Urological Emergencies in Clinical Practice стр.104

History

Patients may present either acutely or months or even years after the object was inserted. They may complain of pain on voiding or suprapubic pain, they may report episodes of haematuria, or may present in urinary retention. The patient may volunteer that they have inserted something into the urethra, but sometimes no such history is forthcoming.

Examination and Investigations

The object may be protruding from the urethral meatus or you may be able to feel it within the urethra. A plain x-ray of the pelvis and genitalia may locate the foreign body if it is radiopaque. Alternatively, an ultrasound can locate the object. If no foreign body is seen ascending, urethrography or flexible cystoscopy can be used to identify its presence and location.

Treatment

Removing the foreign body can be a challenge. Occasionally it may be voided spontaneously, but more often than not you have to go in after it. Attempts may be made to remove it using a flexible cystoscope if it is smooth and small enough to be grasped in a stone basket or grabbed with forceps, but the latter usually cannot apply enough purchase on the object to allow it to be drawn all of the way out of urethra. It may be possible to retrieve the object under general anaesthetic using a rigid cystoscope or wider-bore resectoscope. If this fails, then open cystostomy will be required. If the object is made of glass, such as a thermometer, then it may be safer to avoid the attempt to remove it per the

6. SCROTAL AND GENITAL EMERGENCIES 139

urethra because of the danger that it might break and damage the urethra or even become lodged within the urethra. A formal open cystostomy may be safer for retrieval of glass objects.

If the foreign body is lying within the urethra and it cannot be pulled out or pushed back into the bladder (to be retrieved by rigid cystoscopy or open cystostomy), a urethrostomy will have to be performed in order to extract it.

Foreign bodies that have been attached to the penis, such as rings, may be particularly difficult to remove, especially if they are made of steel. The object may have become obscured from view by penile swelling, in which case the overlying tissues will have to be divided to allow the object to be seen. A technique for removing rings from fingers has been adopted for those stuck on the penis. A silk suture is passed underneath the ring, and the remainder of the suture is then bound tightly around the glans. The proximal end of the suture is then lifted and unwound from the penis, and as this is done the encircling object may be gently pushed distally over the glans, which has been wrapped in the suture. Alternatively, files, saws, or strong bone-cutting forceps may be required to remove the object. If it is made of steel, a high-speed drill, such as a dentist's drill, may be needed to cut it off. These drills can generate a substantial amount of heat as they cut through the metal, and the penis will need to be cooled as the procedure is carried out.


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