- Email: [email protected]
or Diverticula
THE. .JOURNAL OF lTnoLOGY
Vol. 84. No. 3, September 19(i0 Printed 1·n U.S.A..
MAKAGEMENT CW PENOSCIWTAL FISTULAS AKD/OR DIVERTICULA A. ESTI~ C0:\1ARR Frn111 the Spinal Cord Injury Service, Veterans 1tdministrati:on Hospital, Long Reach, Cal. and School of Medicine, College of Medical Evanuelists, Los Angeles, Cal.
Over tlw years many patients arrive at the Veterans Administration Spinal Cord Injury Center at Long Beach, California with suprapubic catheters. Often the reason for this type of drainage has been a urethral abscess or fistula at the penoscrotal junction. The purpose of this paper is to make a plea a) that const'rvative therapy be first attempted in these conditions, and b) that diversion of the urinary stream be used only as a last resort. The etiology, classification, incidence, distribution, symptoms and diagnosis have been presented in previous communications. vVe have shown that pathological changes of the urethra at the penoserotal site can occur not only when the patient is catheter-bound, but months and even years after the patient had been catheterfrcc. It is understandable that a diverticulum and/or fistula can occur even whrn the patient is catheter-free because a constriction at the distal urethra from a "condom-type receptacle" creates an increasPd hydrostatic pressure of the escaping urinr in an area previously damaged during the initial period \\'hen an intraurethral catheter was worn. INITL'lcL THEHAPY
The mere presence of a cliverticulum and/or fistula poses no indication for diversion. A severe abscess or phlegmon requires incision and drainage but not 1ieeessarily diversion. A small periurethral abscess at this site in a catheter-bound patient can be irrigatPd per urethram and its contents can be expressed periodically through thf' distal urethra by the patient or an attendant in the case of a quadripkgic. The introduction of a catheter is justified if a patient has a similar abscess but is catheter-free, and he is treated similarly. fn both patients the catheter aets as a wick. Admittedly, incision and drainage become necessary when the patient shows clinical signs of sepsis. Wlwn incisions are mack with an intraRead before the urological section at the annual meeting of the California Medical Association, February 24, 1960.
urethral catheter in situ, all pockets should be openPd without incising the urethra, i.e., avoid exposure of the cathrter. Usually the urethral opening of the abscess is small; large urethral defects are difficult to repair at a later elate after the acute infection has subsided. THERAPY OF UNCOMPLICATED
DIV~mTICULA
OH FIS'l'ULAS
Therapy of diverticula. At this center we have instructed our patients with clivertieula, whether or not catheter-free, to press out manually the contents of the sac whenever the bladder empties, be this by reflex contraction of the cletrusor or by extrinsic prrssurn. Only when the diverticulurn reaches such size as to beeome prone to recurrent abscess formation or to become generally unmanageable, clo WC' consider surgPIT vV C' have adopted this policy sincr wr observed that di vertieulectomy, without di vrrsion of the urinary strram, rrsults in fistulas at that site in a number of patients. Therapy of penosaotal fistulas. The sequential ordPr of thc•rapy in this group depends on whether or not the patient !ms a well balanced bladder. For the patient who has a wPll balanced (catlwtcr-frrr) bladder tlw following procedure is attempted. The patient is kept at bed-rest until the fistula is healed. He must be turned every 2 to 3 hours day and night to both sides and supine, but never prone, in order to prcv(;nt pressurn upon the urethra. No urinary receptacle must be attaehed to the penis, be it the "ronclom urinal" or a commercial urinal. Thr penis is surrounded with amplr absorbent material, such as abdominal pads, and a metal urinal is placed at the distal end of the penis to catch the stream from the external urethral nwatus. lVIuch of the urine will be collected in the pads especially from the fistula leakage in the early stage of treatment. A changr of pads is imperative as soon as the patient notices that they are wet; an attendant must supervise this care in a tetraplegic patient. The most difficult part of this procedure is to persuade the patient to remain in bed and change 490
MAXACF;MJ~XT OF PENOSCROTAL FISTULAS A'sfl/OH DIVEHTTCULA
pads; resistanc<, to this management is voiced by l'vr,ry pati<'nt. Howevl'l', as th<' first fow days pass and tlw patient notice,; more urine passing through tlw P,dernal urethral meatus rather thau through the fistula, his <:o-operntion increases. Obviously, this nwthod is unsatisfactory when tlw dd<·ct of the un·thra is of such size as to bare tlw catheter. Such a largl' defrct should be first dosed surgically with an intrnurethral catheter as a splint; if a small fistula still persists, the "pad-urinal" trnatnwnt is then attempted. The ]waling time, varies from 1 to ;3 weeks with this type of tr<'atm<'nt. Sevm patimts have stayed closed by this method; si:-.: had an upper motor neuron blaclclcr and mw had a lower motor neuron bladder. Om· of thC'se had a fistula 2 years in duration that requirc·cl an intrnmr,thrnl catheter lwc:ausP of tlw pmi\rne drainage, but lw liacl a well balanced bladder function of uppc•1· motor rn·uron typC'. Two weeks after starting the treatnwnt the outlook appeared dubious. Presuming that :such an old sinus tract may lw fibrntic and lined with epithelium, the tract was lightly <·lcctrnfulgurated. Then the patient was !'('Started 011 the, c·atlwter-free "paclnrinal" regimen and ;3 weeks later the fistula had c·ntirely clisappmred. l\Iilcl fulgurntion is stressr·d sufficient to crPate an acute inflammatory reaction; it must ne,·c•r kacl to an enlargement of the tract to such a ch•gree as to defy this type of eonservative ''pa
cision and drainage of an abseess, as described earlir,r. An occasional fistuh has closed spoutam·ously in the past in spite, of an intramethr:il <·atlwter. The contraindicatiorrn to diversion of the urinary stream are a,; follows: a) After !waling of the repaired site, :1 catheter has to be reinsertc•d into this recently repaired urcthrn in order close a perinml or suprnpubiC' sinus, depending on which type of diversion was usrcl. The intraurPthral catheter endangers thP newly area and a vicious cycle nm)· be started 1d1il'h may eventuate in t\\'o fistulas rather than tlw original mw; b) givc•n a sevr,rely hnieracti\'(' bladder, or a well balanced rdkx (uppn motor neuron) bladder, thl' irritation from the :mprn pubiC' catheter will cause urine to eseapP through the urethra and into the frrshly opern.tc-d pc·uuscrotal site (in spite of bladder relaxant~); c) suprnpuhie sca.rring betwPP!l the bladder donH· and abdominal layers in catheter-free pa.tiPnto umlcsirnble hPcause of the potc>ntial dang<'l' of n later phlegm on; cl) although initially :1 :mprapubiC' mtheter may muse hyperirritability Ill an upprr motor nruron bladder, it may nl~o oc <·asionall)· ea use, such bladder im balnm·c· a~ to lead to complek retention of mine; P) in spik of suprapubic catheter, patients 1\'ith lower motor bladders will still lose urine, per un·thnun in mam i nstarn·es. \\'e have frlt from the very cmset of 01ir· \\'OJ'k in this field that every effmt should be mad<' to create a C'athetrr-free (balanced) ~tatc- lwfon· attempting closun· of a fistula. Till' mPtl10d,; usf'cl to inclucc' bladcll'r balance at this c•c•nte·i havl' been presented in previous communi(';; tirms. If a cathc>ter-frep stat<~ can not bP surgical closure is performed without di vcrsiotl. Sueh attempts may lw rC'pcatl'cl up to thrc·e hnws and will eventually weeeed. In recent months, the anthor has lJC'l'frH'!Yl('d simple electro-incision of tlw vesical neck at (i o'doek upon om' group of catheter-bound JJ/1 tiPnts \\'hich has l'Xpeditcd retum of bladd1•r balance, ancl, thus, removal of the catlwtcr. Tl11' catheter-bound patients who may respond to this simple procedun• an' thos<· who originally became· catheter-free\ spontaneously (without ancl subs1•quently had bladckr regression for onr reason or another, i.e., penoscrotal changes, whicl1 requirc>d reinsertion of a catheter and subseqrn•nt bladder imbalance. 0l'casiona.ll)·, the elcetro
492
A. ESTIN COMARR
inc1s10n includes the interureteric ridge if this structure is elevated. This procedure has worked in both upper and lower motor neuron types of neurogenic bladders. One catheter-bound patient, who had originally become catheter-free by a transurethral resection and regressed, became catheter-free once again by an electro-incision. Only as a last resort is diversion considered. Most of the smaller penoscrotal fistulas will heal spontaneously once diversion is accomplished. Closure of the fistula after diversion will hasten the healing process. The technique of surgical closure of a penoscrotal diverticulum and/ or a fistula is basically identical, with or without divcrnion. The technique is as follows: After the area has been prepared in the usual manner a new catheter is introduced and taped to the abdominal wall in order to straighten the penoscrotal angle. An elliptical incision is made extending both into the skin of the shaft of the penis and scrotum. The divcrticulum or the fistulous tract is dissected down to the urethral plane. After resection of the diverticulum, sufficient mucosa should remain to cover the catheter without tension. A 32-gauge stainless steel wire is used submucosally as a pull-through stitch. The remaining dead space is closed by deep mattress-on-edge sutures using the same size of wire. Dleeding is stopped by electrofulguration. Admittedly, we revert occasionally to a catgut closure when bleeding cannot be controlled solely by electrofulguration. The use of plastic tubing as drscribed by Gibbon may eventually prove to be an excellent aid both prophylactically and theraprutically. -we have not had enough experirnee. with this catheter to assess its value. SUMMARY
A plea is made to attempt every means of conservative treatment rather than to divert the urinary stream at the first sign of pcnoscrotal changes. The patient is instructed in the manual and periodical expression of a cliverticulum. A cliverticulectomy is performed when a large size of the diverticulum makes management impossible. The treatment of the penoscrotal fistula de-
pends initially upon the bladder status, i.e., whether bladder function is balamed or imbalanced. Patients with a well balanced bladder arc trcatrd by a "pad-urinal regimen" without a catheter provided that the following conditions arc fulfilled: a) The diameter of the fistulous tract must be small; b) not the slightest compression must be present around the urethra distal to the fistula, such as results from wearing a "condom urinal," sitting in a wheel chair with trousers; lying in bed in the prone position, etc.; c:) bed rest is indicated up to 3 weeks. Those patients with a fistula and arc not catheter-free are first treated to attain freedom from the catheter along acl'eptrd lines. If a eatlwterfree state cannot be ac:hiPved, surgical closure without urinary diversion is attempted up to 3 times. Diversion is done only as a last resort inasmuch as spontanrous hraling occasionally ol'curs evpn in the presem·r of an intraurcthral catheter. The technique of surgil'al closure of the penoscrotal divrrticulum and/or fistula is identical whether or not diversion of the urinary strram !ms been donr. The method is described. REFERENCES BoRs, E.: Neurogenic bladder. Urol. Survey, 7: 177-250, 1957.
CoMARR, A. E.: The pract,ical urological management of the patient with spinal cord injury. Brit. J. Urol., 31: l-4G, 1959. CoMARR, A. E.: Various practical uses of the condom for management of the nemogenic blndder. J. Urol., 77: 835-839, 1957. CoMARR, A. E.: An adjunct in the management of penoscrotal abscess. J. Urol., 74: 818-SHl, 1955.
CoMARR, A. E. AND BoRs, E.: Pathological changes in the urethra of paraplegic patients. J. Urnl., 66: 355-36 l , 1951. CoMARR, A. E.: N onsmgical closure of urethral penoscrotal fistulae. J. Ind. Med. Prof., 6: 29-74, 1960.
PAULL, D. P.: A condom coupled minal for incontinence. J. Urol., 69: 462, 1953. PA'l'E, V. A., JR. AND BUNTS, R. C.: Urethral diverticula in paraplegics ..J. Urol., 65: 108125, 1951.
REI'l'E, A. AND CoMARR, A. E.: Complications of neurogenic bladder. J. Urol., 72: 41-44, 1954. Ross, J. C.: Treatment of the bladder in paraplegics. Brit. J. Urol., 28: 14-23, 1956. Ross, J.C., GIBBON, N. 0. K. AND DAMANSKr, N.: Recent developments in the treatment of the paraplegic bladder. Lancet, 2: ,520-524, 1957.
Vol. 84. No. 3, September 19(i0 Printed 1·n U.S.A..
MAKAGEMENT CW PENOSCIWTAL FISTULAS AKD/OR DIVERTICULA A. ESTI~ C0:\1ARR Frn111 the Spinal Cord Injury Service, Veterans 1tdministrati:on Hospital, Long Reach, Cal. and School of Medicine, College of Medical Evanuelists, Los Angeles, Cal.
Over tlw years many patients arrive at the Veterans Administration Spinal Cord Injury Center at Long Beach, California with suprapubic catheters. Often the reason for this type of drainage has been a urethral abscess or fistula at the penoscrotal junction. The purpose of this paper is to make a plea a) that const'rvative therapy be first attempted in these conditions, and b) that diversion of the urinary stream be used only as a last resort. The etiology, classification, incidence, distribution, symptoms and diagnosis have been presented in previous communications. vVe have shown that pathological changes of the urethra at the penoserotal site can occur not only when the patient is catheter-bound, but months and even years after the patient had been catheterfrcc. It is understandable that a diverticulum and/or fistula can occur even whrn the patient is catheter-free because a constriction at the distal urethra from a "condom-type receptacle" creates an increasPd hydrostatic pressure of the escaping urinr in an area previously damaged during the initial period \\'hen an intraurethral catheter was worn. INITL'lcL THEHAPY
The mere presence of a cliverticulum and/or fistula poses no indication for diversion. A severe abscess or phlegmon requires incision and drainage but not 1ieeessarily diversion. A small periurethral abscess at this site in a catheter-bound patient can be irrigatPd per urethram and its contents can be expressed periodically through thf' distal urethra by the patient or an attendant in the case of a quadripkgic. The introduction of a catheter is justified if a patient has a similar abscess but is catheter-free, and he is treated similarly. fn both patients the catheter aets as a wick. Admittedly, incision and drainage become necessary when the patient shows clinical signs of sepsis. Wlwn incisions are mack with an intraRead before the urological section at the annual meeting of the California Medical Association, February 24, 1960.
urethral catheter in situ, all pockets should be openPd without incising the urethra, i.e., avoid exposure of the cathrter. Usually the urethral opening of the abscess is small; large urethral defects are difficult to repair at a later elate after the acute infection has subsided. THERAPY OF UNCOMPLICATED
DIV~mTICULA
OH FIS'l'ULAS
Therapy of diverticula. At this center we have instructed our patients with clivertieula, whether or not catheter-free, to press out manually the contents of the sac whenever the bladder empties, be this by reflex contraction of the cletrusor or by extrinsic prrssurn. Only when the diverticulurn reaches such size as to beeome prone to recurrent abscess formation or to become generally unmanageable, clo WC' consider surgPIT vV C' have adopted this policy sincr wr observed that di vertieulectomy, without di vrrsion of the urinary strram, rrsults in fistulas at that site in a number of patients. Therapy of penosaotal fistulas. The sequential ordPr of thc•rapy in this group depends on whether or not the patient !ms a well balanced bladder. For the patient who has a wPll balanced (catlwtcr-frrr) bladder tlw following procedure is attempted. The patient is kept at bed-rest until the fistula is healed. He must be turned every 2 to 3 hours day and night to both sides and supine, but never prone, in order to prcv(;nt pressurn upon the urethra. No urinary receptacle must be attaehed to the penis, be it the "ronclom urinal" or a commercial urinal. Thr penis is surrounded with amplr absorbent material, such as abdominal pads, and a metal urinal is placed at the distal end of the penis to catch the stream from the external urethral nwatus. lVIuch of the urine will be collected in the pads especially from the fistula leakage in the early stage of treatment. A changr of pads is imperative as soon as the patient notices that they are wet; an attendant must supervise this care in a tetraplegic patient. The most difficult part of this procedure is to persuade the patient to remain in bed and change 490
MAXACF;MJ~XT OF PENOSCROTAL FISTULAS A'sfl/OH DIVEHTTCULA
pads; resistanc<, to this management is voiced by l'vr,ry pati<'nt. Howevl'l', as th<' first fow days pass and tlw patient notice,; more urine passing through tlw P,dernal urethral meatus rather thau through the fistula, his <:o-operntion increases. Obviously, this nwthod is unsatisfactory when tlw dd<·ct of the un·thra is of such size as to bare tlw catheter. Such a largl' defrct should be first dosed surgically with an intrnurethral catheter as a splint; if a small fistula still persists, the "pad-urinal" trnatnwnt is then attempted. The ]waling time, varies from 1 to ;3 weeks with this type of tr<'atm<'nt. Sevm patimts have stayed closed by this method; si:-.: had an upper motor neuron blaclclcr and mw had a lower motor neuron bladder. Om· of thC'se had a fistula 2 years in duration that requirc·cl an intrnmr,thrnl catheter lwc:ausP of tlw pmi\rne drainage, but lw liacl a well balanced bladder function of uppc•1· motor rn·uron typC'. Two weeks after starting the treatnwnt the outlook appeared dubious. Presuming that :such an old sinus tract may lw fibrntic and lined with epithelium, the tract was lightly <·lcctrnfulgurated. Then the patient was !'('Started 011 the, c·atlwter-free "paclnrinal" regimen and ;3 weeks later the fistula had c·ntirely clisappmred. l\Iilcl fulgurntion is stressr·d sufficient to crPate an acute inflammatory reaction; it must ne,·c•r kacl to an enlargement of the tract to such a ch•gree as to defy this type of eonservative ''pa
cision and drainage of an abseess, as described earlir,r. An occasional fistuh has closed spoutam·ously in the past in spite, of an intramethr:il <·atlwter. The contraindicatiorrn to diversion of the urinary stream are a,; follows: a) After !waling of the repaired site, :1 catheter has to be reinsertc•d into this recently repaired urcthrn in order close a perinml or suprnpubiC' sinus, depending on which type of diversion was usrcl. The intraurPthral catheter endangers thP newly area and a vicious cycle nm)· be started 1d1il'h may eventuate in t\\'o fistulas rather than tlw original mw; b) givc•n a sevr,rely hnieracti\'(' bladder, or a well balanced rdkx (uppn motor neuron) bladder, thl' irritation from the :mprn pubiC' catheter will cause urine to eseapP through the urethra and into the frrshly opern.tc-d pc·uuscrotal site (in spite of bladder relaxant~); c) suprnpuhie sca.rring betwPP!l the bladder donH· and abdominal layers in catheter-free pa.tiPnto umlcsirnble hPcause of the potc>ntial dang<'l' of n later phlegm on; cl) although initially :1 :mprapubiC' mtheter may muse hyperirritability Ill an upprr motor nruron bladder, it may nl~o oc <·asionall)· ea use, such bladder im balnm·c· a~ to lead to complek retention of mine; P) in spik of suprapubic catheter, patients 1\'ith lower motor bladders will still lose urine, per un·thnun in mam i nstarn·es. \\'e have frlt from the very cmset of 01ir· \\'OJ'k in this field that every effmt should be mad<' to create a C'athetrr-free (balanced) ~tatc- lwfon· attempting closun· of a fistula. Till' mPtl10d,; usf'cl to inclucc' bladcll'r balance at this c•c•nte·i havl' been presented in previous communi(';; tirms. If a cathc>ter-frep stat<~ can not bP surgical closure is performed without di vcrsiotl. Sueh attempts may lw rC'pcatl'cl up to thrc·e hnws and will eventually weeeed. In recent months, the anthor has lJC'l'frH'!Yl('d simple electro-incision of tlw vesical neck at (i o'doek upon om' group of catheter-bound JJ/1 tiPnts \\'hich has l'Xpeditcd retum of bladd1•r balance, ancl, thus, removal of the catlwtcr. Tl11' catheter-bound patients who may respond to this simple procedun• an' thos<· who originally became· catheter-free\ spontaneously (without ancl subs1•quently had bladckr regression for onr reason or another, i.e., penoscrotal changes, whicl1 requirc>d reinsertion of a catheter and subseqrn•nt bladder imbalance. 0l'casiona.ll)·, the elcetro
492
A. ESTIN COMARR
inc1s10n includes the interureteric ridge if this structure is elevated. This procedure has worked in both upper and lower motor neuron types of neurogenic bladders. One catheter-bound patient, who had originally become catheter-free by a transurethral resection and regressed, became catheter-free once again by an electro-incision. Only as a last resort is diversion considered. Most of the smaller penoscrotal fistulas will heal spontaneously once diversion is accomplished. Closure of the fistula after diversion will hasten the healing process. The technique of surgical closure of a penoscrotal diverticulum and/ or a fistula is basically identical, with or without divcrnion. The technique is as follows: After the area has been prepared in the usual manner a new catheter is introduced and taped to the abdominal wall in order to straighten the penoscrotal angle. An elliptical incision is made extending both into the skin of the shaft of the penis and scrotum. The divcrticulum or the fistulous tract is dissected down to the urethral plane. After resection of the diverticulum, sufficient mucosa should remain to cover the catheter without tension. A 32-gauge stainless steel wire is used submucosally as a pull-through stitch. The remaining dead space is closed by deep mattress-on-edge sutures using the same size of wire. Dleeding is stopped by electrofulguration. Admittedly, we revert occasionally to a catgut closure when bleeding cannot be controlled solely by electrofulguration. The use of plastic tubing as drscribed by Gibbon may eventually prove to be an excellent aid both prophylactically and theraprutically. -we have not had enough experirnee. with this catheter to assess its value. SUMMARY
A plea is made to attempt every means of conservative treatment rather than to divert the urinary stream at the first sign of pcnoscrotal changes. The patient is instructed in the manual and periodical expression of a cliverticulum. A cliverticulectomy is performed when a large size of the diverticulum makes management impossible. The treatment of the penoscrotal fistula de-
pends initially upon the bladder status, i.e., whether bladder function is balamed or imbalanced. Patients with a well balanced bladder arc trcatrd by a "pad-urinal regimen" without a catheter provided that the following conditions arc fulfilled: a) The diameter of the fistulous tract must be small; b) not the slightest compression must be present around the urethra distal to the fistula, such as results from wearing a "condom urinal," sitting in a wheel chair with trousers; lying in bed in the prone position, etc.; c:) bed rest is indicated up to 3 weeks. Those patients with a fistula and arc not catheter-free are first treated to attain freedom from the catheter along acl'eptrd lines. If a eatlwterfree state cannot be ac:hiPved, surgical closure without urinary diversion is attempted up to 3 times. Diversion is done only as a last resort inasmuch as spontanrous hraling occasionally ol'curs evpn in the presem·r of an intraurcthral catheter. The technique of surgil'al closure of the penoscrotal divrrticulum and/or fistula is identical whether or not diversion of the urinary strram !ms been donr. The method is described. REFERENCES BoRs, E.: Neurogenic bladder. Urol. Survey, 7: 177-250, 1957.
CoMARR, A. E.: The pract,ical urological management of the patient with spinal cord injury. Brit. J. Urol., 31: l-4G, 1959. CoMARR, A. E.: Various practical uses of the condom for management of the nemogenic blndder. J. Urol., 77: 835-839, 1957. CoMARR, A. E.: An adjunct in the management of penoscrotal abscess. J. Urol., 74: 818-SHl, 1955.
CoMARR, A. E. AND BoRs, E.: Pathological changes in the urethra of paraplegic patients. J. Urnl., 66: 355-36 l , 1951. CoMARR, A. E.: N onsmgical closure of urethral penoscrotal fistulae. J. Ind. Med. Prof., 6: 29-74, 1960.
PAULL, D. P.: A condom coupled minal for incontinence. J. Urol., 69: 462, 1953. PA'l'E, V. A., JR. AND BUNTS, R. C.: Urethral diverticula in paraplegics ..J. Urol., 65: 108125, 1951.
REI'l'E, A. AND CoMARR, A. E.: Complications of neurogenic bladder. J. Urol., 72: 41-44, 1954. Ross, J. C.: Treatment of the bladder in paraplegics. Brit. J. Urol., 28: 14-23, 1956. Ross, J.C., GIBBON, N. 0. K. AND DAMANSKr, N.: Recent developments in the treatment of the paraplegic bladder. Lancet, 2: ,520-524, 1957.