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Traumatic surgery
TRAUMATIC SURGERY DISEASES OF THE GENITOURINARY
TRACT
E. KING MORGAN, M.D. Associate Attending Urologist, Long Island CoIIege HospitaI BROOKLYN, NEW YORK
I
NJURIES
to the genitourinary tract, resuhing from industria1 accidents, are a very smaI1 percentage of the tota numbers recorded each year. However, it is my behef that the IndustriaI Labor Commission has to pass on the merits of twice as many cIaims of injury to the genitourinary tract which are devoid of any descriptive incident or accident involving trauma. The most frequent entity, seen in this atraumatic group, is epididymitis. Many physicians erroneousIy 1abeI these cases as traumatic epididymo-orchitis in their reto facilitate the ports, hoping thereby acceptance of the aIIeged claim. The cIaimant, many times, is the Iaboring type, who, through misinformation, associates scrotaI sweIIing with the much used and abused term “strain.” He is* indignant when toId that his swoIIen testicle is a compIication or extension of his kidney, prostatic or urethra1 infection. Many patients examined for atraumatic epididymitis give the story of the aIIeged muscuIar effort taking place on Friday, with the appearance of sweIIing on Sunday and the subsequent report of the aIIeged strain being made on Monday. One wonders whether this swehing did not resuIt from the Saturday night sociaI activities. In a11 these cases a prostatovesicuIitis can be demonstrated by smear and cuhure of the prostatic secretion. In epididymitis it is important that the treatment not be restricted to IocaI and genera1 rest, pIus ointments and hot and coId applications, but it is also necessary to ascertain the initial focus, culture the organism and institute proper chemotherapy in hopes of eradicating the offending Epididymitis is known for its organism. tendency to have acute exacerbations.
Because the externa1 genitaIs are exposed they are the site of most of the injuries of the genitourinary tract. Injuries to the penis are many and bizarre. CIaims of fractured penises have come before the Labpr TribunaIs. Since the organ has to be in the state of erection in order to be fractured, it is questionabIe whether industry shouId be responsibIe for such an accident. Contusions, hematomas and evuIsions of the cutaneous areas are not uncommon and are handIed by the usual surgica1 routine for such injuries. RecentIy, a patient received an injury in which the termina1 one-fourth inch of the gIans penis, to the right of the meatus, was removed as the resuIt of an accident. His subsequent recovery was rapid. However, the tip of the gIans, on the uninjured Ieft side, protruded beyond the meatus and was puIIed to the opposite side, due to the cicatrix on the right side. This deviation to the right caused the foIlowing mechanica1 interference to the free ffow of urine: When the man voided, the stream wouId strike this obstruction and change its direction to an acute right angIe. He cIaimed disabiIity because of this stream deffection. He refused to have an amputation of the dista1 one-fourth. inch of the gIans penis on the unaffected side. ClinicaIIy, he was not disabIed and had no physica1 disfigurement visibIe to the pubIic. Since there was no scheduIe Ioss for such an injury he was given a cash settIement to cIose out the nuisance value. TREATMENT
Treatment of peniIe hematomas, etc., are the same as Iocalized bleeding elsewhere. However, if the bIeeding is within the corpora cavernosa the end resuIt is fre-
276
American Journal of Surgery
Morgan-Traumatic
quently an organized cIot, resuhing in total or partial priapism. SurgicaI evacuation of clots promptly reheves this condition. Lacerations of the penile urethra shouId receive instant attention by spIinting the urethra with an indwelling urethral catheter for forty-eight hours. The end resuIt is always good, if following the accident, the catheter is inserted into the bIadder before the patient has voided in order to prevent urinary extravasation by way of the tear. ShouId the patient have voided before the instaIIation of the catheter, and a phIegmon deveIop in the penile shaft from the extravasation, the phlegmon shouId be incised and drained in the manner of a peri-urethral abscess. The prophylactic use of the suIfa drugs is indicated, whiIe the patient wears the indweIling catheter, to prevent or Iimit a catheter urethritis and prostatitis. Trauma directIy to the scrotum can and does cause rupture of the testicIe, hydrocele and hematoceIe. These are handIed surgicaIIy. In addition, the hydroceIe can be obIiterated successfuIIy by aspiration of the sac and introduction of scIerosing sohrtion. Torsion of the testicIe is an entity which is too frequentIy missed by the first examining physician who records it by that famiIiar IabeI “traumatic epididymitis” and treats it as an inflammatory Iesion, with the resuIt that the cIaimant has a Iong period of unnecessary, painfu1 suffering, with the added Ioss of time from industry, pIus the inevitabIe useIess atrophied testicIe. The cIinica1 story is typical: (I) A messenger, riding a motorcycIe, runs over a bump, causing him to Iose his seat and he sustains immediate pain in the affected testicIe, usuaIIy accompanied by nausea and vomiting. (2) A busboy, carrying a Ioaded tray, steps on some spiIIed food, causing him to slip. He makes a great effort to regain his baIance and not drop the loaded tray. He succeeds only to have immediate and continuous pain in the affected testicle. Many more incidents of the same pattern could be cited in which the patients were erroneousIy treated for
Surgery
AUGUST, 194’
an infiammatory rather than a mechanica Iesion. Exquisite tenderness, confined to which defies satisfactory the scrotum, paIpation due to extreme pain, pIus the typica history, shouId immediateIy suggest to the examining physician that he is deaIing with an acute torsion, the care of which is surgica1 and not paIIiative. Rupture of the urethra and bIadder, either singIy or in combination, is frequently seen as part and parce1 of crushing injuries in and about the bony peIvis, and it is highIy important that the presence of these injuries be determined earIy and proper measures be taken immediateIy to short-circuit the urinary outAow before the dreaded urinary extravasation is cIinicaIIy evident. I make it a ruIe that a11 patients with peIvic injuries seen in consuItation have an indweIIing IIexibIe catheter inserted for forty-eight hours. FaiIure in catheterization strongIy indicates a break in the urethra1 continuity. If catheterization is successfu1, the question of ruptured bIadder can not be accurateIy determined by the presence or absence of bladder urine. It is not advisabIe to introduce per catheter a known quantity of sterile fluid and then measure the return. If the return fluid equaIs the amount introduced, the deduction is that there is no rupture. However, if the rupture exists, the introduction of ffuid causes either a spread in the existing peritonitis or space of Retzius’ extravasation, depending upon whether the bladder rupture is intra- or extraperitonea1. The safest method is to introduce one or two ounces of air by means of a steriIe syringe, compress the catheter, detach the syringe and pIace the end of the catheter into a basin filled with fluid, (the basin resting on the mattress, beneath the IeveI of the bIadder) and then reIease the catheter compression. If air bubbles into the fluid with force, the bladder is not ruptured. There are two reasons for cystotomizing a11 patients with a ruptured urethra resuIting from crushing injuries: First, the rupture is frequentIy an evuIsion of the bladder neck beneath the suprapubic arch. If the
NEW SERIES VOL. LVII. No. 2
Morgan-Traumatic
rupture is posterior to the membraneous urethra, the extravasation will point into the ihac gutters or space of Retzius and with the suprapubic approach this area will be adequateIy drained. Second, concomitant bIadder rupture may exist which wouId not be detected from a perinea1 approach. In addition, secondary repair of a ruptured urethra, if necessary, can be done with greater dispatch if a prehminary cystotomy has been performed, thereby giving the operator a dry perineum. Kidney injuries divide themselves into two Iarge groups: (I) those cases which result in a perinephritic spiI1 of bIood, urine or both and (2) intrarenal injuries, such as subcapsuIar hematomas and intrapelvic Iacerations with ensuing hematuria. The first group caIIs for surgica1 drainage at the earliest opportunity, and nephrectomy if necessary. In the second group, each case is a ruIe unto itself. Surgery in this group shouId be the Iast resort. UreteraI injuries are a rare entity and are usuaIIy associated with perforating injuries to the abdomen. They are aIways overshadowed by the symptoms resuIting from a concomitant ruptured intestina1 viscera. Back injuries are the most costIy group from the standpoint of time and medica patient with expense. Every ambuIatory an obscure back injury shouId have a prostatic smear and cuIture performed. Patients with injured backs requiring long periods of compIete immobiIization and having associated spina coIumn and cord injuries, often present an added complicathe so-caIIed orthopedic tion, nameIy, urinary caIcuIi. The first question raised is whether the caIcuIus antedated the accident or if it is the resuIt of the osteoporosis incident to complete immobiIization which causes the mobiIization of caIcium with attendant hypercaIcemia. A decision couId be reached more easily if the initia1 x-ray taken, folIowing the accident, wouId incIude detailed fiIms of the kidney areas as we11 as the spine, and aIso if frequent urine tests during the patient’s inactivity were
Surgery
American Journal of Surgery
277
recorded. It is a common finding in cases of osteomyelitis of the pelvis and lower extremities that the plates taken cover onIy these areas, hence, the disputed question of cause and relation of the caIcuIus. It is important that a11 injuries requiring long periods of inactivity have x-rays made of the kidney areas foIIowing such accidents to excIude further controversies. Apropos of kidney caIcuIi, too many cases of back strain are treated too Iong before the underIying renal pathological condition manifests itseIf by hematuria, passage of a caIcuIus or by good medical inspection. The descent of stones from the kidney into the ureter, whiIe at work, causes immediate disability. Does the work initiate the moving of the stone? Many times the Commission has ruIed that the repfacement cystoscopicaIIy of the stone from the ureter back to the kidney pelvis to terminate the pain disabirity, is a11 that is required of the empIoyer to discharge his IiabiIity if it is proved that the worker was performing tasks that wouId precipitate the moving of a caIcuIus. AI1 too frequentIy are cases recorded of hematuria aIIeged to be caused by some obscure accident, such as lifting a plank, etc., hours before the initia1 bIoody micturition. Examination discIoses the source of bIeeding to be from advanced carcinoma of the bladder, an enIarged, engorged prostate or some renaI pathoIogica1 condition such as neopIasm, stone or tubercuIosis. By the greatest stretch of the imagination one cannot state that the underlying condition is caused by this lift. Did the lift cause the bIeeding? Again, who can say? Bloody micturition is not immediate and, furthermore, these underIying conditions bIeed independent of outer body activity because of their progressive destructive nature. The Death CaIendar frequentIy hears cIaims that have for their premise that death was caused by some trivia1 accident. The death certificate wil1 give bIadder carcinoma and uremia as a cause of death and strenuous attempts are made to prove the facts causaIIy reIated.
278
American Journal of Surgery
Morgan-Traumatic
The urologicaI care of the paralyzed bladder resulting from spinal injuries is a very important part of the injured person’s treatment. Immediately following the accident cIosed tidal drainage is the ideal method to be instituted in order to avoid overdistention of the bladder with its attending stasis and infection. This type of treatment is a comphcated one and cystometric readings must be made and properly interpreted at frequent intervals so that the manometric pressure of the apparatus may be changed from 2 to 3 mm. of mercury for the atonic cord bladder up to 20 to 30 mm. of mercury for the hypertonic bladder. The important consideration in the care of bladders, whose nerve suppIy has been interfered with, is to set the organ at rest immediateIy by an indwelhng catheter, and in so doing, use a soft catheter, a No. 14 to 16 French. The larger the catheter, the greater the chances for urethra1 and prostatic infection. Place the patient, as soon as possible, on a regime of sulfanamides by mouth, plus increased fluid intake. If only the bony portion of the spinal column is involved, this treatment wilI suffice untiI the shock and edema have subsided; then micturition will be restored gradualIy. If
Surgery
AUGUST, ,942
the cord is involved with permanent damage to the bIadder nerve supply, tidal drainage is the best method to institute unti1 a so-calIed cord bladder is established. This end result may be obtained only one to three years after the cord injury. In industry, the claim of impotence avaiIs naught since one does not have to be potent to make a living. In the state of New York there is no fixed scheduIe Ioss for the complete loss or functional derangement of the uroIogica1 organs. A person losing a toe or linger is awarded a sum fixed by Iaw, not so in the loss or damage to a kidney, testicIe, etc. As a resuIt, Iitigation is protracted. The world is claim-minded and this applies to the medical profession as well as to the people of industry. Attempts of doctors, under oath, to rationaIize that indirect trauma, such as the opening of a drawer of silk stockings, causes nephroptosis in a thin, long-waisted female, and that orchidectomy performed on a sixty-eight year old man, because of trauma, would six months Iater cause prostatic hypertrophy with ensuing retention, due to sudden endocrine inbaIance as a resuIt of the orchidectomy, is ludicrous, to say the least.
TRACT
E. KING MORGAN, M.D. Associate Attending Urologist, Long Island CoIIege HospitaI BROOKLYN, NEW YORK
I
NJURIES
to the genitourinary tract, resuhing from industria1 accidents, are a very smaI1 percentage of the tota numbers recorded each year. However, it is my behef that the IndustriaI Labor Commission has to pass on the merits of twice as many cIaims of injury to the genitourinary tract which are devoid of any descriptive incident or accident involving trauma. The most frequent entity, seen in this atraumatic group, is epididymitis. Many physicians erroneousIy 1abeI these cases as traumatic epididymo-orchitis in their reto facilitate the ports, hoping thereby acceptance of the aIIeged claim. The cIaimant, many times, is the Iaboring type, who, through misinformation, associates scrotaI sweIIing with the much used and abused term “strain.” He is* indignant when toId that his swoIIen testicle is a compIication or extension of his kidney, prostatic or urethra1 infection. Many patients examined for atraumatic epididymitis give the story of the aIIeged muscuIar effort taking place on Friday, with the appearance of sweIIing on Sunday and the subsequent report of the aIIeged strain being made on Monday. One wonders whether this swehing did not resuIt from the Saturday night sociaI activities. In a11 these cases a prostatovesicuIitis can be demonstrated by smear and cuhure of the prostatic secretion. In epididymitis it is important that the treatment not be restricted to IocaI and genera1 rest, pIus ointments and hot and coId applications, but it is also necessary to ascertain the initial focus, culture the organism and institute proper chemotherapy in hopes of eradicating the offending Epididymitis is known for its organism. tendency to have acute exacerbations.
Because the externa1 genitaIs are exposed they are the site of most of the injuries of the genitourinary tract. Injuries to the penis are many and bizarre. CIaims of fractured penises have come before the Labpr TribunaIs. Since the organ has to be in the state of erection in order to be fractured, it is questionabIe whether industry shouId be responsibIe for such an accident. Contusions, hematomas and evuIsions of the cutaneous areas are not uncommon and are handIed by the usual surgica1 routine for such injuries. RecentIy, a patient received an injury in which the termina1 one-fourth inch of the gIans penis, to the right of the meatus, was removed as the resuIt of an accident. His subsequent recovery was rapid. However, the tip of the gIans, on the uninjured Ieft side, protruded beyond the meatus and was puIIed to the opposite side, due to the cicatrix on the right side. This deviation to the right caused the foIlowing mechanica1 interference to the free ffow of urine: When the man voided, the stream wouId strike this obstruction and change its direction to an acute right angIe. He cIaimed disabiIity because of this stream deffection. He refused to have an amputation of the dista1 one-fourth. inch of the gIans penis on the unaffected side. ClinicaIIy, he was not disabIed and had no physica1 disfigurement visibIe to the pubIic. Since there was no scheduIe Ioss for such an injury he was given a cash settIement to cIose out the nuisance value. TREATMENT
Treatment of peniIe hematomas, etc., are the same as Iocalized bleeding elsewhere. However, if the bIeeding is within the corpora cavernosa the end resuIt is fre-
276
American Journal of Surgery
Morgan-Traumatic
quently an organized cIot, resuhing in total or partial priapism. SurgicaI evacuation of clots promptly reheves this condition. Lacerations of the penile urethra shouId receive instant attention by spIinting the urethra with an indwelling urethral catheter for forty-eight hours. The end resuIt is always good, if following the accident, the catheter is inserted into the bIadder before the patient has voided in order to prevent urinary extravasation by way of the tear. ShouId the patient have voided before the instaIIation of the catheter, and a phIegmon deveIop in the penile shaft from the extravasation, the phlegmon shouId be incised and drained in the manner of a peri-urethral abscess. The prophylactic use of the suIfa drugs is indicated, whiIe the patient wears the indweIling catheter, to prevent or Iimit a catheter urethritis and prostatitis. Trauma directIy to the scrotum can and does cause rupture of the testicIe, hydrocele and hematoceIe. These are handIed surgicaIIy. In addition, the hydroceIe can be obIiterated successfuIIy by aspiration of the sac and introduction of scIerosing sohrtion. Torsion of the testicIe is an entity which is too frequentIy missed by the first examining physician who records it by that famiIiar IabeI “traumatic epididymitis” and treats it as an inflammatory Iesion, with the resuIt that the cIaimant has a Iong period of unnecessary, painfu1 suffering, with the added Ioss of time from industry, pIus the inevitabIe useIess atrophied testicIe. The cIinica1 story is typical: (I) A messenger, riding a motorcycIe, runs over a bump, causing him to Iose his seat and he sustains immediate pain in the affected testicIe, usuaIIy accompanied by nausea and vomiting. (2) A busboy, carrying a Ioaded tray, steps on some spiIIed food, causing him to slip. He makes a great effort to regain his baIance and not drop the loaded tray. He succeeds only to have immediate and continuous pain in the affected testicle. Many more incidents of the same pattern could be cited in which the patients were erroneousIy treated for
Surgery
AUGUST, 194’
an infiammatory rather than a mechanica Iesion. Exquisite tenderness, confined to which defies satisfactory the scrotum, paIpation due to extreme pain, pIus the typica history, shouId immediateIy suggest to the examining physician that he is deaIing with an acute torsion, the care of which is surgica1 and not paIIiative. Rupture of the urethra and bIadder, either singIy or in combination, is frequently seen as part and parce1 of crushing injuries in and about the bony peIvis, and it is highIy important that the presence of these injuries be determined earIy and proper measures be taken immediateIy to short-circuit the urinary outAow before the dreaded urinary extravasation is cIinicaIIy evident. I make it a ruIe that a11 patients with peIvic injuries seen in consuItation have an indweIIing IIexibIe catheter inserted for forty-eight hours. FaiIure in catheterization strongIy indicates a break in the urethra1 continuity. If catheterization is successfu1, the question of ruptured bIadder can not be accurateIy determined by the presence or absence of bladder urine. It is not advisabIe to introduce per catheter a known quantity of sterile fluid and then measure the return. If the return fluid equaIs the amount introduced, the deduction is that there is no rupture. However, if the rupture exists, the introduction of ffuid causes either a spread in the existing peritonitis or space of Retzius’ extravasation, depending upon whether the bladder rupture is intra- or extraperitonea1. The safest method is to introduce one or two ounces of air by means of a steriIe syringe, compress the catheter, detach the syringe and pIace the end of the catheter into a basin filled with fluid, (the basin resting on the mattress, beneath the IeveI of the bIadder) and then reIease the catheter compression. If air bubbles into the fluid with force, the bladder is not ruptured. There are two reasons for cystotomizing a11 patients with a ruptured urethra resuIting from crushing injuries: First, the rupture is frequentIy an evuIsion of the bladder neck beneath the suprapubic arch. If the
NEW SERIES VOL. LVII. No. 2
Morgan-Traumatic
rupture is posterior to the membraneous urethra, the extravasation will point into the ihac gutters or space of Retzius and with the suprapubic approach this area will be adequateIy drained. Second, concomitant bIadder rupture may exist which wouId not be detected from a perinea1 approach. In addition, secondary repair of a ruptured urethra, if necessary, can be done with greater dispatch if a prehminary cystotomy has been performed, thereby giving the operator a dry perineum. Kidney injuries divide themselves into two Iarge groups: (I) those cases which result in a perinephritic spiI1 of bIood, urine or both and (2) intrarenal injuries, such as subcapsuIar hematomas and intrapelvic Iacerations with ensuing hematuria. The first group caIIs for surgica1 drainage at the earliest opportunity, and nephrectomy if necessary. In the second group, each case is a ruIe unto itself. Surgery in this group shouId be the Iast resort. UreteraI injuries are a rare entity and are usuaIIy associated with perforating injuries to the abdomen. They are aIways overshadowed by the symptoms resuIting from a concomitant ruptured intestina1 viscera. Back injuries are the most costIy group from the standpoint of time and medica patient with expense. Every ambuIatory an obscure back injury shouId have a prostatic smear and cuIture performed. Patients with injured backs requiring long periods of compIete immobiIization and having associated spina coIumn and cord injuries, often present an added complicathe so-caIIed orthopedic tion, nameIy, urinary caIcuIi. The first question raised is whether the caIcuIus antedated the accident or if it is the resuIt of the osteoporosis incident to complete immobiIization which causes the mobiIization of caIcium with attendant hypercaIcemia. A decision couId be reached more easily if the initia1 x-ray taken, folIowing the accident, wouId incIude detailed fiIms of the kidney areas as we11 as the spine, and aIso if frequent urine tests during the patient’s inactivity were
Surgery
American Journal of Surgery
277
recorded. It is a common finding in cases of osteomyelitis of the pelvis and lower extremities that the plates taken cover onIy these areas, hence, the disputed question of cause and relation of the caIcuIus. It is important that a11 injuries requiring long periods of inactivity have x-rays made of the kidney areas foIIowing such accidents to excIude further controversies. Apropos of kidney caIcuIi, too many cases of back strain are treated too Iong before the underIying renal pathological condition manifests itseIf by hematuria, passage of a caIcuIus or by good medical inspection. The descent of stones from the kidney into the ureter, whiIe at work, causes immediate disability. Does the work initiate the moving of the stone? Many times the Commission has ruIed that the repfacement cystoscopicaIIy of the stone from the ureter back to the kidney pelvis to terminate the pain disabirity, is a11 that is required of the empIoyer to discharge his IiabiIity if it is proved that the worker was performing tasks that wouId precipitate the moving of a caIcuIus. AI1 too frequentIy are cases recorded of hematuria aIIeged to be caused by some obscure accident, such as lifting a plank, etc., hours before the initia1 bIoody micturition. Examination discIoses the source of bIeeding to be from advanced carcinoma of the bladder, an enIarged, engorged prostate or some renaI pathoIogica1 condition such as neopIasm, stone or tubercuIosis. By the greatest stretch of the imagination one cannot state that the underlying condition is caused by this lift. Did the lift cause the bIeeding? Again, who can say? Bloody micturition is not immediate and, furthermore, these underIying conditions bIeed independent of outer body activity because of their progressive destructive nature. The Death CaIendar frequentIy hears cIaims that have for their premise that death was caused by some trivia1 accident. The death certificate wil1 give bIadder carcinoma and uremia as a cause of death and strenuous attempts are made to prove the facts causaIIy reIated.
278
American Journal of Surgery
Morgan-Traumatic
The urologicaI care of the paralyzed bladder resulting from spinal injuries is a very important part of the injured person’s treatment. Immediately following the accident cIosed tidal drainage is the ideal method to be instituted in order to avoid overdistention of the bladder with its attending stasis and infection. This type of treatment is a comphcated one and cystometric readings must be made and properly interpreted at frequent intervals so that the manometric pressure of the apparatus may be changed from 2 to 3 mm. of mercury for the atonic cord bladder up to 20 to 30 mm. of mercury for the hypertonic bladder. The important consideration in the care of bladders, whose nerve suppIy has been interfered with, is to set the organ at rest immediateIy by an indwelhng catheter, and in so doing, use a soft catheter, a No. 14 to 16 French. The larger the catheter, the greater the chances for urethra1 and prostatic infection. Place the patient, as soon as possible, on a regime of sulfanamides by mouth, plus increased fluid intake. If only the bony portion of the spinal column is involved, this treatment wilI suffice untiI the shock and edema have subsided; then micturition will be restored gradualIy. If
Surgery
AUGUST, ,942
the cord is involved with permanent damage to the bIadder nerve supply, tidal drainage is the best method to institute unti1 a so-calIed cord bladder is established. This end result may be obtained only one to three years after the cord injury. In industry, the claim of impotence avaiIs naught since one does not have to be potent to make a living. In the state of New York there is no fixed scheduIe Ioss for the complete loss or functional derangement of the uroIogica1 organs. A person losing a toe or linger is awarded a sum fixed by Iaw, not so in the loss or damage to a kidney, testicIe, etc. As a resuIt, Iitigation is protracted. The world is claim-minded and this applies to the medical profession as well as to the people of industry. Attempts of doctors, under oath, to rationaIize that indirect trauma, such as the opening of a drawer of silk stockings, causes nephroptosis in a thin, long-waisted female, and that orchidectomy performed on a sixty-eight year old man, because of trauma, would six months Iater cause prostatic hypertrophy with ensuing retention, due to sudden endocrine inbaIance as a resuIt of the orchidectomy, is ludicrous, to say the least.