20. Mar 2023

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  1. Urethral injury and urethral caruncle Dr. Prakash Patel
  2. INTRODUCTION  10- 20 % of all poly trauma patients  Life threatening injuries first but DON’T neglect GU trauma.  Long term morbidity  Impotence  Incontinence
  3. CLASSIFIICATION  Upper urinary tract  Kidney  Ureters  Lower urinary tracts  Bladder  Urethra  External genitalia
  4. Urethral Trauma  10% in male with pelvic fracture  6% in female with pelvic fracture  60% due to blunt trauma  40% due to penetrating and itrogenic.
  7. ANATOMY  In males, the urethra is divided into the proximal (posterior) segment and the distal (anterior) segment by urogenital diaphragm.  The posterior urethra is further divided into membranous (sphincteric) and prostatic segments. About 3 cm long.
  8. CLASSIFICATION  Posterior urethral injuries>> most commonly related to major blunt trauma and major falls, and most of such cases are accompanied by pelvic fractures.  Anterior urethral injuries>> most commonly related to blunt trauma to the perineum( straddle injuries)
  9.  Posterior urethra – fixed at both- urogenital diaphragm and puboprostatic ligament  So bulbo membranous junction is more vulnerable to injury
  10. ETIOLOGY  Blunt trauma  Penetrating trauma  Iatrogenic trauma (Difficult catheterisation)
  11. EXAMINATION  TRIANGLE OF – Blood at meatus Inability to urinate Palpable full bladder  Other findings – On Per rectal examinations High riding of prostate Butter fly perineal Haematoma  First detected at emergency dept when a urethral catheter cannot be placed.  In female – Vulval oedema Blood at vaginal introitus.
  12. POSTERIOR URETHRAL INJURIES  other Clinical Features : Gross haematuria in 98% Pelvic/ Supra pubic tenderness Penile/ scrotal/perineal haematoma ill- defined mass on rectal examination.
  13. DIAGNOSIS Retreograde Urethrogram
  14. Retrograde Urethrogram  When blood at meatus >> an immediate Retrograde urethrogram >> to rule out urethral injury  Pre test KUB film  Supine position 30 degree ( oblique / lateral decubitus position)  Injection of 25ml of contrast medium  X-ray when 10 ml left and after 25ml  Post- voiding X- ray.
  15. INTERPRETATION  Contrast extravasation+ Contrast in bladder >>>>> PARTIAL TEAR.  Contrast extravasation only >>>>> COMPLETE TEAR.
  16. Partial Tear
  17. Complete tear
  18. Urethroscopy  Urethroscopy is done In female patient with suspected urethral injury to direct inspection of urethra.
  20. Management  IF patient is stable  Partial tear  Careful passage of 12-14Fr. Foley.  If any resistance : Surgery  Complete tear:  Supra pubic catheter + Surgery.  Surgery = Primary endoscopic alignment and delayed repair(10 -14 days) or late primary closure ( > 3 month )  Early urethral repair is not recommended because of risk of haemorrhage and infection.
  21.  When urethral catheter is removed after 4-6 weeks after surgery keep supra pubic catheter in situ because there is chances of development of stricture at the site of anastomosis or injury .  If patient voids satisfactorily through urethra >> supra pubic catheter can be removed after 7-14 days .
  22. URETHRAL STRICTURE  Partial ( < 1cm ) – endoscopic repair ( Direct vision internal urethrotomy ) Complete ( long segment >1cm ) - urethroplasty
  23. COMPLEX INJURIES  In case of female urethral disruption Immediate primary repair OR At least urethral re alignment over catheter to avoid subsequent urethrovaginal fistuala  Delayed reconstruction is difficult in female because- too short urethra (4 cm ) Scarring makes surgery difficult.
  24. Delayed Reconstruction.  Prior to reconstruction – Retrograde urethrogram Voiding cystourethrogram to define length of obliterated urethra  Cysto urethroscopy also done  Reconstruction surgery - Posterior urethroplasty through perineal approach
  25. COMPLICATIONS  Stricture  Incontinance  Impotence
  26. Outcome and Prognosis  Men with urethral injuries have an excellent prognosis when managed correctly.  Problems arise if urethral injury is unrecognised and the urethra is further damaged by attempts at blind catheterisation.  In those cases, further reconstruction may be compromised and recurrent stricture rates rise.
  27. Foley Catheter  NO if you suspect a urethral injury  When to suspect urethral injuries: Pelvic # or Gross haematuria  Danger to convert partial into complete  NEVER REMOVE A FOLEY WHEN YOU SUSPECT A PARTIAL TEAR AFTERWARDS.  ANY coloured urine other than yellow >>>> It’s BLOOD until proven otherwise.
  28. Anterior Urethra  More common than posterior  Bulbous injury is the most common urethral injury.  Direct trauma ( Straddle –type)  Usually NO pelvic #  Blood at meatus  Unable to micturate  Penile / Scrotal / Perineal Contusion Haematoma Fluid collection.
  29. Anterior Urethral Rupture
  30. Sleeve Haematoma
  31. Butterfly Haematoma
  32. MANAGEMENT  NO Foley if injury suspected  Retrograde Urethrogram  Surgical treatment
  33. Urethral caruncle
  34. URETHRAL CARUNCLE  Benign, distal urethral lesion.  Most commonly found in post menopausal women  Resembles various urethral lesions like Carcinoma Urethral diverticulum Urethral Prolapse Periurethral gland abscess
  35.  Originates from posterior lip of urethra.  Fleshy outgrowth of distal urethral mucosa  Usually small but can be grow to 1cm or more in diameter
  36. Epidemiology  Common in elderly post menopausal women  Rare in pre and peri menopausal women  Urethral prolapse is similar in appearance  But prolapse is circumferential while caruncles are focal lesion  Prolapse may occur in any age but caruncle almost exclusively in post menopausal women
  37. Relevant Anatomy  Female urethra 4-5 cm long  Distally -Lined by non keratinised stratified squamous epithelium  Proximally – Transitional epithelium  Outer layer –smooth muscle fibres and vasculature.
  38. Pathophysiology  Postmenopausal women >> Oestrogen deficiency >> Urogenital atrophy >> Distal urethral Prolapse >> Development of urethral caruncle >> chronic irritation of exposed urethral mucosa >> growth , Haemorrhage , necrosis of lesion.
  39. PRESENTATION  Mostly asymptomatic  Incidentally noted on pelvic examination  May be painful and associated with dysuria.  May be present with bleeding per urethra. ON EXAMINATION  Pink or reddish exophytic lesion at urethral meatus  Sometime purple or black due to secondary thrombosis
  40. MANAGEMENT CONSERVATIVE  Hot sitz bath  Topical estrogen ointments  Topical anti inflammatory drugs SURGICAL - Excixion and biopsy  In patient with large symptomatic lesions  In whom conservative therapy fails  Uncertain diagnosis
  41. Laboratory Examinations  Urine R/M – To rule out UTI  Histopahtological examination if diagnosis is uncertain
  42.  CYSTOSCOPY – to rule out another causes of haematuria To rule out urinary bladder pathology
  43. HISTOLOGIC FINDINGS  Microscopically – Bed of granulation tissue covered by either squamous or transitional epithelium. Inflammatory infiltrate is common.
  44. Intraoperative Details  Excision and Biopsy  First perform cystourethroscopy to rule out urinary bladder and urethral abnormalities  Place Foley catheter.  Use stay sutures in the epithelium to prevent mucosal retraction and meatal stenosis.  Excise the lesion.  Oversew the edges with 3-0 or 4-0 absorbable sutures
  45. ALTERNATIVE TECHNIQUE  developed by Park and Cho  Base of the caruncle is ligated , allowing it to slough off after 1-2 weeks  technique requires neither anaesthesia nor analgesia.
  46. POSTOPERATIVE  A Foley catheter may be left in place for 1-2 days to allow healing of urethral mucosa.
  47. COMPLICATIONS  Meatal stenosis  Urethral stricture.
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