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Urethral Rupture: Early and Late Posterior Complications
THE JOURNAL OF UROLOGY
Vol. 68, No. 2, August 1952 Printed in U.S.A.
URETHRAL RUPTGRE: EARLY AND LATE POSTERIOR COMPLICATIONS STANFORD W. MULHOLLAND
AND
HARRY M. MADONNA
Crushing injuries of the pelvis and resulting laceration of the urethra and bladder are not uncommon. The most common urethral injury is a laceration ·which almost always takes place at the apex of the prostate. Trauma to the urethra, other than by instrumentation, is frequently treated by the general practitioner. In most cases he sees the patients first, in the hospitals of smaller communities where the accidents occur. He may carry them along without consultation until the problems become complicated. There are three situations that may result: The first is the case where rupture of the urethra is operated upon immediately and a generous catheter is passed. The urethra is allowed to heal around it and no stricture is likely to form. The second is the unrecognized or improperly treated rupture of the urethra in which stricture will form and subsequent treatment ·will be necessary. It is noteworthy that these strictures are very firm and intensely resistant to local treatment (dilation by sounds). Lastly, where primary suture at the time of the injury is impossible due to the extensive fracture of the pelvis. Suprapubic drainage may relieve the situation for a time but severe stricture inevitably results even though a catheter has been used as a splint for the urethra. Perinea! dissection done months later in an attempt to free the prostate, excise the stricture and suture the urethra, is not only difficult but very unsatisfactory. This discussion is primarily concerned ·with the diagnosis and early treatment of rupture of the urethra, but suggests a method of dealing with the scar tissue occuring as a late complication. This scar has been successfully excised by use of the resectoscope guided under vision through the irregular urethra, straightening it and giving it adequate caliber for the free passage of the urinary stream. No interference with continence has resulted. No matter when or by whom the cases are seen, traumatic injury to the urethra presents a varying problem to the urologist. In this day of industrialization, rupture of the urethra, while not common, does occur frequently enough for us to stop and review our present concepts as to proper treatment and to discuss new measures that might add to our skill in caring for these unfortunate individuals. Much knowledge regarding care was acquired due to the casualities seen in VV orld War II. JVIany more cases of severe traumatic injury were seen, treated and evaluated than could be studied in normal peace times. Hinman has classified injury to the urethra according to location: 1) pendulous portion; 2) bulbous portion, anterior to triangular ligament; 3) bulbomembraneous portion, anterior to triangular ligament; 4) membranoprostatic portion, at or posterior to triangular ligament. Read at annual meeting, Mid-Atlantic Section, American Urological Association, April 13, 195L
489
490
STANFORD W. MULHOLLAND AND HARRY M. MADONNA
We can divide injury to the urethra simply as being above or below the triangular ligament. Kimbrough reported a series of 235 casualties involving genito-urinary injury in the European theater of operation in World War II. CASES
Kidney Ureter Bladder External genitalia
33 8
34 160
PER CENT
14 3.4 14.5 68.1
The largest number of injuries occurred in the external genitalia, most of which had accompanying urethral damage. Culp reported 160 cases of wounds of the genito-urinary tract of which 26 or 16.2 per cent were urethral. Fracture of the pelvis was not uncommon with involvement of the bladder. Fracture was the most common complication of urethral injury. Of the 26 injuries to the urethra, 20 -Yvere confined to the portion below the urogenital diaphragm. This finding though true in war injuries, does not usually follow in civilian practice. The injury to the urethra which gives the most disability if not managed properly, is that of complete rupture or partial rupture with fragments of bone tearing the urethra at the apex of the prostate. If one considers the anatomical relations, viz., the fixation at the urogenital diaphragm, it seems obvious why the rupture should occur at this point. Most occur as a result of fracture of the pelvis or subluxation of the symphysis. Lateral compression of the pelvis supposedly causes rupture of the urethra by direct trauma from a bone fragment. Anteroposterior compression may cause separation of the symphysis with resultant tearing or stretching of the urethra. As one might suspect, trauma to the urethra has as its cardinal symptom, bleeding from the external urethral meatus. This sign seems more likely in injury to the urethra anterior to the urogenital diaphragm. This is true because of the accompanying injury to the corpus spongiosum, a spongy vascular structure. The amount of bleeding has no relation to the extent of the injury. Only a minimal amount of bleeding may mean an extensive injury with separation of the urethra while profuse bleeding might be caused only from a laceration that has not penetrated into the deeper structures and thus does not allow extravasation of blood into the tissues, but causes it to flow freely from the external meatus. Acute urinary retention is far more common than urinary extravasation. The urethral injury perhaps sets up reflex spasm of the vesical sphincter and the patient is unable to void. The patient with crushing injury to the pelvis who has a desire to urinate but is unable to do so, is almost certain to have a rupture of the urethra rather than a rupture of the bladder. Extravasation of urine usually occurs only ·when the bladder if unrelieved, finally overflows. The treatment of urethral injuries should be carried out as early as is practicable. Early treatment should be directed toward control of hemorrhage, shock, diversion of the urinary stream and conservation of tissue. lVIost of us agree with Uhle and Erb who regard rupture of the urethra as a surgical emergency that should have open repair as soon as possible. Generally speaking, this will be necessary in all suspected injuries to the posterior urethra owing to the high incidence of complete rupture. Even though there is incomplete rupture, the
URETHRAL RUPTURE
491
-conservative removal of damaged tissue along with evacuation of the hematoma will reduce the risk of fibrosis and liability to stricture formation. Diversion of the urinary stream by suprapubic cystostomy is as important as the initial care -of the injured area. Catheterization of the urethra from within the bladder is helpful in the urethral reconstruction. Millin has shown that two or three sutures placed by the retropubic approach, will hold the prostate in position adjacent to the urogenital diaphragm, thus promoting primary healing of the urethra without scar formation. In general, the passage of a urethral catheter should not be attempted unless facilities for operation are present. Vermooten can see no need for attempting catheterization. He relies on rectal palpation in locating the prostate to determine whether it is elevated and freed from its normal position and a boggy mass substituted in its place. Even if the prostate can be palpated and found not fixed and able to be pushed upward, this would indicate it has been severed from its attachment to the membranous urethra. If the passage of a catheter is attempted and it fails to reach the bladder, one has no way to be sure that this is not due to an old urethral stricture, spasm of the vesical sphincter or passage of the catheter through an opening in the urethra out into the peri-urethral tissues. A catheter may pass into the perivesical space and allow the return of bloody fluid. This does not necessarily mean the catheter is in the bladder. Urethrograms can be done early and are a part of the routine in some clinics. Others consider their use a definite loss of valuable time. Urinary extravasation demands immediate radical incision and drainage with adequate diversion of the urinary stream. Delayed treatment increases morbidity and mortality. If treated within twelve hours, the mortality is usually below 20 per cent; after that time it increases rapidly. If it is agreed that the optimal tin1e for reconstructing the urethra is at the time of the original operation, what measures of closure are used? 1) purse string closure of tears; 2) linear repair; 3) end to end anastomosis over an inlying catheter; 4) traction employing a Foley catheter to pull the apex of prostate down toward the distal urethra (Vermooten-Martin, Reynolds); 5) retropubic suture of the apex of prostate to the membranous urethra (Millin). Delzell and Stevens showed that a gap in the urethra three-quarters of an inch in length would spontaneously regenerate over an inlying catheter. Culver bridged a two inch gap simply by use of an inlying catheter. DeNicola recently reported the use of a silicone tube, making a permanent replacement of the posterior urethra. It is probable polythene or polyvinyl tubing could be made to serve the same purpose. This might be compared to the operation reported by MacLean and Gerrie with the use of a split thickness skin graft over an inlying catheter to form a new urethra. Stilbestrol 1 mg. four times daily may be used to reduce postoperative erection until the skin sutures are ready for removal. The urethral catheter is usually not removed for 3 weeks. Sounds should be used cautiously and should progress up to 28F after removal of the urethral catheter. The advent of newer chemotherapeutic and antibiotic agents has greatly
492
STANFORD W. MULHOLLAND AND HARRY M. MADONNA
helped combat infection which previously doomed good surgical procedures to failure or delayed sound and rapid healing. Unoperated cases frequently develop scar tissue which completely occludes the urethra. The following 2 cases are examples. The details of their care and results are reviewed. CASE REPORTS
Case 1. A man aged 26 was admitted to the hospital June 8, 1950. He complained of marked strangury and the passage of only a few drops of urine for 48 hours. Eleven weeks previously, he had sustained a fracture of the pelvis with associated injury to the urethra, as evidenced by an inability to void and bleeding from the meatus. A No. 20 Foley catheter had been passed to the bladder and was left in place for 5 weeks, while bed rest was needed for fracture of the pelvis. At the end of that time the catheter drained so poorly that it was removed.No attempt was made to replace it. Voiding was accomplished by straining. It was characterized by a small stream and dribbling. Three weeks before admission, increasing stranguria was noted plus a bearing down sensation in the region of the rectum. Forty-eight hours previously, acute urinary retention developed. Multiple attempts at catheterization and the passage of sounds were made. Some attempts were carried out under general anesthesia. Failing to enter the bladder, his physician asked for consultation. The patient dribbled enough urine to give him some relief while on the way to the hospital. Examination: The patient was pale and emaciated. Definite suprapubic tenderness and right lower quadrant tenderness were elicited. Spasm of the right psoas muscle caused the right thigh to be partially flexed. The external urethral meatus was traumatized and the edges were edematous. Marked induration along the penile urethra with a definite urethritis accompanied by a yellowishwhite urethral discharge was noted. There was marked tenderness on palpation over the right ischium. Rectal examination showed the prostate to be small and far anterior. No masses or tenderness per rectum were noted. The past medical history and systemic review were negative. Laboratory studies: Hemoglobin~l3 gm., red blood cells 4,300,000, white blood cells 13,500. Urinalysis showed numerous red blood cells and pus cells. Urine culture showed E. coli. A urethrogram (fig. 1) showed that the posterior urethra was tortuous and occluded near the apex of the prostate. There were three sinus tracts, one extending ventrally toward the symphysis and 2 inches in length and clubbed at its extremity. Two smaller tracts were seen leaving the urethra on each side of what appeared to be the main channel. A small amount of medium appeared to escape into the bladder through two small pin point openings well above the expected site of the internal urethral orifice. Attempts made to pass filiform guides into the urethra were of no avail. Antibiotics were administered. On June 21, 1950, suprapubic cystostomy with exploration of the bladder neck
493
URETHRAL R1~YrUR!;
was carried out. On examination, the internal urethral meatus appeared normal but upon probing the prostatic urethra, one met a definite impassable curtain of fibrous tissue. Above the internal meatus, two small dimples were noted that proved to be the openings of sinuses into the periprostatic tissues. Pressure on these tissues caused serosanguinous fluid to escape from the dimpled areas into the bladder. A No. 24 VanBuren sound ·was introduced into the distal urethra. Upon encountering the curtain of tissue at the apex of the prostate, it was forced through or around the scar tissue and allowed to emerge through the internal urethral orifice. This new channel was thoroughly dilated. A Ko. 24 Foley catheter was drawn into the bladder. A silk thread was attached to the tip of the Foley catheter and the thread led out of the suprapubic wound, lea ting it}oiled on the abdomen as the bladder ,vas closed around a No. 24 drainage tube.
FIG. 1
FIG. 2
On July 19, 1950, the urethral catheter was drawn out of the urethra pulling the accompanying silk thread. The thread was attached to the distal end of a resectoscope which was guided by means of this thread into the bladder. Two areas of obstruction were noted (fig. 2). At the bladder neck there was a pocket beneath the bladder floor. This was covered by a flap of mucosa that could produce obstruction. The pocket was unroofed making the internal urethral orifice rather wide. The verumontanum was identified. Distal to the verumontanum, the point where the urethra had been separated at the apex of the prostate was visualized. The distal urethra could be seen ending in a blind pocket ventral and to the right of the new channel. Resection of some of the scar tissue was carried out. The catheter was replaced. The suprapubic wound healed promptly. The catheter was removed in 10 days. The patient was dismissed from the hospital voiding fairly well. He was seen at weekly intervals during the next three months. Although he was voiding, the stream was not free and sounds were passed with difficulty. ~ ovember 16, 1950, the patient was re-admitted to the hospital and evaluation with the resectoscope was carried out. The bladder neck had healed well. However, the dense scar tissue at the apex of the prostate was firm and distorted the
494
STANFORD W. MULHOLLAND AND HARRY M. MADONNA
contour of the urethra (fig. 3, A). The blind pocket at the distal urethra was: still noted to be quite evident. Ten or twelve pieces of tissue were removed from the thick scar. Sounds were then found to pass easily and freedom of manipulation of the resectoscope was accomplished (fig. 3, B). The patient has continued to void easily with an excellent stream. Sounds to 28F pass with no evidence of the dense scar tissue being present to obstruct. their passage.
Fm. 3
Case .re. A man aged 24 was admitted to the hospital June 10, 1945 with a history of acute urinary retention for 24 hours. He gave a history of having been thrown from an automobile (Jeep) while in the Army and sustaining a fracture of the pelvis. His urethra was treated by catheter splint for 3 weeks. After the pelvic lesions healed, he was dismissed from the hospital and soon discharged from the Service. Three months later acute urinary retention developed. Examination showed a well developed and nourished adult male. The bladder was distended to the umbilicus; the prostate was normal size. Laboratory studies were within normal limits. The patient was taken to the operating room. Filiform guides were passed through a tortuous, scarred urethra. The urethra was dilated to admit a No. 24 resectoscope. A dense scar of the urethra at the apex of the prostate was noted, where it distorted and angulated the urethra at this point. This hard, firm tissue was removed. Sounds were passed freely following this procedure. The patient has continued to void freely and the urine has remained crystal clear.
URETHRAL RUPTURE
495
SUMMARY
The common complication of dense stricture formation with rupture of the urethra is discussed. The severity of the initial injury is often an unreliable sign as to the degree of trauma since intractable strictures often occur where the initial signs are suggestive of only mild injury. A definite fracture in the pubic region, often crushing injuries, lends support to the presumption of posterior urethral injury. Decision must be made then whether immediate exploration is advisable. In most cases it is wise. The prevention of serious complications with urethral rupture is greatly dependent on early diagnosis and efficient treatment. The late complications result from infection and fibrosis and often are serious enough to produce complete and fairly sudden urinary retention. Late urethral repairs mean increased morbidity and difficult surgery. The resectoscope has been used successfully to remove the dense scar tissue of these strictures. We believe it can be used often in others where this complication has been allowed to occur. In spite of the fact that the resection of the scar tissue was carried out at the apex of the prostate, no incontinence resulted.
Parkway House, Philadelphia 30, Pa. REFERENCES CuLP, 0. S.: J. Urol., 57: 1117, 1947. DELZELL, W.R. AND STEVENS, A. R.: J. Urol., 34: 372-383, 1935. DENICOLA, R. R.: J. Urol., 63: 168, 1950. HINMAN, F.: Principles and Practice of Urology. Philadelphia: W. B. Saunders Co., 1935. KIMBROUGH, J. s.: J. Urol., 57: 1105, 1947. MACLEAN, J. R. AND GERRIE, J. W.: J. Urol., 56: 485, 1946. MARTIN, P.: Lancet, 1: 743, 1947. REYNOLDS, C. J.: South. Med. J., 35: 825, 1942. UHLE, C. A. W. AND ERB, H. R.: J. Urol., 52: 42-66, 1944. VERMOOTEN, V.: J. Urol., 56: 228, 1946. VERMOOTEN, V.: J. Oklahoma State Med. Assoc., 41: 376, 1948.
Vol. 68, No. 2, August 1952 Printed in U.S.A.
URETHRAL RUPTGRE: EARLY AND LATE POSTERIOR COMPLICATIONS STANFORD W. MULHOLLAND
AND
HARRY M. MADONNA
Crushing injuries of the pelvis and resulting laceration of the urethra and bladder are not uncommon. The most common urethral injury is a laceration ·which almost always takes place at the apex of the prostate. Trauma to the urethra, other than by instrumentation, is frequently treated by the general practitioner. In most cases he sees the patients first, in the hospitals of smaller communities where the accidents occur. He may carry them along without consultation until the problems become complicated. There are three situations that may result: The first is the case where rupture of the urethra is operated upon immediately and a generous catheter is passed. The urethra is allowed to heal around it and no stricture is likely to form. The second is the unrecognized or improperly treated rupture of the urethra in which stricture will form and subsequent treatment ·will be necessary. It is noteworthy that these strictures are very firm and intensely resistant to local treatment (dilation by sounds). Lastly, where primary suture at the time of the injury is impossible due to the extensive fracture of the pelvis. Suprapubic drainage may relieve the situation for a time but severe stricture inevitably results even though a catheter has been used as a splint for the urethra. Perinea! dissection done months later in an attempt to free the prostate, excise the stricture and suture the urethra, is not only difficult but very unsatisfactory. This discussion is primarily concerned ·with the diagnosis and early treatment of rupture of the urethra, but suggests a method of dealing with the scar tissue occuring as a late complication. This scar has been successfully excised by use of the resectoscope guided under vision through the irregular urethra, straightening it and giving it adequate caliber for the free passage of the urinary stream. No interference with continence has resulted. No matter when or by whom the cases are seen, traumatic injury to the urethra presents a varying problem to the urologist. In this day of industrialization, rupture of the urethra, while not common, does occur frequently enough for us to stop and review our present concepts as to proper treatment and to discuss new measures that might add to our skill in caring for these unfortunate individuals. Much knowledge regarding care was acquired due to the casualities seen in VV orld War II. JVIany more cases of severe traumatic injury were seen, treated and evaluated than could be studied in normal peace times. Hinman has classified injury to the urethra according to location: 1) pendulous portion; 2) bulbous portion, anterior to triangular ligament; 3) bulbomembraneous portion, anterior to triangular ligament; 4) membranoprostatic portion, at or posterior to triangular ligament. Read at annual meeting, Mid-Atlantic Section, American Urological Association, April 13, 195L
489
490
STANFORD W. MULHOLLAND AND HARRY M. MADONNA
We can divide injury to the urethra simply as being above or below the triangular ligament. Kimbrough reported a series of 235 casualties involving genito-urinary injury in the European theater of operation in World War II. CASES
Kidney Ureter Bladder External genitalia
33 8
34 160
PER CENT
14 3.4 14.5 68.1
The largest number of injuries occurred in the external genitalia, most of which had accompanying urethral damage. Culp reported 160 cases of wounds of the genito-urinary tract of which 26 or 16.2 per cent were urethral. Fracture of the pelvis was not uncommon with involvement of the bladder. Fracture was the most common complication of urethral injury. Of the 26 injuries to the urethra, 20 -Yvere confined to the portion below the urogenital diaphragm. This finding though true in war injuries, does not usually follow in civilian practice. The injury to the urethra which gives the most disability if not managed properly, is that of complete rupture or partial rupture with fragments of bone tearing the urethra at the apex of the prostate. If one considers the anatomical relations, viz., the fixation at the urogenital diaphragm, it seems obvious why the rupture should occur at this point. Most occur as a result of fracture of the pelvis or subluxation of the symphysis. Lateral compression of the pelvis supposedly causes rupture of the urethra by direct trauma from a bone fragment. Anteroposterior compression may cause separation of the symphysis with resultant tearing or stretching of the urethra. As one might suspect, trauma to the urethra has as its cardinal symptom, bleeding from the external urethral meatus. This sign seems more likely in injury to the urethra anterior to the urogenital diaphragm. This is true because of the accompanying injury to the corpus spongiosum, a spongy vascular structure. The amount of bleeding has no relation to the extent of the injury. Only a minimal amount of bleeding may mean an extensive injury with separation of the urethra while profuse bleeding might be caused only from a laceration that has not penetrated into the deeper structures and thus does not allow extravasation of blood into the tissues, but causes it to flow freely from the external meatus. Acute urinary retention is far more common than urinary extravasation. The urethral injury perhaps sets up reflex spasm of the vesical sphincter and the patient is unable to void. The patient with crushing injury to the pelvis who has a desire to urinate but is unable to do so, is almost certain to have a rupture of the urethra rather than a rupture of the bladder. Extravasation of urine usually occurs only ·when the bladder if unrelieved, finally overflows. The treatment of urethral injuries should be carried out as early as is practicable. Early treatment should be directed toward control of hemorrhage, shock, diversion of the urinary stream and conservation of tissue. lVIost of us agree with Uhle and Erb who regard rupture of the urethra as a surgical emergency that should have open repair as soon as possible. Generally speaking, this will be necessary in all suspected injuries to the posterior urethra owing to the high incidence of complete rupture. Even though there is incomplete rupture, the
URETHRAL RUPTURE
491
-conservative removal of damaged tissue along with evacuation of the hematoma will reduce the risk of fibrosis and liability to stricture formation. Diversion of the urinary stream by suprapubic cystostomy is as important as the initial care -of the injured area. Catheterization of the urethra from within the bladder is helpful in the urethral reconstruction. Millin has shown that two or three sutures placed by the retropubic approach, will hold the prostate in position adjacent to the urogenital diaphragm, thus promoting primary healing of the urethra without scar formation. In general, the passage of a urethral catheter should not be attempted unless facilities for operation are present. Vermooten can see no need for attempting catheterization. He relies on rectal palpation in locating the prostate to determine whether it is elevated and freed from its normal position and a boggy mass substituted in its place. Even if the prostate can be palpated and found not fixed and able to be pushed upward, this would indicate it has been severed from its attachment to the membranous urethra. If the passage of a catheter is attempted and it fails to reach the bladder, one has no way to be sure that this is not due to an old urethral stricture, spasm of the vesical sphincter or passage of the catheter through an opening in the urethra out into the peri-urethral tissues. A catheter may pass into the perivesical space and allow the return of bloody fluid. This does not necessarily mean the catheter is in the bladder. Urethrograms can be done early and are a part of the routine in some clinics. Others consider their use a definite loss of valuable time. Urinary extravasation demands immediate radical incision and drainage with adequate diversion of the urinary stream. Delayed treatment increases morbidity and mortality. If treated within twelve hours, the mortality is usually below 20 per cent; after that time it increases rapidly. If it is agreed that the optimal tin1e for reconstructing the urethra is at the time of the original operation, what measures of closure are used? 1) purse string closure of tears; 2) linear repair; 3) end to end anastomosis over an inlying catheter; 4) traction employing a Foley catheter to pull the apex of prostate down toward the distal urethra (Vermooten-Martin, Reynolds); 5) retropubic suture of the apex of prostate to the membranous urethra (Millin). Delzell and Stevens showed that a gap in the urethra three-quarters of an inch in length would spontaneously regenerate over an inlying catheter. Culver bridged a two inch gap simply by use of an inlying catheter. DeNicola recently reported the use of a silicone tube, making a permanent replacement of the posterior urethra. It is probable polythene or polyvinyl tubing could be made to serve the same purpose. This might be compared to the operation reported by MacLean and Gerrie with the use of a split thickness skin graft over an inlying catheter to form a new urethra. Stilbestrol 1 mg. four times daily may be used to reduce postoperative erection until the skin sutures are ready for removal. The urethral catheter is usually not removed for 3 weeks. Sounds should be used cautiously and should progress up to 28F after removal of the urethral catheter. The advent of newer chemotherapeutic and antibiotic agents has greatly
492
STANFORD W. MULHOLLAND AND HARRY M. MADONNA
helped combat infection which previously doomed good surgical procedures to failure or delayed sound and rapid healing. Unoperated cases frequently develop scar tissue which completely occludes the urethra. The following 2 cases are examples. The details of their care and results are reviewed. CASE REPORTS
Case 1. A man aged 26 was admitted to the hospital June 8, 1950. He complained of marked strangury and the passage of only a few drops of urine for 48 hours. Eleven weeks previously, he had sustained a fracture of the pelvis with associated injury to the urethra, as evidenced by an inability to void and bleeding from the meatus. A No. 20 Foley catheter had been passed to the bladder and was left in place for 5 weeks, while bed rest was needed for fracture of the pelvis. At the end of that time the catheter drained so poorly that it was removed.No attempt was made to replace it. Voiding was accomplished by straining. It was characterized by a small stream and dribbling. Three weeks before admission, increasing stranguria was noted plus a bearing down sensation in the region of the rectum. Forty-eight hours previously, acute urinary retention developed. Multiple attempts at catheterization and the passage of sounds were made. Some attempts were carried out under general anesthesia. Failing to enter the bladder, his physician asked for consultation. The patient dribbled enough urine to give him some relief while on the way to the hospital. Examination: The patient was pale and emaciated. Definite suprapubic tenderness and right lower quadrant tenderness were elicited. Spasm of the right psoas muscle caused the right thigh to be partially flexed. The external urethral meatus was traumatized and the edges were edematous. Marked induration along the penile urethra with a definite urethritis accompanied by a yellowishwhite urethral discharge was noted. There was marked tenderness on palpation over the right ischium. Rectal examination showed the prostate to be small and far anterior. No masses or tenderness per rectum were noted. The past medical history and systemic review were negative. Laboratory studies: Hemoglobin~l3 gm., red blood cells 4,300,000, white blood cells 13,500. Urinalysis showed numerous red blood cells and pus cells. Urine culture showed E. coli. A urethrogram (fig. 1) showed that the posterior urethra was tortuous and occluded near the apex of the prostate. There were three sinus tracts, one extending ventrally toward the symphysis and 2 inches in length and clubbed at its extremity. Two smaller tracts were seen leaving the urethra on each side of what appeared to be the main channel. A small amount of medium appeared to escape into the bladder through two small pin point openings well above the expected site of the internal urethral orifice. Attempts made to pass filiform guides into the urethra were of no avail. Antibiotics were administered. On June 21, 1950, suprapubic cystostomy with exploration of the bladder neck
493
URETHRAL R1~YrUR!;
was carried out. On examination, the internal urethral meatus appeared normal but upon probing the prostatic urethra, one met a definite impassable curtain of fibrous tissue. Above the internal meatus, two small dimples were noted that proved to be the openings of sinuses into the periprostatic tissues. Pressure on these tissues caused serosanguinous fluid to escape from the dimpled areas into the bladder. A No. 24 VanBuren sound ·was introduced into the distal urethra. Upon encountering the curtain of tissue at the apex of the prostate, it was forced through or around the scar tissue and allowed to emerge through the internal urethral orifice. This new channel was thoroughly dilated. A Ko. 24 Foley catheter was drawn into the bladder. A silk thread was attached to the tip of the Foley catheter and the thread led out of the suprapubic wound, lea ting it}oiled on the abdomen as the bladder ,vas closed around a No. 24 drainage tube.
FIG. 1
FIG. 2
On July 19, 1950, the urethral catheter was drawn out of the urethra pulling the accompanying silk thread. The thread was attached to the distal end of a resectoscope which was guided by means of this thread into the bladder. Two areas of obstruction were noted (fig. 2). At the bladder neck there was a pocket beneath the bladder floor. This was covered by a flap of mucosa that could produce obstruction. The pocket was unroofed making the internal urethral orifice rather wide. The verumontanum was identified. Distal to the verumontanum, the point where the urethra had been separated at the apex of the prostate was visualized. The distal urethra could be seen ending in a blind pocket ventral and to the right of the new channel. Resection of some of the scar tissue was carried out. The catheter was replaced. The suprapubic wound healed promptly. The catheter was removed in 10 days. The patient was dismissed from the hospital voiding fairly well. He was seen at weekly intervals during the next three months. Although he was voiding, the stream was not free and sounds were passed with difficulty. ~ ovember 16, 1950, the patient was re-admitted to the hospital and evaluation with the resectoscope was carried out. The bladder neck had healed well. However, the dense scar tissue at the apex of the prostate was firm and distorted the
494
STANFORD W. MULHOLLAND AND HARRY M. MADONNA
contour of the urethra (fig. 3, A). The blind pocket at the distal urethra was: still noted to be quite evident. Ten or twelve pieces of tissue were removed from the thick scar. Sounds were then found to pass easily and freedom of manipulation of the resectoscope was accomplished (fig. 3, B). The patient has continued to void easily with an excellent stream. Sounds to 28F pass with no evidence of the dense scar tissue being present to obstruct. their passage.
Fm. 3
Case .re. A man aged 24 was admitted to the hospital June 10, 1945 with a history of acute urinary retention for 24 hours. He gave a history of having been thrown from an automobile (Jeep) while in the Army and sustaining a fracture of the pelvis. His urethra was treated by catheter splint for 3 weeks. After the pelvic lesions healed, he was dismissed from the hospital and soon discharged from the Service. Three months later acute urinary retention developed. Examination showed a well developed and nourished adult male. The bladder was distended to the umbilicus; the prostate was normal size. Laboratory studies were within normal limits. The patient was taken to the operating room. Filiform guides were passed through a tortuous, scarred urethra. The urethra was dilated to admit a No. 24 resectoscope. A dense scar of the urethra at the apex of the prostate was noted, where it distorted and angulated the urethra at this point. This hard, firm tissue was removed. Sounds were passed freely following this procedure. The patient has continued to void freely and the urine has remained crystal clear.
URETHRAL RUPTURE
495
SUMMARY
The common complication of dense stricture formation with rupture of the urethra is discussed. The severity of the initial injury is often an unreliable sign as to the degree of trauma since intractable strictures often occur where the initial signs are suggestive of only mild injury. A definite fracture in the pubic region, often crushing injuries, lends support to the presumption of posterior urethral injury. Decision must be made then whether immediate exploration is advisable. In most cases it is wise. The prevention of serious complications with urethral rupture is greatly dependent on early diagnosis and efficient treatment. The late complications result from infection and fibrosis and often are serious enough to produce complete and fairly sudden urinary retention. Late urethral repairs mean increased morbidity and difficult surgery. The resectoscope has been used successfully to remove the dense scar tissue of these strictures. We believe it can be used often in others where this complication has been allowed to occur. In spite of the fact that the resection of the scar tissue was carried out at the apex of the prostate, no incontinence resulted.
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