Urological Emergencies in Clinical Practice стр.84

112 J. REYNARD

thral contusion. If there is extravasation of contrast, with contrast also present in the bladder, the patient has a partial rupture of the anterior urethra. If there is no filling of the posterior urethra or bladder, the anterior urethral disruption is complete.

Management of Anterior Urethral Injuries

Anterior Urethral Contusion

A small-gauge urethral catheter (12 Ch in an adult) is passed. It

is removed a week or so later.

Partial Rupture of Anterior Urethra

The majority of such injuries can be managed by a period of suprapubic urinary diversion, without the need for subsequent surgery. Most will heal without a functionally significant stricture (Cass and Godec 1978, Pierce 1989), after a few weeks of drainage. If there is a penetrating partial anterior urethral disruption (e.g., knife, gunshot wound), primary (immediate) repair may be carried out, but this depends on the presence of a surgeon experienced in these techniques. There is some evidence that the stricture rate with immediate surgical repair is lower than that associated with realignment of the urethra by urethral catheter-isation alone (Husmann et al. 1993).

Suprapubic catheterisation (percutaneously) is preferred over urethral catheterisation because of the concern that a partial rupture can be converted to a complete rupture. If the bladder cannot easily be palpated, such that a suprapubic catheter cannot safely be inserted, then a formal open suprapubic cystostomy (under general anaesthetic) should be performed.

It seems a sensible idea to give these patients a course of a broad-spectrum antibiotic to prevent infection of extravasated urine and blood. A voiding cystogram can be done after 2 weeks to confirm that the urethra has healed, and the suprapubic catheter can then be removed. If there is still extravasation of contrast, the suprapubic catheter can be left in place a little longer.

Seventy percent or more of partial urethral tears heal without stricture formation following a short period of suprapubic catheter drainage alone. The presence of a substantial degree of oedema and of haematoma at the site of injury makes primary closure technically difficult and can convert a short area of ure-thral injury into a longer one. Attempts to re-establish urethral continuity over sounds can also lead to greater damage and should be avoided. With simple suprapubic catheter drainage, if


Предыдущая Следующая