CHAPTER XIX. RUPTURE OF THE URETHRA.* By a fall astride a hard or sharp-margined object, by accidents of saddle or bicycle, by a kick or blow, by a fracture of the pelvis, the urethra may be ruptured. The prognosis and in some degree the treatment depend upon the portion injured, though the exact location is not always easily determined. Again the prognosis and treatment depend upon whether the rupture is total or incomplete, for upon the degree of laceration depend the rapidity of extravasation and later the dimensions of the stricture. suppuration, abscess formation, and general septic infection; on the other hand, later, stricture formation and all its attendant difficulties.
<Callout type="important" title="Important">Always consider the anatomy of the urethra to accurately diagnose injuries.</Callout>
SYMPTOMS OF RUPTURE OF THE URETHRA. Too rupture of the urethra, therefore, is always a serious injury, and in order that its dangers may be obviated, promptness of recognition and intervention is imperative. The symptoms of injury to the urethra are definite though varying in degree and are: retention of urine, hemorrhage from the urethra, and perineal tumor, These symptoms, together with the history of the case, readily make the diagnosis, but only by a careful study of each, recalling at the same time the anatomy of the urethra, may one decide upon the location of the injury. (a) Retention of urine accompanies in some degree all traumatic ruptures, though one should not make a diagnosis from this symptom alone for retention may follow a mere contusion—an interstitial rupture, without any solution of the continuity of the canal and without obstruction. It has its origin in “‘shock,” perhaps, with temporary paralysis of the bladder musculature, In such a case, there is gradual development of « perineal tumor from the contusion, but, on the other hand, the bladder slowly fills and rises out of the pelvis. In a few hours, the urine begins to dribble; a little later micturition becomes voluntary though painful, and gradually the function is restored to the normal. In actual rupture, the retention is complete and continuous. (b) Hemorrhage from the urethra ix indicative of rupture, but its amount in nowise points to the degree of urethral destruction. No inference may be drawn from it as to the severity of the lesion, In fact, the slighter the hemorrhage, the worse the outlook if the other symptoms are aggravated. For instance, if the mucous membrane alone is torn, the hemorrhage is immediate, perhaps voluminous, and yet the lesion is of minor importance. On the other hand, if the rupture is complete, the blood pours out into the lacerated tissues of the perineum, and only a few drops may find their way through the occluded canal. Therefore, one must never conclude that because the hemorrhage from the meatus is slight, the injury is slight. (©) Perineal Tumor.—There is always swelling in some degree follow- ing contusions of the perincum whether the urethra is injured or not. The perineal and scrotal tissues are ecchymosed and excicam 39 610 RUPTURE OF THE URETHRA, especially is likely to be engorged with exudates. If the urethra is ruptured the bladder empties itself into the bruised perineal tismes the ecchymosis rapidly becomes an edewa gradually thickening and expanding. At first perhaps an ovoid swelling in the middle of the per ineum, it gradually spreads until the scrotum, the pelvis, and finally the abdominal walls are infiltrated, thickened or edematous to a marked degree.
<Callout type="warning" title="Warning">Do not pass a catheter if the urethra is ruptured; it may lead to infection.</Callout>
TUE ANATOMY OF THE URETHRA. Stretched across the anterior segment of the pelvic outlet, between the rami of the pubes, is the triangular ligament, dense and fibrowk, and arranged in two layers, separated by a one-half inch space Te contact with the deep or pelvic surface of the triangular ligament, & the apex of the prostate gland. In contact with the superficial or per ineal surfate is the bulb of the urethra, the knobbed Posterior ex: tremity of the corpus spongiosum. The urethra traverses the: perforates and bridges the space between the two layers of the it angular ligament und them tunnels the bulb, runs the length of ihe corpus spongiosum, and emerges at the glans penis, the anterior knobbed extremity of the corpus spongiosum. The part of the urethes anterior to the triangular ligament consists, them, of twe the penile and bulbous; the deep urethra of two, the membranous, which Lster is the part which bridges the apace between the Iwo layers of the triangular ligament.
<Callout type="risk" title="Risk">Failing to locate the bladder end can lead to complications.</Callout>
TREATMENT OF CONTUSION OF THE URETHRA. 6 branous portion is involved and in a minor degree upon whether the rupture is partial or complete.
CONTUSION OF THE BULNOUS PORTION, Tojury to the bulbous portion is by far the more frequent; it is the form which the practitioner will nearly always find. It remains for him to decide whether the injury is a contusion or ruplure, for the prog- nosis and treatment are quite different in the two degrees of injury. Tf the case Is one of contusion, it fs likely the hemorrhage was abundant; the patient complains of pain and inability to pass water; there is no perineal tumor though the tissues may be much bruised. After a few hours he begins to pass water after painful effort. The urethral bleeding may persist, but the bladder keeps well emptied. Treatment.—The treatment is very simple. Keep the patient quiet, relieve the pain if necessary with small doses of morphia, and give some urinary antiseptic such as urotropin. Do not pass a catheter. Why should you? The bladder empties itself; there is no perineal infitration; and to do so would only increase the risk of infection.
<Callout type="tip" title="Tip">Use a soft, large catheter for initial attempts.</Callout>
The normal micturition will return in a few days in the cases of mild contusion, and perhaps in a week the patient will be well. If, however, in such a case, after a few days micturi- tion should become more painful and finally impossible, due to urethral swelling or spasm, catheterization is indicated. Try a large, soft, aseptic catheter first; try to carry it gently along the upper wall of the urethra. You may fail and be forced to fall back on a catheter of small size, but in no case must violence be used or the attempts prolonged. The catheter may be left in if the introduction was difficult, but it must be kept under constant surveillance, and at the first appearance of a perineal tumor, indicative of infiltration, operation is imperative.
If a catheter of small size has to be employed, it may not fill the urethra and there may be some dribbling of urine, which favors infection. In such a case the catheter remaining in the bladder may keep it empty by siphonage, Contusion, with the formation of a large hematoma in the perineum, might simulate rupture, but the presence of a distended bladder dem- onstrates that the perineal tumor is not infiltrated urine. In such a case again, an attempt should le made to pass a catheter if the urine does not begin to flow after three or four hours. If suceesfal, the size of catheter may be increased from day to day.
<Callout type="important" title="Important">Always prepare for operation by having necessary equipment ready.</Callout>
TREATURE YOR RUPTURE OF URETHRA. 613 The end in view is to furnish a free outlet for the urine and if possible to repair the ruptured canal, Operation for External Urethrotomy.—Provide for the operation soft rubber catheters of various sizes; a grooved stall’ or sive] sound; small, curved needles, silk No. 0, and three of four sizes of catgut. General anesthesia is indispensable. Place the patlent In the lithot- omy position with the perincum exposed to a good light. The entire field must be disinfected with extreme care.
AS soon as the patient is anesthetized, an effort may be made ts pass a catheter, and, if successiul, the operation will be greatly facilitated, Otherwise pass the guide as deeply as possible without using force, and let it be held in position by an assistant who also supports the scrotum. The median incision extends from the base of the scrotum to within an inch of the anus, Divide the skin and fascia, when you may reach an area filled with clots and Lacerated tissues, the site of the bulb and its muscular coverings (Fig. 446). You may not be able to recognize the bulb if the destruction has been great, but after wiping out the clots 10, 446.—Incision exposing the bulb of the urethra. (Dsal.) and débris, a cavity is exposed (Fig. 447).
<Callout type="risk" title="Risk">Incorrectly locating the orifice can lead to further complications.</Callout>
Exposure of the point of the guide, and you have thus located the opening Into the distal half of the urethra. Determine the nature of the urethra! tear, whether partial or complete, The subsequent procedure wil depend largely upon the type of injury present.
(a) If you find rupture of the lower wall only, the remnant of the upper wall, a mere band perhaps, will be a great help in the next step, which is to locate the orifice of the prom imal segment of the urethra. The search for this opening must be patient and minus.
(b) Li the rupture is complete and the two ends are Widely separated, the difficulties are aggravated, There is nea trace of the upper wall Jeft to assist in the slightest degree in locating the orifice of the prom imal segment of the urethra. With the point of the grooved director, every small orifion, avery depression, every fringed tubercle must be examined ip the hope that it represents the opening.
<Callout type="tip" title="Tip">Use indirect methods to locate the bladder end if necessary.</Callout>
If you find something which looks like mucosa and the lumen of the canal, introduce the point of your catheter and if it is in the right track, it will glide into the bladder. A good light, patience, perseverance, and an accurate knowledge of the anatomical relations of the injured parts often lead to success in the most difficult cases.
Fes. 448 —Selt Sea pee after repair Pressure on the bladder may sometimes help by forcing a drop or two of urine through and thus exposing the urethral opening. Some- times bleeding from the ruptured artery of the bulb will serve as a guide to the hidden opening. The incision may be extended backward with a view to exposing the canal, but this is often unsatisfactory and care must be taken not to wound the anal sphincter.
Uf, by any of these means, the orifice is finally located and the cath eter carried into the bladder, try to suture the urethral wound over the catheter. Place Lateral sutures of fine silk or catgut, beginning at the upper wall and suturing toward the Jower where the separation, is greatest. Hf possible, pass the suture through the outer conts only
<Callout type="important" title="Important">Ensure adequate drainage after repair.</Callout>
SUPRAPUBIC CYSTOTOMY. (c) What are you to do in case patient search fails to locate the bladder end of the torn canal and you are unable, therefore, to pass the catheter into the bladder and to suture? Two procedures are recom- mended: (2) Pack the wound with iodoform gauze and empty the bladder as necessary by suprapubic puncture. Perhaps at a later examina- tion the opening may be found, or, as will nearly always happen, the bladder is sufficiently drained after a day or two, through the perineal wound. (2) Do a suprapubic cystotomy and “retrograde catheterization.” Where the general condition of the patient and other circumstances permit, this procedure is the better, since it assures drainage and facilitates primary repair by definitely locating the bladder end of the torn urethra in the perineal wound, It is necessarily a delicate operation and should not be undertaken by the wholly inexperienced.
To perform suprapubic cystotomy and retrograde catheterization, begin by carefully disinfecting the abdominal wall. Make an incision two and one-half inches long in the middle line, beginning at the pubes and cutting through the skin and subcutancous tissues and the fascias. Retract the lips of the wound widely, You may not be able to distinguish the peritoneal covering of the bladder, for {t may be above the upper level of the wound. In any event, it must be pushed up out of the way. Next locate the bladder, which is easily felt if it is distended; but if it is not, follow the posterior surface of the pubes. Transfix the anterior wall by a suture on each side of the proposed line of incision, and lift the bladder upward to the abdominal wound and open it by a free incision, A small incision is a nuisance, while a large incision renders the subsequent steps easier and is easily sutured at the end of the operation. With the bladder opened, the next step is to pass the catheter, If possible locate the urethral orifice in the badder and pass the catheter by sight, but you will usually have to depend upon touch for this procedure. Tntroduce the left index and middle fingers into the bladder and touch the base. Now draw the fingers forward in the midS e Yin and the neck of the bladder will be recognized by Ws Taatn, Wo Woe and should be left in the bladder after tl wounds are sutured, as before described.
We must now provide for the drainage of the suprapubic wound. Employ a medium reach almost to the bottom of the bladder Repair the abdominal wall, leaving enough packing about the tube, “Many elaborate methods of suprapubic dri but this tube connected to 2 long rubber tube coupler and terminating beneath the bed in a bots full of bichloride solution, will meet all the re (Taylor, G. U. and Venereal Disease.) ; The tube may be replaced by a smaller one after ty As soon us possible, the wound is allowed to fill up: the drain is entirely removed.
front of the triangular ligament, for the extra spread up into the pelvie cavity and induce cellul mination per rectum will often appear in the perineum. Nothing but free incision and drainage through # of any use. Finally the pendulous portion of the urethra may be m times in coitus, and the hemorrhage may be quite tient;
<Callout type="warning" title="Warning">Be cautious with post-operative care to prevent complications.</Callout>
SUPRAPUBIC CYSTOTOMY. 617 (c) What are you to do in case patient search fails to locate the bladder end of the torn canal and you are unable, therefore, to pass the catheter into the bladder and to suture? Two procedures are recom- mended: (2) Pack the wound with iodoform gauze and empty the bladder as necessary by suprapubic puncture. Perhaps at a later examina- tion the opening may be found, or, as will nearly always happen, the bladder is sufficiently drained after a day or two, through the perineal wound. (2) Do a suprapubic cystotomy and “retrograde catheterization.” Where the general condition of the patient and other circumstances permit, this procedure is the better, since it assures drainage and facilitates primary repair by definitely locating the bladder end of the torn urethra in the perineal wound, It is necessarily a delicate operation and should not be undertaken by the wholly inexperienced.
To perform suprapubic cystotomy and retrograde catheterization, begin by carefully disinfecting the abdominal wall. Make an incision two and one-half inches long in the middle line, beginning at the pubes and cutting through the skin and subcutancous tissues and the fascias. Retract the lips of the wound widely, You may not be able to distinguish the peritoneal covering of the bladder, for {t may be above the upper level of the wound. In any event, it must be pushed up out of the way. Next locate the bladder, which is easily felt if it is distended; but if it is not, follow the posterior surface of the pubes. Transfix the anterior wall by a suture on each side of the proposed line of incision, and lift the bladder upward to the abdominal wound and open it by a free incision, A small incision is a nuisance, while a large incision renders the subsequent steps easier and is easily sutured at the end of the operation. With the bladder opened, the next step is to pass the catheter, If possible locate the urethral orifice in the badder and pass the catheter by sight, but you will usually have to depend upon touch for this procedure. Tntroduce the left index and middle fingers into the bladder and touch the base. Now draw the fingers forward in the midS e Yin and the neck of the bladder will be recognized by Ws Taatn, Wo Woe and should be left in the bladder after tl wounds are sutured, as before described.
We must now provide for the drainage of the suprapubic wound. Employ a medium reach almost to the bottom of the bladder Repair the abdominal wall, leaving enough packing about the tube, “Many elaborate methods of suprapubic dri but this tube connected to 2 long rubber tube coupler and terminating beneath the bed in a bots full of bichloride solution, will meet all the re (Taylor, G. U. and Venereal Disease.) ; The tube may be replaced by a smaller one after ty As soon us possible, the wound is allowed to fill up: the drain is entirely removed.
front of the triangular ligament, for the extra spread up into the pelvie cavity and induce cellul mination per rectum will often appear in the perineum. Nothing but free incision and drainage through # of any use. Finally the pendulous portion of the urethra may be m times in coitus, and the hemorrhage may be quite tient;
<Callout type="important" title="Important">Always ensure thorough disinfection before performing surgery.</Callout>
SUPRAPUBIC CYSTOTOMY. 617 (c) What are you to do in case patient search fails to locate the bladder end of the torn canal and you are unable, therefore, to pass the catheter into the bladder and to suture? Two procedures are recom- mended: (2) Pack the wound with iodoform gauze and empty the bladder as necessary by suprapubic puncture. Perhaps at a later examina- tion the opening may be found, or, as will nearly always happen, the bladder is sufficiently drained after a day or two, through the perineal wound. (2) Do a suprapubic cystotomy and “retrograde catheterization.” Where the general condition of the patient and other circumstances permit, this procedure is the better, since it assures drainage and facilitates primary repair by definitely locating the bladder end of the torn urethra in the perineal wound, It is necessarily a delicate operation and should not be undertaken by the wholly inexperienced.
To perform suprapubic cystotomy and retrograde catheterization, begin by carefully disinfecting the abdominal wall. Make an incision two and one-half inches long in the middle line, beginning at the pubes and cutting through the skin and subcutancous tissues and the fascias. Retract the lips of the wound widely, You may not be able to distinguish the peritoneal covering of the bladder, for {t may be above the upper level of the wound. In any event, it must be pushed up out of the way. Next locate the bladder, which is easily felt if it is distended; but if it is not, follow the posterior surface of the pubes. Transfix the anterior wall by a suture on each side of the proposed line of incision, and lift the bladder upward to the abdominal wound and open it by a free incision, A small incision is a nuisance, while a large incision renders the subsequent steps easier and is easily sutured at the end of the operation. With the bladder opened, the next step is to pass the catheter, If possible locate the urethral orifice in the badder and pass the catheter by sight, but you will