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1. Why do urachal defects occur? What are the three principal anomalies?
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Urachal defects may result from anomalies of the primitive urachal connection. There are three principal anomalies.
(1) Urachal fistula: a persistent urachal tract, resulting in a urinary discharge at the umbilicus.
(2) Urachal diverticulum, an outpouching of the bladder, the urachal equivalent of a Meckel's diverticulum and the vitellointestinal duct.
(3) Urachal cyst: where the urachus persists but is closed above and below. The cyst often becomes infected in later life, presenting with periumbilical pain and inflammation.
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2. What is a urachal fistula?
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A persistent urachal tract, resulting in a urinary discharge at the umbilicus.
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3. What is a urachal diverticulum?
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An outpouching of the bladder, the urachal equivalent of a Meckel's diverticulum and the vitellointestinal duct.
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4. What is a urachal cyst?
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Where the urachus persists but is closed above and below. The cyst often becomes infected in later life, presenting with periumbilical pain and inflammation.
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5. How would you treat a urachal anomaly?
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In all cases treatment is excision.
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6. What is bladder exstrophy? How might this present?
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Failure of fusion of the structures forming the anterior abdominal wall may cause a number of anomalies. Lower urinary tract changes include bladder exstrophy, where the ureters together with the bladder trigone open directly onto the anterior abdominal wall below the umbilicus. This is usually associated with a failure of fusion of the pubic bones and, in the male, there is an associate epispadias. Typically there is a widened pelvis with a waddling gait. The infant is completely incontinent of urine, with excoriation of the abdominal skin and a permanent unpleasant ammoniacal smell of infected urine. If the condition is untreated the child may die of pyelonephritis, or else frequently develops a stratified squamous carcinoma of the bladder rudiment after initial metaplastic change.
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7. How would you treat bladder exstrophy?
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Traditional treatment is reimplantation of the ureters either into the colon or into an ileal loop (ureteroileostomy) combined with excision of the bladder itself as a prophylaxis against malignant change. Nowadays complex reconstructive operations are performed soon after birth to fashion a new bladder.
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8. What is the worst prognosis for bladder exstrophy?
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Malignant change in the bladder.
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9. In which ways may the urinary bladder rupture?
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The bladder may rupture either intraperitoneally or extraperitoneally.
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10. What are the features of intraperitoneal rupture of the urinary bladder?
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This follows a penetrating wound (e.g. a bullet wound) or crush injury to the pelvis when the bladder is distended. Occasionally, it is consequent upon instrumentation of the bladder during transurethral resection of a tumour; rarely, the overdistended bladder may rupture spontaneously.
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11. What are the features of extraperitoneal rupture of the urinary bladder?
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This is more common than intraperitoneal rupture; the bladder may be torn by a spicule of bone in a pelvic fracture or occasionally may be wounded during a hernia operation or repair of a cystocele.
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12. What are the clinical features of intraperitoneal rupture of the urinary bladder?
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Intraperitoneal rupture produces the typical picture of peritonitis with generalized abdominal pain, marked rigidity and a silent abdomen.
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13. What are the clinical features of extraperitoneal rupture of the urinary bladder?
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Extraperitoneal rupture is associated with extraperitoneal extravasation of blood and urine producing a painful swelling that arises out of the pelvis. In this case, differentiation must be made from rupture of the membranous urethra, although this may not be possible until surgical exploration is carried out. Typically, however, a urethral tear is accompanied by anterior displacement of the prostate, which can be detected on rectal examination. In either circumstance traumatic bladder rupture causes haematuria.
