62) Injuries to the Urethra скачать в хорошем качестве

62) Injuries to the Urethra

Injuries to the Urethra - Such injuries usually affect two parts of the urethra - 1. Rupture of the bulbous part of the urethra and 2. Rupture of the membranous part of the urethra. 1.RUPTURE OF THE BULBOUS PART OF THE URETHRA ( ANTERIOR URETHRA) Aetiologia - nowadays such injury is seen in cycle accidents in gymnastic accidents ( fall astride the beam) . SYMPTOMS - the typical three complaints are usually noted local pain in the perineum. bleeding per urethra inability to pass urine. Always there is is a tender swelling in the perineum Rectal examination reveals a normally situated prostate ( this differentiates this condition from rupture of membranous urethra there is massive urinary extravasation and infection in the perineum the skin is usually swollen and discolored scrotum. Management - Two types of rupture are usually noticed - complete or incomplete ( when some part of the circumference of the urethra wall remains intact ) patient should be instructed not to pass prevent extravasation patient should not be catheterized in the ward chemotherapy is started immediately. If the catheter cannot be passed the patient is kept in the lithotomy position and a midline perineal incision is made to expose the ruptured urethra an attempt is made to suture end - to - end the whole circumference of the urethra with fine catgut the knots of which are left outside of the wall. Complications - (i)SUBCUTANEOUS EXTRAVASATION OF URINE - (ii)STRICTURE- is a common complication regular dilatation or internal urethrotomy. 2) RUPTURE OF THE MEMBRANOUS URETHRA ( POSTERIOR URETHRA ) Aetiology - This usually occurs as result of fracture of the pelvis fractured pelvis sustain either rupture of membranous urethra or extra peritoneal rupture of bladder or both SYMPTOMS - blood at the external urinary meatus and inability to micturate . SIGNS - Blood at the urethral meatus is the single most important sign of urethral injury the importance of this finding cannot be over emphasized and this should immediately indicate not to pass a urethral catheter. Suprapubic tenderness and a large developing pelvic haematoma. Complications - 1.URETHRAL STRICTURE 2.URINARY INCONTINENCE 3.IMPOTENCE EXTRAVASATION OF URINE - The spread of the extravasated urine depends on the part of the urethra through which urine has come out. Superficial extravasation due to rupture of the bulbous urethra Bulb of the urethra often ruptures. from injury to the perineum or when a peri-urethral abscess bursts The urines first collects in the superficial perineal pouch, which is bounded below by the fascia of Colle's and above by the inferior fascia of the urogenital diaphragm. URETHRITIS - Inflammation which may affect urethra. Location of the urethral meatus Lack of protection of the urethral meatus by prepuce seems to be the main can cause . URETHRAL STRICTURE - Aetiology- There are various causes of stricture of the urethra. The commonest is the traumatic particularly rupture of the membranous urethra following fracture of the pelvis The various causes of urethral stricture are (i) Congenital see page-no. 1304 (ii) Traumatic - it may follow rupture of bulbous or membranous urethra (iii) Inflammatory-Gonorrhoea is the commonest in this group, followed by non-gonorrhoea acute urethritis followed by tuberculosis. (iv) Instrumental - Introduction of indwelling catheter in inexperienced hands Introduction of endoscopy v) Postoperative - following prostatectomy or amputation of penis. (v)CONGENITAL STRICTURE COMPLICATIONS- 1. Obstruction to the outflow of urine . 2.Because of stasis infection occurs 3. Due to stasis of urine and infection, calculi formation is quite 4.Due to infection of the stagnant urine just proximal to the stricture periurethral abscess may develop Urethral diverticulum 4.Retention of urine is due to obstruction to the flow of urine by the urethral stricture. 6.Hernia DILATATION - Dilatation is now carried out gently with bougies of increasing size There are three tunes of instruction intermittent continuous and rapid dilatation intermittent dilatation This is by far the most popular method of the 3 types of instrumental dilatation a structure is not cured by single dilatation It requires repeated dilations at regular intervals At the commencement a medium size bougie is taken to dilate the stricture. Subsequently, bigger size bougies are introduce to dilate the stricture. SURGERY 1. EXTERNAL URETHROTOMY - 2 INTERNAL URETHROTOMY -- URETHROPLASTY OR SURGICAL RECONSTRUCTION If the above methods fail. open surgical methods in the form of urethroplasty should be resorted to if there is short stricture in the bulbous urethra, it may be excised and end-to-end anastomosis is performed .