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Fourth stage
Surgery (urology)
Lec-13
د.محمد فوزي
29/11/2015
Male urethral injuries and bladder injury
Urethral injury divided into
• Anterior Urethral injury
• posterior Urethral injury
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Anterior urethral injury (bulbar urethral injury)
Causes
• blow to the perineum
• Stradal injury: cycling, loose manhole covers
Clinical features
Suspect urethral injury after blunt perineal trauma when;
1. The man goes into retention
2. There is perineal swelling "butterfly hematoma"
3. There is blood at urethral meatus
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Treatment
Once urethral injury is suspected
• Dont allow the patient to urinate
• Dont insert a foleys cathter
unless after doing retrograd urethrography
Accordingly the injury can be divided
into
1. Contusion : the dye pass to
bladder ,no exravasation
2. Partial rupture : the dye pass to
bladder ,with exravasation
3. Complete rupture : the dye did
not pass to bladder ,with
exravasation
"Retrograde ureththrography show
Anterior partial urethral injury"
• Contusion
--->
analgesic and antibiotic
• Partial and compleat rupture -->
"suprapubic cystostomy"
analgesic and antibiotic
after 3 weeks retrograde urethrography done to asses the urethra,usually there
will be a stricture which should be treated by dilatation,or urethrotomy,or
urethroplasty
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Posterior urethral injyry (membranous urethral injury)
• Intra pelvic rupture of membranous urethra occur near the apex of prostate
• Most comonlly due to blunt trauma withe pelvic fracture
Clinical picture
• History or trafic accident,fall
• Blood at external urethral meatus
• There may be associated injury to head,chest,abdomin,fracture of long bones,which
may take priority in management to keep the pationt a live
• KUB : usually there is pubic bone fracture
• PR examination : very high prostate, pelvic hematoma
• Retrograde urethrography :extravasation of dye
Treatment
• ABC "Espicially when there is multiple injury"
• Suprapubic cystostomy should be formal type when associated intraperitoneal
bladder injury is suspected to repair the bladder at the same time
• Some surgion prefer rail roading method to realign the seperated urethral ends
• after 6 to 8 weeks asses the uretha by urethrography or urethroscopy
Complication of post urethral injury
1. Urethral stricture
2. Urinary incontinence
3. Impotence
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Bladder injuries
Causes
• Peroperative TURP..TURBT,,cystolitholapaxy,cystoscopic bladder biobsy,caeserean
section,
• blunt pelvic trauma
• Penetrating trauma
Types of perforation
1. Intraperitoneal perforation : the urine escape to the peritoneal cavity
2. Extraperitoneal perforation : the urine escape into the space around the
bladder
Diagnosis
If injury occur During endoscopic operation the diagnosis is clear on visual inspiction
alone,a dark hole or loop of bowel is seen
In case of blunt trauma ,The classicall symtoms and sign are
1-suprapubic pain and tenderness
2-in ability to pass urine
3-haematuria
these sign and symtoms are indication for retrograde cystography
Retrograde cystogram
300 to 400 cc of contrast is ingecteto the bladder and film is takin then another film post
evacuation is takin
In intraperitoneal perforation loop of bowel may be out line by the contrast
In extraperitoneal perforation the cotrast is limitted to immediate area surrounding the
bladder
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Treatment
Extraperitoneal
---->
Blader drainage with a urethral drainage for 2 weeks followed by
cystogram to conferm healing of perforation
Indication for surgical repair
1. a bone spike protruding to the bladder
2. associated rectal or vaginal perforation
Intraperitoneal ----> Usually required surgically to prevent complications from leakage of
urine to the peritoneal cavity