Murphy’s Triad – Acute Appendicitis

Murphy’s triad is a classic clinical combination seen in acute appendicitis:

• Abdominal pain
• Vomiting
• Fever

Typical sequence:
Pain starts first → followed by vomiting → then fever.

High-yield point:
Pain preceding vomiting is a key feature that favors appendicitis over other causes.

Clinical tip:
If vomiting occurs before pain, consider other diagnoses.


Diagnosis is mainly clinical and supported by imaging if needed.

⚠️ Important note:
Do not confuse Murphy’s triad with Murphy’s sign of acute cholecystitis.

Murphy’s sign:
Inspiratory arrest during deep palpation of the right upper quadrant.

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🚨 Urethral Trauma

Trauma to the urethra is serious and most commonly occurs with pelvic fractures, especially in males.

🔺 Key Red Flags
• Blood at the urethral meatus
• Inability to pass urine
• Distended bladder

⚠️ Clinical Pearls
• Classic Triad: blood at meatus + Perineal hematoma + distended bladder

• Do NOT insert a catheter until urethral injury is ruled out

• Often occurs with pelvic fractures or straddle injuries

• Early recognition = prevents long-term complications: stricture, incontinence


❇️ Diagnosis
• Retrograde urethrogram (RUG) → gold standard
• Avoid blind catheterization

High-Yield Tip
• Think urethral injury every time there is pelvic trauma + blood at meatus

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🔰Bladder Injury

🔷Mechanisms Of Bladder Injury
📍1. Iatrogenic Injury During :
▪︎TURBT (TransUrethral Resection Of Bladder Tumours Most Common Iatrogenic Cause)

▪︎Anti-Incontinence Surgery

▪︎Pelvic Surgery (Hysterectomy/CS/ColoRectal Surgery)

📍2. After Abdominal Trauma Or Pelvic Fractures (Most Common Non-Iatrogenic Causes)

📍3. Spontaneous Rupture After Bladder Augmentation Due To OverDistention (in Patients With Limited Bladder Sensation)


🔷Types Of Bladder Injury
📍1. ExtraPeriToneal (Most Common 65%) :
▪︎Urine Leakage into RetroPubic Space With Intact Peritoneal Membrane

📍2. IntraPeriToneal (25%) :
▪︎Urine Leakage into The Peritoneal Cavity Due To Injury To The Peritoneal Membrane Over The Bladder

▪︎High Risk Of Urine Peritonitis & Ileus & More Complications

📍3. Mixed (Extra & Intra Peritoneal)

📍4. Only Bladder Contusions (No Urine Leakage)


🔷Grades Of Bladder Injury
📍1. Only Contusions & IntraMural Hematoma Or Partial Thickness Lacerations

📍2. ExtraPeriToneal Bladder Wall Lacerations <2cm

📍3. ExtraPeriToneal ≥2cm Or IntraPeriToneal <2cm

📍4. IntraPeriToneal ≥2cm

📍5. Lacerations Extending into Bladder Neck Or Trigone (Urethral Orifice)


🔷Clinical Features & Dx Of Bladder Injury
📍1. SupraPubic Pain

📍2. Not Able To Pass Urine

📍3. Hematruia

📍4. Abdominal Distention

📍5. Urine Peritonitis

📍6. Confirm Dx (Retrograde CytoGram Or CT CystoGram) :
▪︎Leakage Of Contrast Limited To The Area Surrounding The Bladder (Flame Shape) ➡ ExtraPeriToneal Leakage

▪︎Contrast Surrounding The Bowel ➡ IntraPeriToneal Leakage


🔷Mx Of Bladder Injury
📍1. ExtraPeriToneal Injury :
🔻I. Urethral Catheterization For 10-14 Days (Allows Spontaneous Healing)

🔻II. Immediate Repair For :
▪︎Iatrogenic Bladder Injury If Identified During Operation

▪︎Bladder Repair During Operations For Pelvic Fracture Or Rectal Or Vaginal Perforation Repair


📍2. IntraPeriToneal Injury :
🔺I. Open Surgical Repair

🔺II. Bladder Catheterization With Close Monitoring ➡ For Small IntraPeriToneal Leakage & Stable Patient

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🔰 Bladder Anomalies
📍1. Bladder Exstrophy :
▪︎Failure Development Of The Lower Part Of The Anterior Abdominal Wall Results in Exposure Of The Bladder To The Outside

▪︎More in Males

▪︎Associated With :
🔺I. EpiSpadias (Anterior Opening Of The Urethra)

🔺II. Diastasis Of The Symphysis Pubis/Waddling Gate

🔺III. Wide Pubic Bones/External Rotation Of Anterior & Posterior Bony Pelvis (Results in Outward Rotation Of Lower Limbs)

🔺IV. Short Penis & Vagina & Bifid Clitoris

🔺V. Incontinence & VUR

🔺VI. Low Set Umbilicus With Triangular Shape Fascial Defect in The Lower Abdomen & High Risk Of indirect Inguinal Hernia

🔺VII. Rectal Prolapse/Imperforated Anus/Short Perineum/Anteriorly Displaced Anus

▪︎Need Surgical Correction Of The Anomalies



📍2. Bladder Diverticulae :
▪︎It's Protrusion (Out-Pouching) Of Some Bladder Wall Layers (Mucosa) Through Wall Weakness To The Outside

🔻I. Acquired Diverticulae (Secondary) Occurs in :
▪︎Adult Men With BPH (Most Common)

▪︎Children With Posterior Urethral Valve (Infra-Vesical Obstruction) Or NeuroGenic Bladder (Detrusor Sphincter Dyssynergia DSD)

▪︎Characterized By Elevated Bladder Pressure & Thick Bladder Walls (Trabeculations) & Multiple Diverticulae


🔻II. Congenital Diverticulae (Primary) :
▪︎It's Bladder Wall Mucosal Herniation Through Congenital Muscular Weakness (Defect) Between Intra-Vesical Ureter & Roof Of Ureteral Hiatus (Hutch Diverticulum)

▪︎Associated With VUR

▪︎Characterized By Normal Bladder Pressure & Thin Walls & Usually Single Diverticulum


🔻III. Clinical Features & Dx & Mx Of Bladder Diverticulae :
▪︎Asymptomatic (Usually in Small Congenital Diverticulae)

▪︎Hematruia (30%)

▪︎Recurrent UTI & Bladder Stones

▪︎Urine Retention & Hydronephrosis

▪︎Risk Of Malignancy (1%)

▪︎Dx ➡️ US/CT/MRI/CystoGram/Cystoscope

▪︎Mx ➡️ Surgical Correction Only If Symptomatic (Bladder Outlet Obstruction) Or Malignancy Developed

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🔴Bladder Cancer

▪︎Usually Transitional Type Arise From The UroThellium Of The Bladder

▪︎More in Men

▪︎Usually Superficial Low Grade Tumour With Good Prognosis (70-90% 5-Year Survival Rate)

▪︎High Grade Tumours (Muscle Invasion) Has 10-60% 5-Year Survival Rate

▪︎UroThelial Tumours Can Affect Other Parts Of Urinary Tract (Renal Pelvis/Ureter/Urethra)


🔷Risk Factors For Bladder Cancer
📍1. Smoking (Most Common)

📍2. Occupational & Environmental Exposure To Tanner/Rubber/Paints & Dyes/Gas & Tar/Arsenic in Water/HairDressers/Plumbers/Painters

📍3. Chronic Bladder Inflammation Results in Squamous Metaplasia Then Squamous Carcinoma (Catheter/Stones/Recurrent UTI/Schistosomiasis)

📍4. Drugs (Phenacetin/Cyclophosphamide)

📍5. Pelvic Radiation


🔷Types Of Bladder Cancer
📍1. Transitional Cell Carcinoma (Most Common >90%)

📍2. Squamous Cell Carcinoma (1-7%) ➡️ Usually Occurs Due To Chronic Inflammation in The Bladder (Stones/Prolonged Catheterization/Schistosomiasis)

📍3. Adenocarcinoma (2%) ➡️ Arise in The Dome Of The Bladder (Urachus) Or From Bowel Tissue Present in The Bladder (During Augmentation Entero-CystoPlasty Or Bladder Extrophy Repair)


🔷Clinical Features & Dx Of Bladder Cancer
📍1. Painless Visible Hematruia (Most Common Presentation 85%)

📍2. Lower Urinary Tract Symptoms (Frequency/Urgency/DysUria)

📍3. Recurrent UTI

📍4. Features Of Advanced Malignancy :
▪︎Flank/Pelvic/Bone Pain
▪︎Weight Loss
▪︎Lower Limb Edema

📍5. Confirm Dx :
▪︎Urine Exam & Culture & Cytology (Looking For Malignant Cells)

▪︎CT UroGram (Gold Standard)

▪︎CystoUrethroScopy & Biopsy (Direct Visualization Of The Bladder For Patients With Suspicious Of Cancer)


🔷Mx Of Bladder Cancer
📍1. No Bladder Muscle Invasion (NMIBC) :
▪︎TransUrethral Resection Of The Bladder Tumours (TURBT)

▪︎Then IntraVesical Chemotherapy To Reduce Risk Of Recurrence (MitoMycin C Course For 6w)

▪︎Then Regular Follow Up Using Cystoscope

▪︎IntraVesical BCG For Patients With Bladder Carcinoma in Situ (CIS Have Risk Of Progression into Bladder Cancer But Response To BCG)


📍2. Bladder Muscle Invasion (MIBC) :
▪︎Chemotherapy (Neoadjuvant) Then Radical CysteCtomy With Urinary Diversion (Preferred For Patients <70 Years Of Age)

▪︎Chemo-RadioTherapy Only (For Older Patients)


🪀Methods Of Urinary Diversion :
🔺I. OrthoTopic Bladder :
▪︎Creates New Bladder Pouch From Colon Or Small Bowel Tissue Then Connect it To The Urethra

▪︎Used When The Urethra Intact (in Good Condition)

▪︎Studer Pouch Most Commonly Performed

▪︎Not Used If There's Widespread Bladder Carcinoma in Situ (CIS) Or Tumours in The Prostatic Urethra


🔺II. Cutaneous Diversion (HeteroTopic Bladder) :
▪︎Connecting The Ureters To The Appendix Or Ileum

▪︎Then Creates Opening in The Skin (Stoma Near Umbilicus Or RIF) For Self Catheterization

▪︎Used When Urethra Removed Or Not-Functioning

▪︎Ileal Conduit is The Best Method Due To Low Risk Of Complications


🔺III. UretroSigmoidoStomy :
▪︎Attach Ureters To Sigmoid Colon So Urine Pass With Faeces

▪︎Need Good Anal Sphincter Function (To Prevent Incontinence Of Urine)

▪︎High Risk Of Complications (Ascending UTI/Malignancy/Bowel Frequency/Urge Incontinence/Metabolic Disturbances)

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