 |
 |
 |
Primary Surgery Vol.2 – Trauma |  |
 |
|
|
|
|
Primary Surgery Vol.2 – Trauma | |
|
|
This extends Section 51.3 on the care of a severely injured patient. Suspect that a patient may have injured his lower urinary tract if: (1) he has some injury which makes this likely (especially a fractured pelvis), or (2) he cannot pass urine after an accident, or (3) there is blood at the tip of his urethra. CAUTION! Don’t pass a diagnostic catheter up the patient’s urethra because: (1) The information it will give you will be unreliable. (2) You may contaminate the haematoma round the injury. (3) You may damage the slender bridge of tissue that joins the two halves of his injured urethra.
How did the injury occur? This will tell you the kind of injury to suspect.
Has the patient passed urine since the accident? If he wants to pass urine, let him try, gently without straining. If he strains, urine will extravasate into his tissues.
If he has passed blood–free urine since the accident, his urinary tract has not been seriously injured. If he can pass no urine, or only a little blood stained urine, with frequency and dysuria, his urethra has been injured.
If his bladder is distended, you may have to needle it to reduce his distress.
Has he ever had even a little bleeding from the external orifice of his urethra? If necessary, milk his urethra to demonstrate blood at its tip. You will usually find this bleeding if you look for it. It confirms a rupture (complete or partial) of some part of his urethra (injuries D, E, or F, and occasionally B, or C). He needs a suprapubic catheter.
The absence of bleeding is of no significance.
Is there a vague swelling in the patient’s perineum, scrotum, or upper thigh? Early, this may be due to bruising, later, it may be caused by urine extravasating from injuries C, D, or E.
Is he tender above his pubis? The swelling may be more severe on one side than on the other. It indicates an injury, but not necessarily to his urinary tract. The swelling may be due to bleeding, or to a mixture of blood and urine from injuries B, C, or D.
If he has a perineal haematoma, its size is no guide as to the probability of a urethral injury. Injuries E, and F, always cause a perineal haematoma; C, and D, may do.
![\includegraphics[width=\linewidth ]{/home/kumasi/Desktop/primsurg-tex/vol-2/ch-68/fig/68-2.eps}](images/img-0229.png)
Examine him rectally. Feel his prostate. This will not be easy if his pelvis is fractured. He may have so much tenderness and swelling that you cannot feel anything, except perhaps an indefinite doughy swelling (blood and urine) where his prostate should be. You may feel his prostate displaced upwards, floating freely, and running away from your examining finger as in Fig. 68-2. if so, he has ruptured his urethra in sites C, or D. The rupture is complete and he needs primary expert repair, or ’railroading’, as in Section 68.5 as soon as his general condition permits. A dislocation of the prostate which you can be sure about on rectal examination is rare. This is such a difficult sign that some surgeons consider it valueless.
At the same time feel for a rectal injury. Can you feel a spicule of bone from a fractured pelvis penetrating his rectum? Is there blood on your glove? If so, goto Section 66.15 on rectal injuries.
If the patient’s bladder is distended, aspirate it with a needle and look at his urine. if this is blood stained, either his bladder is bruised or ruptured, or the blood may have come from his kidney.
If you have to do a laparatomy for other trauma, you can examine his bladder with his other viscera.
X–RAYS If you suspect that a patient has ruptured his posterior urethra, X–ray his pelvis. A fracture is usually but not always present. The severity of his bony injuries is no indication of the probability of rupture.
An IVP is useful to establish a kidney injury, but is not useful for the bladder. You may need it for diagnosis.
Can you feel the dome of the patient’s distended bladder distinct from the rest of the swelling? If his bladder is intact, it will now have had time to distend, and you may be able to feel it. In the presence of other signs, a distended bladder makes an injury to his urethra (C, D, E, or F) very likely, and a ruptured bladder (A or B) impossible.
CAUTION! (1) A distended bladder is a useful but not invariable sign in distinguishing ruptures of the urethra inside the pelvis (C, or D) from Intraperitoneal or extraperitoneal rupture of the bladder (A, or B). (2) A bladder can only distend if it has urine to distend with, so make sure you correct the patient’s hypovolaemia and dehydration, so that he has some urine to secrete.
Read on for the management of rupture of the bladder (A, and B), and injuries to the urethra (C, D, E, and F). If you refer a patient with a suprapubic cystostomy, try to send someone with him to help him during the journey.
|
|
|
Primary Surgery Vol.2 – Trauma | |
|
|