59) Retention of Urine & Urinary Diversion скачать в хорошем качестве

59) Retention of Urine & Urinary Diversion

Retention of urine means accumulation of urine in the urinary bladder. The patient is unable to pass urine or small quantity of urine. Retention of urine can be of three types (i) Acute retention, (ii0 Chronic retention and (iii) Acute on chronic retention (i) Acute retention is sudden inability to pass urine and it is a painful condition (ii) Chronic retention is gradual accumulation of urine in the bladder due to inability of the patient to empty the bladder completely. The result is an enlarged painless bladder, which may reach upto umbilicus without even knowledge of the patient (iii) Acute on chronic retention is a condition in which acute retention superimposed on chronic retention. Causes of retention of urine A. Mechanical - (a) urinary bladder- Stones, tumor, blood clot and contracture of the bladder neck (b) Prostate - Prostatic abscess, benign and malignant prostatic enlargement (c) Urethra- Urethral stricture, rupture, congenital valves, foreign body, acute urethritis, stone, growth, pinhole meatus meatal ulcer with scarring (d) Prepuce- Phimosis From outside - Pregnancy (retroverted gravid uterus), fibroid, ovarian cyst, carcinoma of the cervix uteri and rectum and any pelvic growth Neurogenic (a) Spinal cord diseases e.g. disseminated sclerosis, tabs dorsalis, transverse myelitis etc. (b) Injuries and diseases of the spine e.g. fracture dislocation, Pott's disease etc. (e) Miscellaneous e.g. post-operative retention, hysteria, tetanus, drugs such as anticholinergics, smoot muscle relaxants, tranquillizers etc. CLINICAL FEATURES ---Typical symptom is that the patient has not passed urine for several hours In acute retention the patient is in extreme pain presence of distended bladder. female this condition pregnancy (retroverted gravid uterus), in fibroid, in case of rectal or pelvic growth, in multiple sclero and hysteria. MANAGEMENT - The patient should take a hot bath to diminish internal congestion Hot and cold application may be given to the suprapubic region This sometimes helps the patient to pass urine un by diminishing congestion at the bladder neck. If this fails, a catheter should be passed, Closed drainage system should be adopted to prevent introduction of infection into the bladder if after considerable attempts with various catheters, catheterization into the bladder has not been possible one of the following four methods may be adopted - 1.Suprapubic puncture.- 2.suprapubic cystostomy- 3. Immediate prostatectomy - 4. Urethral instrumentation- Retention with overflow. In this condition the patient fails to control, so that small amounts of urine com out involuntarily from time to time from a completely filled bladder It usually follows a neglected to retention case though it may occur rarely in acute retention also The treatment is decompression of the bladder, which must be carried out slowly. URINARY DIVERSION - Urinary diversion means diversion of urinary pathway from its natural path Urinary diversion may be temporary procedure to relieve distal obstruction e. g tubed nephrostomy. It may be performed as a permanent procedure and this reconstructive surgery is gradually acquiring a common place The indications for permanent urinary diversion are - (a) when the bladder has to be removed. (b) when the sphincter of the bladder and the detrusor muscle have been damaged or have lost their normal neurological control, (c)when there is irremovable obstruction in the bladder and distal to that, (d)In cases of ectopic vesical and (e)when there is incurable vesico-vaginal fistula. Methods of urinary diversion-There are various methods of urinary diversion which include both temporary and permanent procedures. COMPLICATIONS - (i)Pyelostomy or nephrostomy or urethrostomy (with indwelling catheters) - temporary procedures (ii)Suprapubic cystostomy- temporary procedure (iii)Bladder diversion (iv)Rectal bladder (v)Culancous ureterostomy (Vi)Uretero-sigmoidostomy (vii)Ureteric transplantation into isolated ileal or colonic conduit Uretero-Sigmoidostomy.- COMPLICATIONS- (i)Reflux of urine (ii)Biochemical changes iii)Renal infection- iv)Stricture formation - Ileal conduit - This is the most frequently employed from of permanent urinary diversion. RESULTS and COMPLICATIONS (i) Infection (ii)Urinary leakage at uretero-ileal anastomosis is a complication which can be avoided by meticulous anastomosis (iii)Viability of the terminal portion (iv)Stenosis at the uretero-ileal junction and (v)Stricture of the ileal loop in probably (vi) Resorptive problem - Colon conduit- Ileo-caecal segment - Use of the caecum and terminal ileum as a bladder substitute has been used with some success. Lowsley's operation - Rectosigmoid junction is divided completely and its lower end is closed the ureters are implanted excluded lowers segment so that the rectum now functions as bladder, it is also called, ‘Rectal bladder’.