POSTERIOR URETHRAL INJURIES

This follows from Sections 51.3, and 68.1, and is the same for injuries in sites C, and D, in Fig. 68-1.

IS IMMEDIATE REPAIR INDICATED?

If a patient’s prostate is widely displaced immediately after the injury (rare), and there is a boggy feeling on rectal examination, he probably has a complete rupture. Insert a suprapubic catheter, and refer him immediately. Experts can do primary repair. if this is impractical, goto Section 68.4 and railroad him yourself immediately. If you are not sure if his rupture is complete or not, because displacement on rectal examination is such a difficult sign, treat him conservatively, as described below.

If his prostate is not displaced, his urethra may not be completely ruptured, conservative treatment is indicated, and his prognosis is good. CONSERVATIVE TREATMENT Put him to bed with a suprapubic catheter on continuous drainage. Use a fine plastic, suprapubic tube (23.6 and 23.7), not a suprapubic Foley catheter.

Figure 68.4: RAILROADING WITH CATHETERS. A, feeling for the tip of the Foley catheter in the patient’s retropubic space. B, the two catheters have been joined together. C, the Foley catheter has been pulled through into his bladder, which has been closed. D, a tortuous stricture is sure to form. You will have to use sounds to get the feel of it before it becomes tightly fibrotic. Record in the patient’s notes how the stricture is best negotiated-it may not be sounded by you next time, and your successor will be grateful! Kindly contributed by Peter Bewes.

Insert the catheter by open exposure of his bladder (23.7). Do this at a laparotomy which will: (1) enable you to examine any other abdominal viscera which may also be injured, and (2) let you assess the extent of his prostatic dislocation. You don’t want to bring him back to the theatre for another operation soon afterwards.

Pass a long 26 Ch suprapubic catheter (this is about the size of intravenous plastic tubing) with side holes, and anchor it with a stout stitch.

CAUTION! Remember that exploring his bladder converts a closed fracture of his pelvis into an open one, so give him perioperative antibiotics (2.7).

TREAT HIS PELVIC FRACTURE If he has a hinge fracture, use a sling or traction as in Section 76.2. Ignore butterfly compression fractures.

THREE WEEKS AFTER A POSTERIOR URETHRAL INJURY

Clamp the patient’s suprapubic tube, and see if he can pass urine.

If he can pass no urine, he probably has a complete rupture. Refer him for accurate open repair by an expert. If you cannot repair him, railroad him.

If he can pass urine, his outlook is good. When he has passed as much urine as he can through his urethra, empty his bladder thoroughly through his suprapubic tube. This is his residual urine. Measure it.

If his residual urine is less than 75 ml, his urethra is sufficiently healed for you to remove his suprapubic tube.

If his residual urine is more than 75 ml, leave the tube in for a few more days and try again.

If it remains more than 75 ml, and gets steadily worse, he has a complete rupture, and his prognosis is poor, especially if repair is delayed beyond 3 weeks. This situation is rare. Usually, he either recovers completely, or can pass no urine.

If referral really is impossible, attempt railroading.

CAUTION! Beware of: (1) The elderly man with an enlarged prostate. (2) The young boy who may have considerable difficulty starting micturition and whose rupture is likely to be just below his bladder neck.

If railroading fails or is impossible, he will be left with a permanent suprapubic catheter, unless he can be referred for urethral reconstruction.