68.5 Injuries of the penile urethra (injuries E, and F)

Rupture of a patient’s anterior urethra resembles that of his posterior urethra (68.4) except that: (1) It is caused by a blow to his perineum rather than by a fractured pelvis. (2) He has a severe perineal haematoma. (3) He is more likely to bleed through his urethra, and when he does bleed, the bleeding will be more severe. (4) The diagnosis is easier, and he is less likely to die. Treatment with a trial of conservative treatment is similar. You will hardly ever have to operate on the injured area itself because the injury is nearly always incomplete. But, if conservative treatment fails, and the rupture turns out to be complete, you can cut down on his anterior urethra, as if you were doing an ex ternal urethrotomy (23.9), which is less difficult. Scar tissue forms more readily in Africans, so strictures are a major problem in these patients.

\includegraphics[width=\linewidth ]{/home/kumasi/Desktop/primsurg-tex/vol-2/ch-68/fig/68-5.eps}
Figure 68.5: RAILROADING WITH SOUNDS. A, shows how the rubber tube must fit tightly over the sound. B, the two sounds meeting in the patient’s retropubic space. C, the lower sound has entered his bladder. D, the rubber tube has been fitted on to the lower sound and it is now being drawn through his urethra. E, the rubber tube has been stitched to the Foley catheter and is drawing it through. F, monofilament has been fixed to the Foley catheter, so that if it slips out, another one can be drawn through. G, traction is being exerted. H, an alternative, guiding a sound into the bladder with your little finger. Kindly contributed by Peter Bewes.

INJURIES OF THE PENILE URETHRA

If the patient can pass urine, let him do so; his urethra is not seriously injured.

CONSERVATIVE TREATMENT OF INJURIES OF THE PENILE URETHRA

If he cannot pass urine, take him to the theatre, do a formal cystostomy (23.7), insert a suprapubic catheter, and leave it in for 3 weeks. Use a fine plastic tube, not a Foley catheter. Provided that the haematoma in his scrotum or perineum is not so tense as to endanger the skin over it, leave it. Otherwise, open it, evacuate it, and tie any bleeding vessels.

If his wound is open, goto Section 68.9.

If at 3 weeks he cannot pass urine, he has a complete tear and you will have to refer him for repair, or repair him yourself by the method which follows.

REPAIRING THE PENILE URETHRA

ANAESTHESIA (1) Caudal epidural anaesthesia (A 7.3). (2) Subarachnoid anaesthesia (7.4). (3) General anaesthesia (A 11.3).

\includegraphics[width=\linewidth ]{/home/kumasi/Desktop/primsurg-tex/vol-2/ch-68/fig/68-6.eps}
Figure 68.6: EXTRAVASATION OF URINE. Urine leaking from the bulbar urethra may at first be limited to the penis if the fascia around it (Buck’s fascia) remains intact, as in A. If this fascia is breached, urine can spread much more widely, as in B. Adapted with kind permission from an original painting by Frank H. Netter, M.D. from the CIBA COLLECTOION OF MEDICAL ILLUSTRATIONS, copyright by CIBA Pharmaceutical Company, Division of CIBA–GEIGY Corporation.

METHOD Put the patient into the lithotomy position. Pass a straight bougie. See how far it goes. Mark the obstruction site by your usual method (23.8).

Cut down on his bulbospongiosus at the site of the obstruction, as for an external urethrotomy (23.9).

If you cannot find the proximal end of his urethra, open his bladder, and pass a catheter down from above.

If his whole urethra is disrupted, mobilize his bulbospongiosus proximally and distally as necessary, so that it will stretch to meet without tension (it is a very elastic organ).

Repair his urethra and bulbospongiosus end to end with 3/0 plain catgut and leave a silastic Foley catheter in for 6 weeks on intermittent drainage.

At 6 weeks remove the catheter, and follow him up for a stricture. He will need bouginage for life.

If you don’t have a silastic catheter, insert a suprapubic catheter, at the same time as the repair, and leave the repair without a splint. Use the next 3 weeks to get one of the bougles in Fig. 23-9 made. At the end of 3 weeks gently pass it under lignocaine anaesthesia. Measure his residual urine. When this is 75 ml or less, remove the suprapubic catheter.

POSTOPERATIVE CARE All patients need repeated dilatation, starting at 6 weeks, and eventually every 3 months for life.