Posterior urethral injury[summary]Posterior urethral injury due to pelvic compression injuries. According to the literature, the incidence o
Posterior urethral injury
Posterior urethral injury due to pelvic compression injuries. According to the literature, the incidence of pelvic fracture with posterior urethral injury was 1.6%~25%. Traditionally, it is thought that the prostate is separated by a solid fascia and the urogenital diaphragm, and the shear force produced by the pelvic fracture will tear the upper urethra. Recently, however, the autopsy showed no obvious urogenital diaphragm from the prostatic sphincter. Urethral sphincter is not in the same horizontal plane, is around the membranous urethra, urethra and prostate muscle for muscle to the perineal membrane at the end abruptly, rather than stop the ball ball at the junction of the urethra, so the membranous urethra is the most weak, pelvic fracture occurred urethral injury should be membranous and near the bulbar urethra.
1 types of pelvic fracture and posterior urethral injury:
(1) stable fracture: a report of the fracture of the branch of the 3 ramus and the fracture of the ilium.
(2) unstable fractures: 4. Sciatic bone fracture; the pelvic ring fracture and posterior arch fractures; the Malgaigne (side ischiopubica or pubic symphysis fracture, with extensive sacrum, sacroiliac joint or bone fracture). Unstable fracture combined with posterior urethral injury is more common in stable fracture, bilateral pubic fracture combined with urethral injury is more common than unilateral pubic fracture. Malgaigne combined with severe posterior urethral injury, mortality rate of up to 21%.
2 types of posterior urethral injury
(1) I type: traction injury, urethral integrity.
(2): type II membrane urethra partially or completely to pelvic fracture, urinary extravasation.
(3) type III: urogenital diaphragm rupture, urethral ball membrane rupture (66%~85%), urinary extravasation to the perineum, also to pelvic extravasation.
(4) type of bladder neck and prostate urethra injury, only seen in children, urinary extravasation to the perineum and pelvic.
Essentials of diagnosis
Crush injury or falling height, the emergence of lower abdominal pain, can not urinate, a small amount of blood flow out of the urethra. Severe cases may be accompanied by shock. Physical examination revealed abdominal muscle tension; suprapubic tenderness, percussion dullness (hematoma or bladder filling), perineal hematoma, levator ani muscle tear visible anus hematoma, cannot rotate pelvis, iliac crest tenderness, suggestive of unstable pelvis; lower limb shortening, but no bone fracture, suggesting that pelvic shift. Rectal examination revealed that the prostate was floating in the high position and in the rectum. If the anal finger blood examination, may need to pay attention to with rectal injury. Pelvic X-ray findings of pelvic fractures. Retrograde urography is an important basis for the diagnosis of urethral injury. Take venography dilution agent for retrograde urethrography, such as developing and no urethral contrast extravasation tip contusion or partial laceration; such as urethral and developing extravasation of contrast agent suggests that the partial rupture; such as contrast agent into the proximal urethra and large overflow revealed severe rupture or fracture. The diagnosis of urethral catheterization may make partial urethral injury become completely injury, increase the bleeding or hematoma secondary to infection, so this check should be used with caution.
1 after the secondary massive hemorrhage urethral injury early indwelling catheter, will inevitably lead to pelvic hematoma, while the catheter blockage of the urethra obstruction of drainage. The end and the injury of prostatic venous plexus hemorrhage infection leads to fracture, the urine bladder blood clot with poor drainage, resulting in repeated hemorrhage shock. In these circumstances should replace the catheter in porous clot and suprapubic bladder infection after hematoma after. On the far side of the prostate, balloon and bulbourethral position on several side hole, so that the surrounding pelvic and urethral secretions with urine drainage by catheter can be excreted, infection and bleeding under control.
2 urethral fistula balloon traction can be close to the urethra. If the horizontal axis and the trunk traction, urethra catheter compression of penile suspensory ligament below, causing necrosis, abscess formation of urethral fistula, perforation into. It is necessary to pay attention to the use of too thick, too hard catheter, traction direction should be 45 degrees with the trunk, the catheter is connected to a smooth rope, across the fixed in the bed of the tail pulley, vertical traction. Traction should not be too heavy, too long, so as not to damage the bladder sphincter.
3 urethral stricture, urethral obstruction and infection may cause urethral stricture. Short segment of the urethra can be used to cure, many patients need surgery. Using transurethral cold knife incision, cauterization or laser vaporization expanding channels, defects can also be too elderly in transurethral scar, will be wrapped around the free wrapping sheet double balloon catheter to skin graft in the urethral defect, indwelling 3~6 weeks. Open urethral anastomosis via the perineal incision is free bulbar urethral to penile suspensory ligament, excision of scar tissue of urethral stricture, exposed healthy prostate, with absorbable suture accurately urethral anastomosis, indwelling catheter porous 2~3 weeks. If there is no tension, good healing, generally do not need urethral dilation.
Urethral stricture after resection if the defect with the pedicled scrotal skin flap can be too long urethral, two end anastomosis. Surgery is the first stage of perineal urethrostomy, formation of hypospadias, 3 months after urethroplasty.
4 of patients with urinary incontinence after urethral injury in the prostate after the sphincter has been damaged by the anterior sphincter of the control of urination. After the occurrence of urinary incontinence after urethral injury, we must first rule out whether it is caused by urinary incontinence caused by urinary incontinence, such patients should have chronic urinary retention. The results showed that the bladder neck of patients with sphincter injury caused by bladder neck open, may be due to the neck of the bladder neck by scar pull, and adhesion in the pubic symphysis, lose the function of closing. After the release of the pubic scar, the anterior wall of the bladder neck is folded, and the space of the pubic symphysis is filled with the omentum. Treatment failure can be buried prosthetic urethra bulb, preventing urine leakage.
5 erectile dysfunction of posterior urethral injury with impotence due to pelvic fracture damage mainly related to nerve vascular erectile function caused by the beam, the penis blood pressure measurement, color Doppler ultrasound and selective pudendal artery angiography confirmed diagnosis after underwent penile revascularization surgery to restore erectile function.
The treatment of posterior urethral rupture or fracture with pelvic fracture has not been fully unified at home and abroad. Simple suprapubic cystostomy or urethral realignment surgery, although simple, but the narrow high incidence (97%); a urethral anastomoses can reach anatomical reduction, satisfactory effect is good, but the surgical field deep, difficult, serious injuries bear surgery, a higher incidence of impotence (44%~56%). Young (1929) advocate primary suture, after the injury to 7~10d implementation, but may increase the incidence of iatrogenic impotence. Ormond stands for initial alignment realignment. Do the suprapubic incision, insert the metal fingers from the probe from the urethra, bladder into the posterior urethra as a guide, will probe into the bladder, and then bring out 1 catheter joint 1 20 balloon catheter into the bladder, with saline inflatable balloon, and trunk 45 degrees, with 500g the broken end near the gravity traction catheter (Figure 1), 1 weeks after the lifting of the gravity, the catheter indwelling were 4~8 weeks. There are also improved from the bladder neck 4 points and 8 points with 10 silk suture to perineum pad, rubber ring ligation, the upward shift of the prostatic urethra reduction, reduce postoperative urethral stricture rate, but will damage the viable tissue, causing impotence and incontinence.
Figure 1 para urethral realignment
It has recently been advocated to use urethral, bladder endoscopy or radiology to perform initial urethral alignment without increasing the risk of injury. 1~2 weeks after injury. Supine, from suprapubic No. 4 ureteral catheter through the hollow metal, probe or cystoscopy after insertion from the urethra, urethral mouth mirror is inserted into the urethra distal urethral catheter forceps, the introduction of 18~20 Foley catheter. Radiological method is the guidewire through a catheter inserted into the urethra from the suprapubic catheter in the urethra, and another time, the injection of a small amount of contrast agent as a guide for the guide wire smooth or retrograde insertion or inserted into the urethra, and then set into the Foley catheter. With the head of the 16F coaxial catheter, in the perspective of retrograde insertion into the urethra. The utility model is characterized in that the magnetic suction is met, the bladder is brought into the bladder, the guide wire is inserted into the urethra from the side hole of the catheter, the catheter is pulled out, and the Foley catheter is inserted into the bladder.