Urethral injury

　　Urethral injury is a common injury in the urinary system, mostly occurring in males, with young and middle-aged individuals being the majority, especially in the more fixed glans or membranous urethra. The causes of urethral injury include:

　　1. Closed urethral injury

　　1. Perineal riding injury:Mostly caused by falling from a height or being struck in the perineum when falling, with the perineum riding on a hard object or being struck violently. The injured area is mostly located in the glans urethra, and a few can injure the glans-membranous urethra. Since the glans urethra is relatively fixed below the pubic symphysis, when the perineum rides on a hard object, the glans urethra is squeezed between the hard object and the pubic symphysis, making it prone to injury. Such injuries generally do not occur with pelvic fractures.

　　2. Pelvic fracture:The most common pelvic fracture injuries with urethral injuries occur during traffic accidents, industrial accidents, or natural disasters, and the location is almost always in the posterior urethra. The posterior urethral injuries caused by pelvic fractures are mostly lacerations of the urethra caused by fractures, and a few are caused by puncture injuries at the fracture ends. Due to the puboprostatic ligament being fixed below the pubic symphysis, the membranous urethra passes through the urogenital diaphragm and is fixed by it. When the pelvic fracture causes the anteroposterior diameter of the pelvic ring to increase and the lateral diameter to decrease, or vice versa, the puboprostatic ligament is subjected to sudden traction, along with the sudden displacement of the prostate, causing the junction between the prostate urethra and the membranous urethra to tear or break, or due to the tear of the urogenital diaphragm caused by the fracture, causing the membranous urethra passing through it to tear or break.

　　Second, open urethral injury

　　Commonly seen in sharp or firearm injuries, occasionally seen in animal bites and horn injuries, etc., often complicated with injuries or loss of the penis and perineum, with complex injury conditions.

　　Third, iatrogenic injury

　　Commonly caused by improper operation of urethral instruments. It often occurs at the urethral orifice, bulbous urethra, membranous urethra, or prostatic urethra. Urethra with lesions, especially with obstruction, is more prone to injury. The degree and scope of injury vary, ranging from mucosal contusion to urethral penetration, even penetrating into the rectum.

　　Urethral injury is common in urological injuries, accounting for about five percent of urogenital injuries. It almost always occurs in male urethra, especially in the more fixed bulbous or membranous part. Although urethral injury is not a very serious disease, it can also affect our normal life and work. If not handled properly, it can cause infection, stricture, obstruction, and sexual dysfunction and other phenomena. The clinical manifestations of urethral injury are as follows:

　　First, shock:Due to urethral injury after pelvic fracture, the incidence of shock is very high, about百分之.

　　Second, urethral hemorrhage:Manifested as hematuria or bleeding from the urethral orifice, which is an important basis for diagnosing urethral injury.

　　Third, pain:If urethral injury occurs locally, there is often a feeling of pain and tenderness, with the sensation of pain during urination radiating to the glans penis and perineum.

　　Fourth, difficulty in urination and urinary retention:If a patient with severe urethral injury cannot urinate immediately after the injury, the suprapubic area can be palpated for an enlarged bladder after a longer period of injury.

　　Fifth, hematomas and ecchymosis:In the local subcutaneous tissue, contusions and hematomas can be clearly observed in crush injuries, and they will also extend to the perineum, causing the scrotum and perineal skin to swell and turn purple.

　　Sixth, urinary extravasation:Whether urinary extravasation occurs after urethral injury and the location of the extravasation depend on the degree and location of the urethral injury. Urethral rupture or fracture with frequent urination often leads to urinary extravasation. Periurethral extravasation can cause rectal irritation symptoms and lower abdominal peritoneal irritation symptoms. If urinary extravasation is not treated in time or secondary infection occurs, it can lead to tissue necrosis, suppuration, and in severe cases, systemic toxic symptoms may appear. Local infection or necrosis can form a urethral fistula.

　　To prevent urethral injury, it should focus on preventing trauma, as well as the following measures:

　　1. Drain urine and relieve urinary retention.

　　2. Make multiple skin incisions to thoroughly drain the urinary extravasation site.

　　3. Restore the continuity of the urethra.

　　4. The most fundamental measure to prevent complications such as urethral stricture and vesicovaginal fistula is to handle fresh urethral injury once.

　　5. Pay attention to the prevention and treatment of shock and the treatment of associated injuries. The treatment method depends on the location, degree, and time of the injury.

　　Urethral injury accounts for about 5% of urogenital tract injuries. Most severe urethral injuries are caused by blunt trauma. The rupture of the posterior urethra can involve the urogenital diaphragm and is often accompanied by pelvic fracture, while anterior urethral injury is often caused by perineal straddle injury. Penetrating urethral injury is less common, and urethral endoscopy or catheterization can cause iatrogenic injury. Possible complications of acute urethral injury include stricture formation, infection, erectile dysfunction, and urinary incontinence.

　　90% of urethral injuries caused by trauma manifest as microscopic hematuria, and urine examination and other examinations have little help in the diagnosis of ureteral injury caused by other reasons, unless there is bilateral ureteral obstruction, otherwise, the level of blood creatinine is normal.

　　1. Intravenous urography

　　More than 95% of ureteral injuries can be diagnosed by intravenous urography, 50% can locate the level of ureteral injury, which can manifest as complete obstruction of the ureter, ureteral torsion or angulation; ureteral rupture, perforation, and manifestation of contrast medium extravasation, and dilatation of the renal pelvis and ureter above the lesion.

　　2. Retrograde ureteral catheterization and pyeloureteral造影

　　When intravenous pyelography cannot make a clear diagnosis or there is doubt, it should be combined with retrograde ureteral catheterization and pyeloureteral造影 to make a clear diagnosis.

　　3. Ultrasound examination

　　It can detect hydronephrosis and urinary extravasation, which is a good examination method for early exclusion of ureteral injury after surgery.

　　4. CT examination

　　Due to the different locations and nature of the injury, CT manifestations are different. Ureteral rupture caused by pelvic surgery often has contrast medium leakage, and CT scanning shows high-density ascites.

　　5. Indocyanine green venous injection test

　　When there is a suspicion of ureteral injury during surgery, indocyanine green is injected intravenously, and blue urine will flow out from the ureteral fissure.

　　During or after surgery, cystoscopy should be performed, and indocyanine green venous injection should be done. If there is no blue urine ejected from the ureteral orifice on the injured side, and the ureteral catheter is blocked at the injury site, it usually indicates ureteral obstruction.

　　6. Methylene blue test

　　By injecting methylene blue solution through the catheter, it can differentiate between ureteral fistula and vesical fistula. If the fluid flowing out of the bladder or vaginal wound is still clear, bladder fistula can be excluded.

　　7. Excretory urography and computed tomography

　　All can show urinary extravasation at the site of ureteral injury, urine leakage, or obstruction. Retrograde pyelography can show obstruction or contrast medium extravasation.

　　8. Radionuclide renal imaging

　　It can show obstruction of the upper urinary tract on the ligated side.

　　The following are the points to be noted in the diet after urethral injury surgery:

　　Urethral injury patients often have a lot of bleeding, long-term bed rest, and reduced food intake, often with varying degrees of malnutrition. Therefore, it is recommended to have light and balanced diet. After surgery, it is necessary to consume liquid food such as milk, fruit juice, vegetable juice, meat soup, and various nutritional fluids, which require high nutrition, high calories, high protein, and low fiber. This is not only conducive to the healing of the incision but also helps to control defecation appropriately.

　　Secondly, avoid spicy and刺激性, fragrant, hot, and easy-to-heat foods, such as scallions, garlic, chili peppers, Sichuan pepper, fennel, clove, preserved vegetables, tobacco and alcohol, tangerines, cherries, waxberries, lychees, longan meat, grapes, vinegar, sparrows, geese, mutton, beef, yellow croaker, herring, eel, shrimp roe, Astragalus, Zi He Chi, Dang Shen, Dong Chong Xia Cao, chestnuts, jujube, Euryale ferox, etc. Avoid stimulants such as coffee, cola, and alcohol.

　　Symptoms of urethral injury may include pain, hematuria, subcutaneous ecchymosis or swelling under the injured area, difficulty in urination and urinary retention, and urinary extravasation. Treatment of these symptoms in traditional Chinese medicine can be divided into two types of treatment, namely, the syndrome of blood stasis and the syndrome of damp-heat descending to the lower jiao.

　　(1) Syndrome of blood stasis

　　Composition of the medicine: Chen Xiang, Ju Pi, Dang Gui, Chi Shaoyao, Wu Ling Zi, Pu Huang, Shi Wei, Hu Shi, Dong Kui Zi, Wang Bu Lü Xing.

　　Function: Activate blood and promote urination.

　　Formula: The medicine is a combination of Chen Xiang San and Shi Xiao San with modifications. The production of blood stasis is often due to trauma or external evil, various hemorrhages, emotional injury, chronic illness, and deficiency of the body's vital energy, affecting the normal function of Qi and blood or the blood vessels, causing poor blood circulation, and even blood stasis that does not disperse, forming the syndrome of blood stasis. The ingredients Chen Xiang and Ju Pi have a bitter, spicy, warm taste and a fragrant smell. The spicy taste can disperse, the bitter taste can relieve, the fragrant smell can penetrate, and the warm nature can promote circulation, so it has the effect of smoothing the Qi. Dang Gui, Chi Shaoyao, Wu Ling Zi, and Pu Huang can activate blood and remove blood stasis, promote blood circulation, and stop pain due to blood stasis. Shi Wei, Hu Shi, and Dong Kui Zi can promote urination and relieve dampness. The whole formula works to promote Qi, activate blood, and promote urination and relieve dampness.

　　(2) Syndrome of damp-heat descending to the lower jiao

　　Composition of the medicine: She Xiang, Qiu Mai, Mu Tong, Che Qian Zi, Hu Shi, Da Huang, Shan Zhi, Gan Cao Shao, Dong Kui Zi, Shi Wei.

　　Function: Clearing and benefiting the damp-heat.

　　Formula: The medicine is a combination of Ba Zheng San and Shi Wei San with modifications. Traditional Chinese medicine believes that the bladder is the palace of body fluid, and damp-heat accumulates in the lower jiao, descending to the bladder. Damp-heat blocks the kidney and bladder, causing abnormal Qi transformation of the kidney and bladder, leading to difficulties in urination,涩痛, urine redness, cloudy urine, frequent urination, and dysuria, which are urinary tract irritation symptoms such as frequent urination, urgency, and short urination. The formula uses She Xiang, Qiu Mai, Mu Tong, Che Qian Zi, and Hu Shi to relieve dampness and urinate. Da Huang, Shan Zhi, and Gan Cao Shao are used to clear heat and purge fire, Dong Kui Zi and Shi Wei to relieve dampness and remove blood stasis. The whole formula works to clear and relieve damp-heat.