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URETHRAL INJURY AND URETHRAL CARUNCLE.pptx
- 1. Urethral injury and urethral caruncle Dr. Prakash Patel
- 2. INTRODUCTION 10- 20 % of all poly trauma patients Life threatening injuries first but DON’T neglect GU trauma. Long term morbidity Impotence Incontinence
- 3. CLASSIFIICATION Upper urinary tract Kidney Ureters Lower urinary tracts Bladder Urethra External genitalia
- 4. Urethral Trauma 10% in male with pelvic fracture 6% in female with pelvic fracture 60% due to blunt trauma 40% due to penetrating and itrogenic.
- 5. ANATOMY
- 6. ANATOMY
- 7. ANATOMY In males, the urethra is divided into the proximal (posterior) segment and the distal (anterior) segment by urogenital diaphragm. The posterior urethra is further divided into membranous (sphincteric) and prostatic segments. About 3 cm long.
- 8. CLASSIFICATION Posterior urethral injuries>> most commonly related to major blunt trauma and major falls, and most of such cases are accompanied by pelvic fractures. Anterior urethral injuries>> most commonly related to blunt trauma to the perineum( straddle injuries)
- 9. Posterior urethra – fixed at both- urogenital diaphragm and puboprostatic ligament So bulbo membranous junction is more vulnerable to injury
- 11. ETIOLOGY Blunt trauma Penetrating trauma Iatrogenic trauma (Difficult catheterisation)
- 12. EXAMINATION TRIANGLE OF – Blood at meatus Inability to urinate Palpable full bladder Other findings – On Per rectal examinations High riding of prostate Butter fly perineal Haematoma First detected at emergency dept when a urethral catheter cannot be placed. In female – Vulval oedema Blood at vaginal introitus.
- 13. POSTERIOR URETHRAL INJURIES other Clinical Features : Gross haematuria in 98% Pelvic/ Supra pubic tenderness Penile/ scrotal/perineal haematoma ill- defined mass on rectal examination.
- 15. Retrograde Urethrogram When blood at meatus >> an immediate Retrograde urethrogram >> to rule out urethral injury Pre test KUB film Supine position 30 degree ( oblique / lateral decubitus position) Injection of 25ml of contrast medium X-ray when 10 ml left and after 25ml Post- voiding X- ray.
- 16. INTERPRETATION Contrast extravasation+ Contrast in bladder >>>>> PARTIAL TEAR. Contrast extravasation only >>>>> COMPLETE TEAR.
- 17. Partial Tear
- 18. Complete tear
- 19. Urethroscopy Urethroscopy is done In female patient with suspected urethral injury to direct inspection of urethra.
- 20. MANAGEMENT Initial Management SUPRA PUBIC CYSTOSTOMY
- 21. Management IF patient is stable Partial tear Careful passage of 12-14Fr. Foley. If any resistance : Surgery Complete tear: Supra pubic catheter + Surgery. Surgery = Primary endoscopic alignment and delayed repair(10 -14 days) or late primary closure ( > 3 month ) Early urethral repair is not recommended because of risk of haemorrhage and infection.
- 22. When urethral catheter is removed after 4-6 weeks after surgery keep supra pubic catheter in situ because there is chances of development of stricture at the site of anastomosis or injury . If patient voids satisfactorily through urethra >> supra pubic catheter can be removed after 7-14 days .
- 23. URETHRAL STRICTURE Partial ( < 1cm ) – endoscopic repair ( Direct vision internal urethrotomy ) Complete ( long segment >1cm ) - urethroplasty
- 24. COMPLEX INJURIES In case of female urethral disruption Immediate primary repair OR At least urethral re alignment over catheter to avoid subsequent urethrovaginal fistuala Delayed reconstruction is difficult in female because- too short urethra (4 cm ) Scarring makes surgery difficult.
- 25. Delayed Reconstruction. Prior to reconstruction – Retrograde urethrogram Voiding cystourethrogram to define length of obliterated urethra Cysto urethroscopy also done Reconstruction surgery - Posterior urethroplasty through perineal approach
- 26. COMPLICATIONS Stricture Incontinance Impotence
- 27. Outcome and Prognosis Men with urethral injuries have an excellent prognosis when managed correctly. Problems arise if urethral injury is unrecognised and the urethra is further damaged by attempts at blind catheterisation. In those cases, further reconstruction may be compromised and recurrent stricture rates rise.
- 28. Foley Catheter NO if you suspect a urethral injury When to suspect urethral injuries: Pelvic # or Gross haematuria Danger to convert partial into complete NEVER REMOVE A FOLEY WHEN YOU SUSPECT A PARTIAL TEAR AFTERWARDS. ANY coloured urine other than yellow >>>> It’s BLOOD until proven otherwise.
- 29. Anterior Urethra More common than posterior Bulbous injury is the most common urethral injury. Direct trauma ( Straddle –type) Usually NO pelvic # Blood at meatus Unable to micturate Penile / Scrotal / Perineal Contusion Haematoma Fluid collection.
- 31. Sleeve Haematoma
- 33. MANAGEMENT NO Foley if injury suspected Retrograde Urethrogram Surgical treatment
- 35. URETHRAL CARUNCLE Benign, distal urethral lesion. Most commonly found in post menopausal women Resembles various urethral lesions like Carcinoma Urethral diverticulum Urethral Prolapse Periurethral gland abscess
- 36. Originates from posterior lip of urethra. Fleshy outgrowth of distal urethral mucosa Usually small but can be grow to 1cm or more in diameter
- 37. Epidemiology Common in elderly post menopausal women Rare in pre and peri menopausal women Urethral prolapse is similar in appearance But prolapse is circumferential while caruncles are focal lesion Prolapse may occur in any age but caruncle almost exclusively in post menopausal women
- 38. Relevant Anatomy Female urethra 4-5 cm long Distally -Lined by non keratinised stratified squamous epithelium Proximally – Transitional epithelium Outer layer –smooth muscle fibres and vasculature.
- 39. Pathophysiology Postmenopausal women >> Oestrogen deficiency >> Urogenital atrophy >> Distal urethral Prolapse >> Development of urethral caruncle >> chronic irritation of exposed urethral mucosa >> growth , Haemorrhage , necrosis of lesion.
- 40. PRESENTATION Mostly asymptomatic Incidentally noted on pelvic examination May be painful and associated with dysuria. May be present with bleeding per urethra. ON EXAMINATION Pink or reddish exophytic lesion at urethral meatus Sometime purple or black due to secondary thrombosis
- 42. MANAGEMENT CONSERVATIVE Hot sitz bath Topical estrogen ointments Topical anti inflammatory drugs SURGICAL - Excixion and biopsy In patient with large symptomatic lesions In whom conservative therapy fails Uncertain diagnosis
- 43. Laboratory Examinations Urine R/M – To rule out UTI Histopahtological examination if diagnosis is uncertain
- 44. CYSTOSCOPY – to rule out another causes of haematuria To rule out urinary bladder pathology
- 45. HISTOLOGIC FINDINGS Microscopically – Bed of granulation tissue covered by either squamous or transitional epithelium. Inflammatory infiltrate is common.
- 46. Intraoperative Details Excision and Biopsy First perform cystourethroscopy to rule out urinary bladder and urethral abnormalities Place Foley catheter. Use stay sutures in the epithelium to prevent mucosal retraction and meatal stenosis. Excise the lesion. Oversew the edges with 3-0 or 4-0 absorbable sutures
- 47. ALTERNATIVE TECHNIQUE developed by Park and Cho Base of the caruncle is ligated , allowing it to slough off after 1-2 weeks technique requires neither anaesthesia nor analgesia.
- 48. POSTOPERATIVE A Foley catheter may be left in place for 1-2 days to allow healing of urethral mucosa.
- 49. COMPLICATIONS Meatal stenosis Urethral stricture.
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