Urethral injury

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Urethral injury

  1. 1. DISCUSS URETHRAL INJURY DR BASSEY, A E
  2. 2. OUTLINE• INTRODUCTION – DEFINITION – STATEMENT OF SURGICAL IMPORTANCE – EPIDEMIOLOGY • RELEVANT ANATOMY • CLASSIFICATION – SITE – TYPE OF INJURY • AETIOPATHOGENESIS • MANAGEMENT – RESUSCITATION – HISTORY – EXAMINATION – INVESTIGATION – TREATMENT – COMPLICATIONS • FOLLOW UP/PROGNOSIS • FUTURE TRENDS • CONCLUSION • REFERENCES
  3. 3. INTRODUCTION • URETHRAL INJURY IS A BREACH IN THE STRUCTURAL INTEGRITY OF THE URETHRA RESULTING FROM EXCESSIVE TRAUMA • WITH INCREASING INDUSTRIALIZATION, HIGH-SPEED COMMUTE, HUMAN CONFLICT AS WELL AS ADVANCES IN SURGICAL SCIENCE THE INCIDENCE OF URETHRAL INJURY IS ON THE RISE. TIMELY AND ACCURATE DIAGNOSIS ARE NECESSARY FOR APPROPRIATE ACUTE MANAGEMENT AND REDUCTION OF LONG TERM MORBIDITY
  4. 4. INTRODUCTION • EPIDEMIOLOGY – IT IS THE COMMONEST CAUSE OF URETHRAL STRICTURE IN NIGERIA1,2 – MAKES UP MAJORITY OF GU INJURIES4,5 – 10% OF PELVIC FRACTURES ASSOC WITH URETHRAL INJURY6
  5. 5. RELEVANT ANATOMY
  6. 6. CLASSIFICATION • SITE – POSTERIOR URETHRAL INJURY – ANTERIOR URETHRAL INJURY • TYPE OF INJURY – CONTUSION – PARTIAL RUPTURE – COMPLETE RUPTURE
  7. 7. AETIOPATHOGENESIS • POSTERIOR URETHRAL INJURY – PELVIC FRACTURE – 10% ASSOC WITH URETHRAL INJURY. ALMOST ALL PU INJURY 2O BLUNT TRAUMA HAVE ASSOC PELVIC FRACTURE7 – RTA COMMONEST CAUSE OF PELVIC FRACTURE8 – INJURY OCCURS IN MEMBRANOUS URETHRA – 3 MECHANISMS – OFTEN ASSOC WITH MULTIPLE ORGAN TRAUMA – IATROGENIC – CATHETER-RELATED – BOUGINAGE – ENDOSCOPY – MECHANICAL OR ELECTRICAL – SURGERY – RADICAL PROSTATECTOMY
  8. 8. AETIOPATHOGENESIS – FOREIGN BODY – CALCULUS – PENETRATING INJURY – THIS IS RARE
  9. 9. AETIOPATHOGENESIS • ANTERIOR URETHRAL INJURY (USU. ISOLATED) – STRADDLE INJURY – INJURY OCCURS IN BULBAR URETHRA – IATROGENIC – CATHETER-RELATED – BOUGINAGE – ENDOSCOPY – MECHANICAL OR ELECTRICAL – CIRCUMCISION – PENETRATING INJURY – GUNSHOT – PENILE FRACTURE – SELF-MUTILATION – MENTALLY ILL – SEXUAL GRATIFICATION
  10. 10. AETIOPATHOGENESIS • FEMALE URETHRA – PELVIC FRACTURE – VAGINAL SURGERY
  11. 11. MANAGEMENT • RESUSCITATION – PARTICULARLY OF IMPORTANCE IN PU INJURY DUE TO PELVIC FRACTURE – LIFE-THREATENING CONDITIONS TAKE PRECEDENCE OVER URETHRAL INJURY AND MUST BE AMELIORATED FIRST !!!
  12. 12. MANAGEMENT • HISTORY – INABILITY TO PASS URINE DESPITE THE URGE – HAEMATURIA – PAINFUL MICTURITION – URETHRAL BLEEDING – HISTORY OF THE AETIOLOGIC EVENT
  13. 13. EXAMINATION • GENERAL EXAMINATION NOT SPECIFICALLY CONTRIBUTORY TO DIAGNOSIS OF URETHRAL INJURY • ABDOMEN – ECCHYMOSIS – DISTENDED URINARY BLADDER • EXT. GENITALIA – BLOOD AT MEATUS – ANY SURGERY OR PENETRATING INJURY? – PENILE OR PERINEAL ECCHYMOSIS – FOREIGN BODY IN URETHRA MAY BE FOUND
  14. 14. EXAMINATION – URETHRAL BLEEDING
  15. 15. EXAMINATION – PENILE FRACTURE
  16. 16. EXAMINATION • DIGITAL RECTAL EXAM – BOGGINESS – HIGH RIDING OR ABSENT PROSTATE • VAGINAL EXAM – BLEEDING – VAGINAL LACERATION • MUSCULOSKELETAL – POSITIVE PELVIC COMPRESSION AND DISTRACTION TESTS
  17. 17. INVESTIGATION • TO CONFIRM DIAGNOSIS – RETROGRADE URETHROGRAPHY • CONFIRMS INJURY • TYPE • LOCATION • PRESENCE OF FOREIGN BODY • ASSOC INJURY e.g. BLADDER
  18. 18. INVESTIGATION – URETHRAL CONTUSION
  19. 19. INVESTIGATION – PARTIAL URETHRAL RUPTURE
  20. 20. INVESTIGATION – COMPLETE URETHRAL RUPTURE
  21. 21. INVESTIGATION • TO DETERMINE EXTENT OF DISEASE – PELVIC XRAY – IMAGING FOR INVOLVED ORGAN SYSTEMS • TO SUPPORT MANAGEMENT – FBC – EUCr – URINALYSIS – CXR – ECG
  22. 22. TREATMENT • AIM IS TO HAVE A CONTINENT PATIENT WITH SATISFACTORY VOIDING AND SEXUAL FUNCTION • PATIENT IS GIVEN ANALGESIA AND ANTIBIOTICS • AVOID REPEATED ATTEMPTS AT BLIND CATHETERIZATION • PENETRATING INJURY IS JUDICIOUSLY DEBRIDED • DEFINITIVE TREATMENT IS ACHIEVED BY – EARLY REPAIR OR – DELAYED REPAIR
  23. 23. TREATMENT • EARLY REPAIR • DONE WITHIN ONE WEEK OF INJURY • URINE DIVERSION VIA SUPRAPUBIC CYSTOSTOMY • MODALITIES INCLUDE – USE OF INTERLOCKING URETHRAL SOUNDS (‘RAILROADING’) – ENDOSCOPIC REALIGNMENT – OPEN SURGERY AND REPAIR OVER A CATHETER • IT IS FRAUGHT WITH COMPLICATIONS SUCH AS – INFECTION OF HAEMATOMA – STRICTURE – 70%5 – ERECTILE DYSFUNCTION – 45%5 – INCONTINENCE – 20%5
  24. 24. TREATMENT • DELAYED REPAIR • URINE DIVERSION BY SUPRAPUBIC CYSTOSTOMY • AT 12 WEEKS POSTINJURY RUG IS DONE TO ASSESS URETHRAL STRICTURE • REPAIR OF STRICTURE IS CARRIED OUT • COMPLICATION RISK – STRICTURE – 50%5 – ERECTILE DYSFUNCTION – 12%5 – INCONTINENCE – 2%5 • IT’S THE OPTION BEEN FAVOURED BY UROLOGISTS IN THE PAST 25 YEARS
  25. 25. TREATMENT • CATHETERS LEFT IN SITU FOR 4 WEEKS • PERICATHETER RUG DONE AND CATHETER REMOVED IF NO EXTRAVASATION NOTED • PATIENT’S VOIDING ABILITY NOTED
  26. 26. COMPLICATIONS • EXTRAVASATION OF URINE NECROTIZING INFECTION OF PENILE AND PERINEAL SKIN • URETHRAL STRICTURE • ERECTILE DYSFUNCTION • URINARY INCONTINENCE
  27. 27. FOLLOW-UP • FOLLOW-UP SHOULD BE LIFELONG6 • AT EACH CLINIC VISIT, NOTE PATIENT’S VOIDING HISTORY. IF LUTS DEVELOP, RUG SHOULD BE DONE • NOTE ALSO PATIENT’S CONTINENCE STATUS AND ERECTILE FUNCTION
  28. 28. PROGNOSIS • WITH PROPER MGT PROGNOSIS IS EXCELLENT6 • UNRECOGNIZED URETHRAL INJURY HOWEVER LEADS TO HIGHER INCIDENCE OF COMPLICATIONS
  29. 29. FUTURE TRENDS • USE OF MAGNETIC CATHETERS FOR EARLY REALIGNMENT OF THE URETHRA
  30. 30. CONCLUSION RECOGNITION OF CARDINAL SIGNS AND SYMPTOMS OF URETHRAL INJURY FACILITATES TIMELY RADIOGRAPHIC DIAGNOSIS AND EARLY COMMENCEMENT OF APPROPRIATE INITIAL MANAGEMENT. THE ASTUTE CLINICIAN MUST MAINTAIN A HIGH INDEX OF SUSPICION, AS THESE INJURIES ARE FREQUENTLY OVERSHADOWED BY MULTISYSTEM TRAUMA.
  31. 31. THANK YOU
  32. 32. REFERENCES 1. THE NEW PATTERN OF URETHRAL STRICTURE DISEASE IN LAGOS, NIGERIA. NIGER POSTGRAD MED J 2009 JUN;16(2):162-5 2. THE CHANGING PATTERN OF URETHRAL STRICTURE DISEASE IN MIDWESTERN NIGERIA. J MED BIOMED RESEARCH 2006 DEC;5(2):50-54 3. DIAGNOSIS & CLASSIFICATION OF URETHRAL INJURIES. UROL CLIN N AM (2006) 73 – 85 4. TRAUMATIC UROLOGIC INJURIES IN ILE-IFE, NIGERIA J EMERG TRAUMA SHOCK 2010 OCT-DEC;3(4):311 - 3 5. PRINCIPLES & PRACTICE OF SURGERY INCLUDING PATHOLOGY IN THE TROPICS, 4TH Ed, 2009:185 – 7 6. EMEDICINE.MEDSCAPE.COM/ARTICLE/451797 7. DIAGNOSIS AND INITIAL MANAGEMENT OF UROLOGICAL INJURIES ASSOCIATEDWITH 200 CONSECUTIVE PELVIC FRACTURES.
  33. 33. REFERENCES 8. POST-TRAUMATIC POSTERIOR URETHRAL STRICTURES IN CHILDREN: A 20 YEAR EXPERIENCE. J UROL 1997;157:641.

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