CHAPTER 68

The lower urinary and genital tract

68.1 The general method for an injury of thelower urinary tract

The two sexes injure their lower urinary tracts in differentways. A woman’s urinary tract is vulnerable to obstetricdisaster, but seldom to trauma, whereas a man may sustainany of the injuries in Fig. 68-1. He can occasionally rupturehis bladder into his peritoneal cavity (A). Much more often,he ruptures it extraperitoneally (B). He can also rupture hisposterior urethra (C), his membranous urethra (D), his bul-bous urethra (E), or his penile urethra (F). His prostatic ure-thra is protected by his zostate and is seldom injured. Blowsto his lower abdomen burst his bladder (A). Fractures of hispelvis cause injuries B, C, and D. Blows to his urethra causeinjuries D, E, and F. He may have more than one injury, andcombinations of injuries B, and C, are not uncommon. Apenetrating wound can injure any part of his urinary tract.

Always explore, repair, and drain a ruptured bladder.Ruptures of the urethra, on the other hand, are often incom-plete and may heal themselves if you treat them conserva-tively, by diverting a patient’s urine with a suprapubic cys-tostomy for three weeks. This will allow him to recover fromany other injuries he may have, and give you time to referhim for endoscopy and expert repair, should the rupture ofhis urethra unfortunately turn out to have been complete. Ifyou cannot refer him, you may have to repair him yourself.

Diagnosis is seldom difficult. The important sign in all in-juries of the lower urinary tract is that the patient cannot passurine after an injury. If his bladder bursts into his peritonealcavity (A), he has the signs of a slowly developing peritoni-tis. If it bursts extraperitoneally (B), his urine slowly ex-travasates, and may eventually become infected. With bothof these injuries (A, and B) his bladder usually fails to dis-tend, but occasionally it may do, if there is a flap–like injuryto its wall. So failure to pass urine after an injury, combinedwith failure of the bladder to distend, is usually an indica-tion of injuries A or B.

In all more distal injuries (C, D, E, and F) the patient’sbladder, including its internal sphincter, is intact, so after afew hours it always distends with urine. The combination ofretention of urine with a distended bladder is characteristicof all injuries below the bladder neck, and occasionally ofthose above it. Another critical sign of injury of the lowerurinary tract is blood at the patient’s external meatus (evena drop is significant) in all urethraj injuries (occasionally inC, and almost always in D, E, and F). His penis, scrotum,

and perineum may also be injured.Injuries to a patient’s urinary tract are less urgent than

some other abdominal catastrophes. If he has a rupturedspleen or liver, he needs an urgent laparotomy, but youhave a few hours (never more than 24) in which to explorehis ruptured bladder. Most surgeons would agree that youshould not try to pass a urethral catheter, because it mayintroduce infection, and it can be misleading.

CAN THE PATIENT PASS URINE AFTER AN INJURY?IS THERE BLOOD AT THE TIP OF HIS MEATUS?

IS HIS BLADDER DISTENDING?

THE GENERAL METHOD FOR INJURIES OF THELOWER URINARY TRACT

This extends Section 51.3 on the care of a severely injuredpatient. Suspect that a patient may have injured his lower

INJURIES OF THE LOWER URINARY TRACT

B

fractures ofthe pelvis causeinjuries B, C, D

lower abdomen bursts

the bladder into

the peritoneum (A)

a blow to the

a blow in the

injuries D, E, and F.

perineum causes

(straddle injury)

blood, this is theimportant sign ofinjuries D, E, and F

urogenital diaphragm

bladder

rectum

bruising

rupturepartial

completerupture

ED

A

F

C

Fig. 68.1: INJURIES TO THE MALE LOWER URINARY TRACT. A,rupture of the bladder into the peritoneum. B, rupture outside the peri-toneum. C, rupture of the posterior urethra. D, rupture of the membra-nous urethra. E, rupture of the bulbous urethra. F, rupture of the penileurethra.

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68 The lower urinary and genital tract

urinary tract if: (1) he has some injury which makes thislikely (especially a fractured pelvis), or (2) he cannot passurine after an accident, or (3) there is blood at the tip of hisurethra.

CAUTION! Don’t pass a diagnostic catheter up the pa-tient’s urethra because: (1) The information it will give youwill be unreliable. (2) You may contaminate the haematomaround the injury. (3) You may damage the slender bridge oftissue that joins the two halves of his injured urethra.

IMMEDIATELY AFTER AN INJURY OF THE LOWERURINARY TRACT

How did the injury occur? This will tell you the kind ofinjury to suspect.

Has the patient passed urine since the accident? If hewants to pass urine, let him try, gently without straining. Ifhe strains, urine will extravasate into his tissues.

If he has passed blood–free urine since the accident, hisurinary tract has not been seriously injured. If he can passno urine, or only a little blood stained urine, with frequencyand dysuria, his urethra has been injured.

If his bladder is distended, you may have to needle it toreduce his distress.

Has he ever had even a little bleeding from the exter-nal orifice of his urethra? If necessary, milk his urethra todemonstrate blood at its tip. You will usually find this bleed-ing if you look for it. It confirms a rupture (complete or partial)of some part of his urethra (injuries D, E, or F, and occasion-ally 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 bruis-ing, later, it may be caused by urine extravasating from in-juries C, D, or E.

Is he tender above his pubis? The swelling may bemore severe on one side than on the other. It indicates aninjury, but not necessarily to his urinary tract. The swellingmay be due to bleeding, or to a mixture of blood and urinefrom injuries B, C, or D.

If he has a perineal haematoma, its size is no guide asto the probability of a urethral injury. Injuries E, and F, alwayscause a perineal haematoma; C, and D, may do.

Examine him rectally. Feel his prostate. This will not beeasy if his pelvis is fractured. He may have so much tender-ness and swelling that you cannot feel anything, except per-haps an indefinite doughy swelling (blood and urine) wherehis prostate should be. You may feel his prostate displacedupwards, floating freely, and running away from your exam-ining finger as in Fig. 68-2. if so, he has ruptured his ure-thra in sites C, or D. The rupture is complete and he needsprimary expert repair, or ’railroading’, as in Section 68.5 assoon as his general condition permits. A dislocation of theprostate which you can be sure about on rectal examina-tion is rare. This is such a difficult sign that some surgeonsconsider it valueless.

At the same time feel for a rectal injury. Can you feel aspicule of bone from a fractured pelvis penetrating his rec-tum? Is there blood on your glove? If so, goto Section 66.15on rectal injuries.

If the patient’s bladder is distended, aspirate it with aneedle and look at his urine. if this is blood stained, either

his bladder is bruised or ruptured, or the blood may havecome from his kidney.

If you have to do a laparatomy for other trauma, youcan examine his bladder with his other viscera.

X–RAYS If you suspect that a patient has ruptured hisposterior urethra, X–ray his pelvis. A fracture is usually butnot always present. The severity of his bony injuries is noindication of the probability of rupture.

An IVP is useful to establish a kidney injury, but is notuseful for the bladder. You may need it for diagnosis.

SOME HOURS AFTER AN INJURY OF THE LOWERURINARY TRACT

Can you feel the dome of the patient’s distended bladderdistinct from the rest of the swelling? If his bladder isintact, it will now have had time to distend, and you may beable to feel it. In the presence of other signs, a distendedbladder makes an injury to his urethra (C, D, E, or F) verylikely, and a ruptured bladder (A or B) impossible.

CAUTION! (1) A distended bladder is a useful but not in-variable sign in distinguishing ruptures of the urethra insidethe pelvis (C, or D) from Intraperitoneal or extraperitonealrupture of the bladder (A, or B). (2) A bladder can only dis-tend if it has urine to distend with, so make sure you correctthe patient’s hypovolaemia and dehydration, so that he hassome urine to secrete.

Type C injury

mass ofblood andurine

interpreting what youexamine rectally;

feel may be difficult

tip of theurethra

blood at the

INTRAPELVIC RUPTUREOF THE URETHRA

Fig. 68.2: RECTAL EXAMINATION FOR RUPTURE OF THE POS-TERIOR URETHRA (injury C). This patient’s urethra is completely rup-tured. If you cannot refer him, ’railroad’ him immediately. With the kindpermission of Hugh Dudley.

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68.2 Rupture of the bladder

FURTHER MANAGEMENT OF AN INJURY OF THELOWER URINARY TRACT

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 re-fer a patient with a suprapubic cystostomy, try to send some-one with him to help him during the journey.

NEVER PASS A DIAGNOSTIC CATHETER IF THERE ISBLOOD AT THE EXTERNAL MEATUS

68.2 Rupture of the bladder

Intraperitoneal rupture A drunk patient with a distendedbladder staggers in front of a motor vechicle. He receives ablow to his abdomen which bursts the dome or the poste-rior surface of his bladder, and floods his peritoneal cavitywith urine (injury A, in Fig. 68-1). He feels sudden intensepain followed by shock and fainting. These immediate acutesymptoms soon pass; there is no lower abdominal swelling,and his pain improves temporarily before signs of peritoni-tis follow after about 24 hours.

Extraperitoneal rupture Commonly, a patient is broughtin with multiple injuries, one of which is a fracture of hispelvis which has ruptured his bladder outside his peritonealcavity (injury B). Although he may want to pass urine, all he

RUPTURE OF THE BLADDER

Intraperitoneal (A)

Extraperitoneal (B) suprapubictendernessand swelling

follows a blowto the abdomen

follows a fracturedpelvis

Fig. 68.3: INTRAPERITONEAL AND EXTRAPERITONEAL RUP-TURE OF THE BLADDER If you diagnose any kind of rupture of thebladder, you will have to refer the patient urgently, or operate. With thekind permission of Hugh Dudley.

can produce is a drop of blood. The broken ends of his pu-bic bones have torn the anterior wall of his bladder closeto its neck. Sometimes, his posterior urethra has rupturedalso. Blood and urine fill his prevesical space and trackbetween his peritoneum and his transversalis fascia. Theyinfiltrate laterally towards his anterosuperior iliac spines,and down towards his prostate. If he is not treated, thismixture of blood and urine becomes pus, which may ulti-mately discharge through his sacrosciatic notches into hisbuttocks, through his obturator foramina into his thighs, orout through his inguinal canals. There is such devastatingnecrosis within his pelvis that he becomes severely toxaemicand may die.

In the first few hours after the accident, you may not beable to tell if a patient’s fractured pelvis has ruptured hisbladder, or has merely caused bleeding behind his pubicbones. But, even if his bladder has been ruptured, nothingmuch happens for the first 24 hours, so you have a day inwhich to observe him. Don’t delay more than 24 hours, andtake great care not to infect the injured area by passing a diagnos-tic catheter meanwhile.

You can usually tell quite easily if a patient’s bladder hasruptured inside or outside his peritoneum from: (1) The his-tory of the injury—a blow to his abdomen suggests ruptureinside the peritoneum, whereas a fractured pelvis suggestsrupture outside it. (2) The distribution of the tenderness—inextraperitoneal rupture this is narrowly localised suprapu-bically, in intraperitoneal rupture it is more diffuse over hislower abdomen and ends in obvious peritonitis.

If you are in doubt, there are twoinvestigations that mayconfirm that his bladder has ruptured, and show you whereit has ruptured, but they are usually not necessary: (1) Youcan do a retrograde cystogram. Unfortunately, this requiresthe use of a catheter, and with it the risk of infection. (2) Youcan do an intravenous pyelogram, which is safer but lessreliable.

You will be wiser to wait a few hours to confirm the di-agnosis, rather than to operate unnecessarily and find onlya haematoma which bleeds profusely or even disastrouslywhen you open it. If you have to do an immediate laparo-tomy for other reasons, say for a suspected rupture of thepatient’s spleen, you can easily examine his bladder at thesame time.

If you diagnose any kind of rupture of the bladder, youwill have to refer the patient urgently, or operate. A lowermidline incision will bring you into his prevesical space out-side his peritoneum just above his pubis. If this is full ofurine and blood, his bladder has ruptured extraperitoneally.If it is normal, open his peritoneal cavity. If it contains bloodand urine, his bladder has ruptured into it. The easiest wayto find a tear is to open his bladder, put a finger into it, andfeel for the tear. If an extraperitoneal rupture is large andeasy to reach, it should not be too difficult to suture. Butif the tear is difficult to get at, leave it, insert a suprapubicFoley catheter into his bladder and let it drain. An intraperi-toneal rupture is usually larger, so always suture it and in-sert a suprapubic catheter drain.

Be sure to close a patient’s bladder mucosa with catgut.If you use any other sutures, they may form a focus for theformation of stones. If his bladder has ruptured extraperi-toneally, be sure to drain his prevesical space adequately.

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68 The lower urinary and genital tract

RUPTURE OF THE BLADDER

INDICATIONS Inability of the patient to pass urine within24 hours of an injury, combined with: (1) The absence ofa distended bladder (A, or B, in Fig. 68-1). (2) Increasingperitoneal irritation (A). (3) The appearance of a suprapu-bic swelling that might be extravasated blood and urine (B,or C). (4) Penetrating injuries that might have involved hisbladder.

Make sure you have corrected the patient’s hypovolaemiaand dehydration, so that if his bladder is intact, it will containsome urine and be easier to find.

EQUIPMENT A general set. 2/0 plain catgut for the mu-cosa of the bladder, and 2/0 chromic catgut for its musclewall.

ANTIBIOTICS Give the patient perioperative antibiotics(2.7).

OPERATION Take him to the theatre as carefully as youcan, so as not to displace the broken fragments of his pelvisany further. Lie him supine with his legs slightly apart, sothat you can, if necessary, pass a catheter. Drape him soas to expose his whole abdomen. Clean his urinary meatus,and its surroundings. If you are right handed, you may findit convenient to work from the left side of the table.

INCISION Make a midline incision from just below the pa-tient’s umbilicus to 1 cm above his pubic symphysis. Cutthrough the aponeurosis, and retract his rectus muscles.This will expose his prevesical space. Open it up with yourfingers and inspect the front of his bladder. If you find urine,look where it is coming from.

CAUTION! (1) Don’t open his peritoneum yet. (2) If thereis any danger that he may have other abdominal injuries, in-spect the rest of his abdominal organs later in the operation.

If blood and urine flood up from his prevesical space,his bladder has ruptured extraperitoneally. Suck and mopthe blood away. if bleeding is excessive, pack the space withgauze. Proceed as for extraperitoneal rupture, as describedbelow.

If no blood and urine flood up from his prevesicalspace, find the upper surface of his bladder with its peri-toneal reflexion, and use gauze dissection to displace thisupwards. You will recognize that it is his bladder from themuscle fibres on its surface.

Incise his peritoneum by making a generous opening justabove its attachment to his bladder. Enlarge the incisionupwards as far as is necessary. Examine his abdominal or-gans and look for a retroperitoneal haematoma. If you findany other injuries, treat them first.

If his peritoneal cavity is normal, close it.If his peritoneal cavity contains urine mixed with

blood, his bladder has ruptured into it. Suck and mop awaythe blood and urine. The tear will probably be on its uppersurface and you will find it easily. Proceed as for intraperi-toneal rupture of the bladder, as described below.

If you are in doubt, open the patient’s bladder as de-scribed below and inspect it from inside. Tears are moreeasily found from inside. Be prepared to find more than onetear.

EXTRAPERITONEAL RUPTURE OF THE BLADDER

The tear will probably be in the anterior wall of the patient’sbladder, just above his prostate. It may be difficult to findwhen his bladder is empty and there is clot everywhere.

Recognize his bladder by the muscle bundles in its walls,and the prominent veins on its surface.

If the tear is small, or difficult to find, don’t suture it, ortry to look for it in the blood and urine in front of his bladder.Instead, insert a suprapubic catheter, drain his retropubicspace, and close his abdomen.

If the tear is large and easy to repair, suture it frominside.

Open the bladder between stay sutures, as for a Freyer’sprostatectomy (23.19). There will now be two (or more)holes in its wall—the original tear, and the incision you havejust made. Put your finger into it, and feel the tear from in-side.

CAUTION! If the tear is near the ureters, pass a finecatheter up them to help to prevent you tying them off.

Go round to the left side of the table, if you are not al-ready there. Suture the tear with a single layer of plain catgutstitches going deeply into the muscle.

Repair the patient’s bladder in two layers, as for a prosta-tectomy (22.17), with an inner layer of continuous 3/0 plaincatgut, and an outer layer of continuous chromic 2/0 catgut.

DRAINING THE BLADDER You will now need to drain thepatient’s bladder.

If there has been no blood at his external meatus, hisurethra is probably unharmed. So drain his bladder throughan indwelling 22 Ch Foley catheter passed up through hisexternal meatus.

If there has been any blood at the patient’s externalmeatus, his urethra has probably been injured. Avoid a ure-thral catheter. Instead, insert a 26 Ch Foley catheter throughthe cystotomy wound and sew his bladder wall round it withcatgut (22.7).

Drain his prevesical space with a large (6 corrugations)rubber drain, or leave the wound partly open. Close thewound and anchor both his suprapubic catheter and his pre-vesical drain to his skin with stitches.

INTRAPERITONEAL RUPTURE OF THE BLADDER

Tilt the head of the table slightly downwards, and pack offthe patient’s intestines to make more room in his pelvis.

If there is an obvious tear in his bladder, feel and ifpossible look at the interior of his bladder through it. Alter-natively, open his bladder through a separate incision anteri-orly. Be sure to find and protect his ureters before you insertany sutures.

Control all bleeding inside the bladder, so as to reducethe risk of clot retention. Close the tear in his mucosa withcontinuous plain catgut, and its serosa with chromic catgut.

Remove the packs, level the table, mop up any free fluidin his peritoneal cavity, and close it. Drain his bladder witha urethral or suprapubic catheter, and drain his suprapubicspace on the indications given above.

If there is frank peritonitis, insert a suprapubic peritonealdrain.

THE POSTOPERATIVE CARE OF A BLADDER INJURY

This is the same for both kinds of rupture. Connect thecatheter to a closed drainage system, and check that it isdraining. As soon as the patient has recovered from shock,raise him gradually into the sitting position.

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68.3 Rupture of the posterior urethra (injuries C, and D)

If he has an extraperitoneal rupture, give him a broadspectrum antibiotic for 5 days in the hope of preventing thehuge haematoma in his pelvis from becoming infected.

Prevesical drain Remove this at 5 days.

Indwelling urethral catheter. Remove this at 7 to 14days. When it is removed he should be able to pass urinenormally.

Suprapubic catheter (if you decide to insert one). Keepthis in until after you have removed his urethral catheter. Re-move this at 10 days. Try spigotting it first to see if he canpass urine.

DIFFICULTIES WITH BLADDER INJURIES

If there is SEVERE BLEEDING as you open the patient’sprevesical space, fragments of his fractured pelvis havetorn the vessels of his pelvic wall. The bleeding vessel maybe impossible to find. When you remove the blood, most ofthe bleeding will probably stop. If it does not, pack his pre-vesical space and its lateral recesses, and leave the pack infor 15 minutes. Then, with an enlarged incision and a goodlight, have another look. You may find and be able to tie thebleeding vessel. If you don’t find it, replace the pack, givehim antibiotics, and remove it 24 hours later.

If he has an OPEN WOUND of his bladder, explore it,close the tear in its wall, do a suprapubic cystostomy, anddrain his prevesical space. The tear may be posterior, inwhich case you may be forced to cut open the front of hisbladder, in order to repair it from the inside.

If you have OPENED HIS BLADDER ACCIDENTALLYduring the course of another operation, what you shoulddo depends on when you recognize it.

If you recognise an accidentally opened bladder dur-ing the operation, close it in two layers and insert a supra-pubic or urethral catheter. Leave it to drain for about twoweeks before removing it.

If you recognize it only some days later, insert acatheter as above, and also a peritoneal drain through a stabincision in one of his rectus muscles, being careful to avoidhis inferior epigastric arteries. Don’t put the suprapubic tubeand the peritoneal drain too close together.

You are most likely to injure the bladder accidentally dur-ing Caesarean section (18.8), or when you repair a slidinghernia (14.2), or when you drain a patient’s peritoneal cav-ity suprapubically for peritonitis. The main way of prevent-ing injury is to catheterize a patient’s bladder after you haveanaesthetized him, before doing any of these procedures.if you decide to catheterize him first, leave the catheter inplace to prevent his bladder filling up before you come tooperate.

If he gets CLOT RETENTION, wash out his bladder thor-oughly through his urethral or suprapubic catheter to removeall clot.

68.3 Rupture of the posterior urethra(injuries C, and D)

Suspect that a severely injured patient has ruptured his pos-terior urethra, if he has: (1) A fractured pelvis, particularly

if he has a ’butterfly fracture’ (D, Fig. 76-1), or a ’hinge frac-ture’ (E, in this figure). (2) Bleeding from his external mea-tus. (3) A distended bladder. (4) A boggy swelling displac-ing or partly concealing his prostate.

If a patient’s prostate is not widely displaced, and there is noboggy feeling when you examine him rectally (a difficultand unreliable sign), the rupture of his posterior urethra isprobably incomplete. and will heal itself if you leave it for 3weeks, and insert a suprapubic catheter to prevent his urineextravasating meanwhile. If a small bridge of urethral tissuesurvives, his urethra may reform with very little stricture—provided that the infection which may follow catheteriza-tion does not destroy it. The prevention of this infection oneof the reasons why you should not try to catheterize him.The other reason is that you may make his injury worse. Ifhis rupture heals during three weeks of waiting, it was in-complete. The best test of this is to see if he can pass urinenormally when you clamp off the suprapubic tube. If hecannot, the chances are that the rupture was complete, sotry to refer him for expert repair at 3 weeks. Don’t leave himlonger than this because increasing fibrosis will make repairmore difficult. Repair at 3 weeks is seldom easy, but it is nomore difficult than it would have been immediately after theaccident.

If his prostate is widely displaced, and there is a boggy feel-ing when you examine him rectally, his urethra is probablycompletely ruptured. If you cannot refer him, you will haveto try to ’railroad’ him, as in the next section.

The great advantage of conservative treatment is that itwill usually avoid railroading, which is difficult and bloody.Your first sight of the retropubic space of a patient with afractured pelvis and a torn urethra will be daunting indeed.

POSTERIOR URETHRAL INJURIES

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

IS IMMEDIATE REPAIR INDICATED?

If a patient’s prostate is widely displaced immediatelyafter the injury (rare), and there is a boggy feeling onrectal examination, he probably has a complete rupture.Insert a suprapubic catheter, and refer him immediately. Ex-perts can do primary repair. if this is impractical, goto Sec-tion 68.4 and railroad him yourself immediately. If you arenot sure if his rupture is complete or not, because displace-ment on rectal examination is such a difficult sign, treat himconservatively, as described below.

If his prostate is not displaced, his urethra may notbe completely ruptured, conservative treatment is indicated,and his prognosis is good. CONSERVATIVE TREATMENTPut him to bed with a suprapubic catheter on continuousdrainage. Use a fine plastic, suprapubic tube (23.6 and23.7), not a suprapubic Foley catheter.

Insert the catheter by open exposure of his bladder (23.7).Do this at a laparotomy which will: (1) enable you to exam-ine 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 anotheroperation soon afterwards.

Pass a long 26 Ch suprapubic catheter (this is about thesize of intravenous plastic tubing) with side holes, and an-chor it with a stout stitch.

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68 The lower urinary and genital tract

CAUTION! Remember that exploring his bladder convertsa closed fracture of his pelvis into an open one, so give himperioperative antibiotics (2.7).

TREAT HIS PELVIC FRACTURE If he has a hinge frac-ture, use a sling or traction as in Section 76.2. Ignore butter-fly compression fractures.

THREE WEEKS AFTER A POSTERIOR URETHRALINJURY

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

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

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

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

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

RAILROADINGWITH CATHETERS

A

C

B

D

Fig. 68.4: RAILROADING WITH CATHETERS. A, feeling for the tipof the Foley catheter in the patient’s retropubic space. B, the two cathetershave been joined together. C, the Foley catheter has been pulled throughinto his bladder, which has been closed. D, a tortuous stricture is sure toform. You will have to use sounds to get the feel of it before it becomestightly fibrotic. Record in the patient’s notes how the stricture is bestnegotiated-it may not be sounded by you next time, and your successorwill be grateful! Kindly contributed by Peter Bewes.

If it remains more than 75 ml, and gets steadily worse,he has a complete rupture, and his prognosis is poor, espe-cially if repair is delayed beyond 3 weeks. This situation israre. Usually, he either recovers completely, or can pass nourine.

If referral really is impossible, attempt railroading.CAUTION! Beware of: (1) The elderly man with an en-

larged prostate. (2) The young boy who may have consider-able difficulty starting micturition and whose rupture is likelyto be just below his bladder neck.

If railroading fails or is impossible, he will be left witha permanent suprapubic catheter, unless he can be referredfor urethral reconstruction.

68.4 ’Railroading’

This is a method of passing a catheter through a patient’surethra when it is torn, and when the two ends of the ure-thra are widely separated. ’Railroading’ is not easy, andshould very rarely be necessary. If there is much fibrosis,you will have to use sounds, but you should start by us-ing a catheter. Pass one catheter up his urethra from below,feel for it in his retropubic space and bring it out into thewound. Pass another catheter down through his bladderfrom above. Find it in his prevesical space and bring it tooout into the wound. Push the end of the lower catheter intothe cut end of the upper one, and stitch them if necessary.Then use the upper one to pull the lower one through intohis bladder.

If you use sounds, pass one sound up his urethra frombelow, and another down through his bladder from above.You will feel them meeting in the blood clot where his pos-terior urethra should be. Use the upper sound to guide thelower one up through his prostatic urethra into his bladder.When the lower sound is in his bladder, fix a rubber tube toit and use this to pull a Foley catheter up into his bladder.There is a great danger that you will create false passages,so be careful!

RAILROADING

Refer the patient if you can.INDICATIONS (1) A severely displaced prostate immedi-

ately after the injury. (2) Failure to pass urine after 3 weeksof conservative treatment with suprapubic catheter’drainage.(3) increasing residual urine after attempted conservativetreatment.

INVESTIGATIONS If possible, do an ascending urethro-gram, and a micturating cystourethrogram. Use the supra-pubic tube to get the contrast medium into the patient’s blad-der. Fill his bladder as full as you can, and then get him topass urine as a film is taken.

ANAESTHESIA Give him a general anaesthetic with a re-laxant, and lie him supine. Have blood cross–matched.

USING CATHETERS FOR RAILROADING

Lubricate the patient’s urethra and try to pass a 16 or 18Ch soft rubber catheter. If this passes immediately after theinjury, your diagnosis was at fault. Remove it at once butleave the suprapubic catheter in for the full 3 weeks.

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

If a Foley catheter fails to enter his bladder, make a lowermidline incision to expose and open his bladder with a supra-pubic cystotomy as in Section 68.2. Make a fairly large ver-tical incision in his bladder. An opening of a reasonablesize will make the procedure much easier. The catheter willpresent in his pelvis through the torn lower end of his ure-thra. If necessary, use ‘finger dissection’ deep in his retropu-bic space. Finding it may not be easy, and there may be a lotof clot to be swept away. Pass another larger 24 Ch catheterdown through his bladder, into his internal urinary meatusand then through into his retropubic space. Bring it out intothe wound. Remove its tip and eyes and push the end ofthe Foley catheter into it. If necessary, suture them together.Try to make a smooth join that will cause the minimum oftrauma. Then pull the Foley catheter into his bladder.

If (in late cases) the Foley catheter fails to pass intohis retropubic space, because there is too much fibrosis,you will have to use sounds.

USING SOUNDS FOR RAILROADING

EQUIPMENT Two curved metal sounds, apiece of rubber orplastic tube that will fit tightly over one of them, as in A, Fig.68-5, and will not come off when you draw it through thepatient’s uretha. A 20 Ch silicone latex Foley catheter.

SOUNDING If a rubber catheter does not pass, gently tryto pass a curved Lister’s sound. If this does not pass, findwhere it is held up; see under difficulties’ below.

If all is well the sound should pass easily into the pa-tient’s retropubic space. Pass another sound down throughhis bladder. You should feel a metallic ’clink’ as the soundstouch (B). If you don’t, mobilize the apex of his prostate abit more and try to feel the ends of the two sounds in thewound. Or, ask your assistant to put his finger in the rectumand feel the ends of the two sounds.

Keeping the two sounds in contact with one another, usethe upper one to guide the lower one into the bladder (C).Fix the piece of tube to the tip of the lower sound (D), anduse it to draw this tube down through his urethra.

Alternatively, pass your finger through his prostatic ure-thra, try to feel the sound and guide it into his bladder, as inH, Fig. 68-5.

Stitch the tip of a Foley catheter snugly to the tube anduse this to pull the catheter up into the patient’s bladder (E).If the tube and the catheter do not fit snugly, the join willfurther injure his urethra as it passes through.

WHEN THE FOLEY CATHETER IS IN PLACE stitch astout monofilament suture to its tip, and bring this outthrough the patient’s abdominal wall (F).

Blow up the balloon of the Foley catheter, and close thepatient’s bladder as usual (23.7). Keep the monofilamentsuture long, roll it round a swab and fix it to his abdominalwall. If the balloon bursts, you can use it to railroad anotherFoley catheter into place without doing a second laparotomy.

Send the patient back to the ward with the catheter oncontinuous drainage. If there was a tendency for the bladderto ’ride high’ far from the pelvic diaphragm, tie the distal endof the catheter (perhaps its side tube) with a long string to a20 ml specimen bottle full of water. Lead this over the end ofhis bed; it will exert just enough traction to keep his prostatein place (G).

CAUTION! (1) Keep the balloon blown up. (2) Don’t exerttoo much traction, or you will pull the balloon out of the pa-

tient’s bladder into his retropubic space, or cause the baseof his bladder to necrose. Most surgeons don’t exert anytraction if the bladder doesn’t ’ride high’.

Keep up this gentle traction for 3 weeks. Then remove thecatheter, and see if he can pass urine.

As soon as possible, bougie him with a large Listerbougie. Repeat it after 3 weeks, then 4, then 5 weeks un-til he is stable. He will certainly have a difficult stricture, sofollow him up for life.

Alternatively insert a second Foley suprapubically, anddrain his bladder through this. A Foley catheter which isexerting traction is not ideal for draining the bladder at thesame time.

DIFFICULTIES WITH URETHRAL INJURIES

If the SOUND IS HELD UP IN THE PATIENT’S PERINEUM,cut down on its tip, as for external urethrotomy (23.9), andcontinue as for this operation.

If the SOUND IS HELD UP AT HiS PERINEAL MEM-BRANE, remove it, and do a laparotomy as for Freyer’sprostatectomy (23.17), but with a lower midline abdominalincision. Open his retropubic space right down to his per-ineal membrane. Use the index fingers of both your handsto open up this space. Then open up his bladder as forFreyer’s prostatectomy. Find his internal meatus. You maybe able to guide a Foley catheter past the obstruction intohis bladder. If you fail, reintroduce the urethral sound, andpass another one down through his bladder and his internalurinary meatus as in B, Fig. 68-5.

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

Rupture of a patient’s anterior urethra resembles that of hisposterior urethra (68.4) except that: (1) It is caused by a blowto his perineum rather than by a fractured pelvis. (2) He hasa severe perineal haematoma. (3) He is more likely to bleedthrough his urethra, and when he does bleed, the bleedingwill be more severe. (4) The diagnosis is easier, and he isless likely to die. Treatment with a trial of conservative treat-ment is similar. You will hardly ever have to operate on theinjured area itself because the injury is nearly always incom-plete. But, if conservative treatment fails, and the ruptureturns out to be complete, you can cut down on his ante-rior urethra, as if you were doing an ex ternal urethrotomy(23.9), which is less difficult. Scar tissue forms more readilyin Africans, so strictures are a major problem in these pa-tients.

INJURIES OF THE PENILE URETHRA

If the patient can pass urine, let him do so; his urethra isnot seriously injured.

CONSERVATIVE TREATMENT OF INJURIES OF THEPENILE URETHRA

If he cannot pass urine, take him to the theatre, do a formalcystostomy (23.7), insert a suprapubic catheter, and leave itin for 3 weeks. Use a fine plastic tube, not a Foley catheter.Provided that the haematoma in his scrotum or perineum is

7

68 The lower urinary and genital tract

not so tense as to endanger the skin over it, leave it. Other-wise, 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 himyourself 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).

METHOD Put the patient into the lithotomy position. Passa straight bougie. See how far it goes. Mark the obstructionsite by your usual method (23.8).

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

RAILROADING

A

B

C D

E F

H

sound

tight fitrubber tube

"clink"

lowersound inbladder

tube fixedto lowersound

stout monofilamentthroughFoley cathetertube drawing

stitch

alternativelyfeel the soundwith your finger

20 mlspecimen bottle

drainage

monofilament rolled up

G

Fig. 68.5: RAILROADING WITH SOUNDS. A, shows how the rubbertube must fit tightly over the sound. B, the two sounds meeting in thepatient’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 nowbeing drawn through his urethra. E, the rubber tube has been stitched tothe Foley catheter and is drawing it through. F, monofilament has beenfixed to the Foley catheter, so that if it slips out, another one can be drawnthrough. G, traction is being exerted. H, an alternative, guiding a soundinto the bladder with your little finger. Kindly contributed by Peter Bewes.

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

If his whole urethra is disrupted, mobilize his bulbospon-giosus proximally and distally as necessary, so that it willstretch to meet without tension (it is a very elastic organ).

Repair his urethra and bulbospongiosus end to end with3/0 plain catgut and leave a silastic Foley catheter in for 6weeks on intermittent drainage.

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

If you don’t have a silastic catheter, insert a suprapubiccatheter, at the same time as the repair, and leave the repairwithout a splint. Use the next 3 weeks to get one of thebougles in Fig. 23-9 made. At the end of 3 weeks gentlypass it under lignocaine anaesthesia. Measure his residualurine. When this is 75 ml or less, remove the suprapubiccatheter.

POSTOPERATIVE CARE All patients need repeated di-latation, starting at 6 weeks, and eventually every 3 monthsfor life.

68.6 Extravasation of urine complicatingurethral injuries

A patient’s urine extravasates if he tries to pass it through aruptured urethra. Try to prevent this happening by draininghis bladder. In injuries B, C, and D, in Fig. 68-1, combinethis with draining his prevesical space. Extravasation canalso complicate a urethral stricture (23.10).

Extravasation can be superficial or deep. Superficial ex-travasation appears as a large, expanding, tender swelling

The fascia aroundthe penis remainsintact, and spreadis limited

draining theextravasatedurine

The fascia around thepenis is torn andurine spreads widely

C

B

A

EXTRAVASATIONOF URINE

Fig. 68.6: EXTRAVASATION OF URINE. Urine leaking from the bulbarurethra may at first be limited to the penis if the fascia around it (Buck’sfascia) remains intact, as in A. If this fascia is breached, urine can spreadmuch more widely, as in B. Adapted with kind permission from an original paint-ing by Frank H. Netter, M.D. from the CIBA COLLECTOION OF MEDICAL IL-LUSTRATIONS, copyright by CIBA Pharmaceutical Company, Division of CIBA–GEIGY Corporation.

8

68.8 Injuries of the penis and scrotum

of the patient’s penis, or a swelling in his scrotum, per-ineum, or lower abdomen. Provided he has not beencatheterized, the urine which has escaped is unlikely to beinfected. If it is infected, severe necrotizing cellulitis will fol-low.

EXTRAVASATION OF URINE

If a patient presents late with a large red oedematousswelling, insert a suprapubic catheter into his bladder (23.6),and let out the stinking fluid through multiple wide incisionsin the swelling. Give him antibiotics (2.7) and wait. This isnot the time to start repairing his urethra.

If you cannot refer him, you can try the residual urineregime (68.3) after a month or so of suprapubic drainage. Ifhe has only a little residual urine, try bouginage. If that issatisfactory, remove his suprapubic catheter when his resid-ual urine is less than 75 ml. If the overlying skin sloughs,graft his wound.

68.7 Strictures after urethral injuries

Unfortunately, a stricture usually follows an injury to anypart of the urethra, so any patient who has ever had a urethralinjury must be regularly reviewed (22.8). Monitor his streamwith a bucket and tape measure as in Fig. 23-9, or with astop watch. If there is any deterioration at all, pass bougiesto calibrate the size of his stricture, and decide whether ornot to start life long bouginage. He may have an ’S’ bend de-formity of his membraneous urethra, resulting from partialbackwards displacement of his prostate. If you instrumenthim forcibly, you can easily make a false passage at the ’S’bend. If his stream is diminishing, bouginage for life is in-evitable. The secret of success is to diagnose an impendingstricture early, and to start bouginage before he notices his streamis tailing off. If he has an anterior stricture, he may be ableto bougie himself with the homemade bougie in Fig. 23-9.Tell him to boil it and leave it in the water until the waterbecomes tepid. Warn him also that he will probably haveurinary infections and should present early for treatment.The strictures that follow injuries will be easier to manageif you don’t leave them too long before you start to bougiethem.

A STRICTURE ALMOST ALWAYS FOLLOWS A URETHRALINJURY

68.8 Injuries of the penis and scrotum

When the skin of a patient’s penis is avulsed, its shaft is usu-ally uninjured, and you can graft it quite easily. When thereis a defect in the skin of his scrotum, you can usually closethe wound with the skin which remains. Don’t try to graftthe scrotum, because there is no way of applying pressureto the graft.

INJURIES OF THE PENIS AND SCROTUM

BRUISING is the result of injury to the patient’s non–erectorgan. Treat it as a urethral injury. Can he pass urine? if hecan, his urethra is not seriously injured.

INJURY OFTHE TESTIS A

B

C

D

a patient’sinjury

a generoustoilet

a drain in his scrotum only

his scrotumclosed

his tunica albugineaclosed tightly

E

Fig. 68.7: AN INJURY OF THE TESTIS. A, the patient’s injury. B, agenerous toilet. C, his tunics being closed. D, his scrotum being E, adrain in his scrotum. From the Early Care of the Injured Patient. The committeeon Trauma of the American College of Surgeons. Edited by A.J. Walt. With kindpermission.

If he cannot pass urine, insert a suprapubic catheter,and treat him as a urethral injury.

If his penis starts to swell with blood or urine, treathim as for a fractured penis as described below.

OPEN WOUNDS Do a wound toilet, you will probably notneed to excise any skin. The urethra may be very difficult torecognize in the bleeding tissue—don’t injure it! if in doubt,assume that injured tissue will recover. Use delayed closure.

If the penis needs bandaging, let this mimic the erect po-sition. if the urethra is injured, insert a suprapubic catheter.

AVULSION (DEGLOVING) INJURIES if any flaps of skinremain on a patient’s injured penis, even if they are com-pletely detached, replace them immediately, because theywill probably live.

If any part of the shaft of his penis is bare, cover itwith split skin, allowing for contraction. Cover the graft witha firm, even dressing. Or, if the deep layer of his foreskinremains attached to the shaft proximal to the corona, youmay be able to use both layers to make a high quality flap orgraft.

Alternatively, bury the shaft of a patient’s penis in his scro-

9

68 The lower urinary and genital tract

tum and release it later.If any flaps of scrotal skin remain, remove them.If the skin of his scrotum has been avulsed, but

enough remains, try to make a bag for his testes. If nec-essary, undercut the skin of his thighs. Or, make incisionsin his thighs to hold his testes and cords until you can referhim for a plastic repair.

FRACTURE OF THE PENIS is the result of the suddenposterior angulation of an erect penis. Open up the hugeswelling with an incision over the most swollen part andevacuate the clot. Then suture the capsule of the rupturedcorpora cavernosa.

If the patient’s corpus spongiosum and urethra havebeen fractured, insert a suprapubic catheter for 3 weeksand proceed as for a urethral injury (68.5).

DIFFICULTIES WITH INJURIES OF THE PENIS ANDSCROTUM

If a patient’s TESTIS IS INJURED, toilet his wound, thenclean and close his tunics albuginea. Drain his scrotum onlyand don’t insert a drain under his tunics.

If his PENIS IS JAMMED in a circular object, the distalpart becomes engorged and swollen. In early cases trysucking some of the blood from his corpora cavernosa with aneedle and syringe, then compress the distal part with coldcompresses for 15 minutes. In later cases you will haveto open up the circular object, if necessary under generalanaesthesia.

If the distal part of his penis becomes gangrenous, ampu-tate it, and proceed as for carcinoma of the penis (Chapter32).

10