia of Buck is not torn, extravasation is confined to the penis; however, if the trauma also tears the deep fascia of Buck, then extravasation of urine occurs within the superficial perineal space.

3. Urine leakage as a result of incontinence a. Total incontinence is continuous involuntary loss of urine. It usually is caused by an ectopic ureter or a vesicovaginal fistula and is treated by surgical repair.

b. Stress incontinence is involuntary loss of urine associated with increases in abdominal pressure. It usually is caused by coughing, sneezing, or Valsalva movement, or occurs after childbirth. It is treated by ephedrine or phentolamine (to increase outlet resistance) or surgical repair.

c. Urge incontinence is involuntary loss of urine associated with an intense desire to void. It usually is caused by uncontrolled contraction of the detrusor muscle. It is treated by oxybutynin or imipramine (to stabilize detrusor muscle contraction).

d. Overflow incontinence is involuntary loss of urine as bladder filling overcomes sphincter control. It usually is caused by prostate cancer, stricture of the urethra, or an atonic neurogenic bladder. It is treated by catheterization or surgery.

4. Neurogenic bladder a. Hypertonic neurogenic bladder is a voiding dysfunction characterized by a small urinary bladder (i.e., decreased capacity) and detrusor hyperreflexia (overactivity of the detrusor muscle) that causes thickening of the walls of the bladder ("pine tree bladder"). It causes urgent, frequent voiding. It is associated with upper motor neuron lesions (e.g., tumors of the brain or spinal cord, upper spinal cord injury, cerebrovascular accidents, multiple sclerosis, or Parkinson disease). It is treated with anticholinergics, catheterization, and surgical augmentation of the bladder.

b. Atonic neurogenic bladder is a voiding dysfunction characterized by a large urinary bladder (i.e., increased capacity) and detrusor areflexia (underactivity of the detrusor muscle). It causes urine retention and subsequent overflow incontinence. It is associated with lower motor neuron lesions (e.g., spina bifida with meningomyelocele in the sacral region, sacral spinal cord injury, lumbar disk herniation that impinges on the sacral spinal nerves or the cauda equina, pelvic surgery or trauma that damages the pelvic splanchnic nerves, diabetes leading to peripheral neuropathy, tabes dorsalis, syringomyelia). It is treated with catheterization or surgical diversion of urine.

5. Transitional cell carcinoma is the most common type of tumor found in the bladder (> 90%). It is staged as Tis (carcinoma in situ), T1 (invasion of the lamina propria and submucosa), T2 (invasion of superficial muscle), T3 (invasion of deep muscle and surrounding fat), and T4 (invasion of other organs). Clinical findings include painless hematuria.

6. Cystocele occurs when the wall of the urinary bladder prolapses into the anterior wall of the vagina.

IV. URETHRA

A. The male urethra has three components.

1. The prostatic urethra courses through (and is surrounded by) the prostate gland. Its posterior wall contains an elevation called the urethral crest that contains the openings of the ejaculatory ducts. The openings of the prostatic ducts are located lateral to the urethral crest.

2. The membranous urethra courses through the urogenital diaphragm. It is surrounded by the deep transverse perineal muscle and sphincter urethrae muscle (external urethral sphincter), both of which are skeletal muscle innervated by the pudendal nerve.

3. The penile (spongy, or cavernous) urethra courses through the penis and is surrounded by the corpus spongiosum. It enlarges into the fossa navicularis just before it terminates at the external urethral orifice. The openings of the bulbourethral glands of Cowper are located just below the urogenital diaphragm.

B. The female urethra courses through the urogenital diaphragm. It is surrounded by the deep transverse perineal muscle and sphincter urethrae muscle (external urethral sphincter), both of which are skeletal muscle innervated by the pudendal nerve. The posterior surface of the female urethra fuses with the anterior wall of the vagina, and the external urethral sphincter does not completely surround the female urethra. For this reason, there is a high incidence of stress incontinence in women, especially after childbirth. The urethra terminates at the external urethral orifice, which opens into the vestibule of the vagina between the labia minora.

V. MICTURITION REFLEX. As the bladder fills with urine, sensory impulses from stretch receptors within the bladder travel to the sacral spinal cord through the pelvic splanchnic nerves (parasympathetics; S2—S4). Motor impulses travel with the pelvic splanchnic nerves (parasympathetics; S2—S4), which contract the detrusor muscle. The sphincter urethrae muscle (external urethral sphincter) is innervated by the pudendal nerve and is voluntarily relaxed.

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Responses

  • Rita
    How to treat retention of urine in a buck?
    6 years ago
  • danait
    Is abdominal peritoneal cavity continues with urethra?
    6 years ago

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