Urethral Trauma

　　First, closed injury

　　1. Bulbar urethral trauma: sitting on a hard object in the perineum, injury to the bulbar urethra due to the pressure of the pubic arch and the hard object.

　　2. Membranous urethral trauma: violence can cause pelvic fracture, the broken ends of the fracture can pierce the urethra, or the fracture displacement can cause the urogenital diaphragm to shift and tear, leading to urethral trauma, which is located in the membranous urethra.

　　3. Urethral trauma: mostly due to iatrogenic injury, improper use of various urethral instruments such as urethral sound, metal catheter, cystoscope, or transurethral resection scope, and ureteroscope, etc., or patients self-placing foreign bodies or accidentally injecting corrosive drugs into the urethra can cause urethral injury.

　　Second, open injury

　　1. Seen in wartime firearm injuries, or in daily blade injuries or animal bites. Firearm injuries are often accompanied by associated injuries.

　　2. Urethral trauma can be divided into contusion, partial rupture, and complete rupture according to the degree of injury.

　　Possible complications of acute urethral injury include stricture formation, infection, erectile dysfunction, and urinary incontinence.

　　1. Anterior urethral injury:Large bleeding can occur at the perineum or urethral orifice due to cavernous body injury. Compression of the bleeding site in the perineum can control the bleeding. When bleeding is difficult to control, emergency surgery is required. The complications of urinary extravasation are mainly infection and sepsis. After infection occurs, thorough debridement and adequate drainage are required. Narrowing at the site of injury is a common complication, but it may not necessarily require surgical reconstruction unless there is severe narrowing and a significant decrease in urine flow rate.

　　2. Post-urethral injury:Narrowing, impotence, and urinary incontinence are the most serious complications of prostatic membrane urethral injury. The narrowing that appears after the first-stage repair and anastomosis can be seen in half of the cases. If suprapubic cystostomy is performed first and then the repair surgery is performed later, the incidence of narrowing can be reduced by 5%. Impotence occurring after the first-stage repair is seen in 30% to 80% of patients, averaging about 50%. However, delaying urethral reconstruction and only performing suprapubic drainage can reduce the incidence of impotence by 10% to 15%. About 1/3 of those who undergo reconstruction and anastomosis in the first stage experience urinary incontinence, and delaying the reconstruction can reduce it to less than 5%.

　　1. Shock:General urethral injury does not usually accompany shock. Membranous urethral trauma, due to accompanying pelvic fracture, has a large amount of bleeding, and about half of the injured personnel have shock.

　　2. Urethral hemorrhage:Fresh blood flows out from the urethral orifice after injury, which is unrelated to urination. The chance of bleeding from the urethral orifice is less in traumatic injuries of the membranous urethra or complete rupture.

　　3. Urinary obstruction:Due to pain and sphincter spasm, there is a feeling of bladder distension and the desire to urinate, but urine cannot be voided.

　　4. Urinary extravasation

　　How to prevent urethral trauma, due to improper treatment or severe infection, often leads to urethral stricture. It occurs earlier, and most symptoms appear within three months. Severe cases can cause complete urinary retention. Urethral stricture often accompanies chronic infection or per urethral inflammation, per urethral abscess, and urinary fistula, making treatment more difficult. Diagnostic urethral probing can be used to diagnose urethral stricture, and adults who cannot pass F16 can be considered to have stricture. X-ray urethral angiography can understand the location, degree, and length of the stricture. For those with mild stricture, regular urethral dilation can be performed. If dilation fails or cannot improve after repeated dilation, surgical treatment should be considered. Various methods should be selected according to the condition of the stricture segment, such as stricture segment resection and anastomosis, urethral intubation, and using skin flaps or bladder mucosa for urethraloplasty. Early proper treatment is very important to prevent urethral stricture, and the anastomosis should be wide and satisfactory. Postoperative infection control and regular urine dilation should be done well.

　　1. Digital rectal examination:It can be found that the anterior wall of the rectum is full and has a fluctuating sensation. If it is a complete rupture injury, the prostate can float or shift.

　　2. X-ray examination:Plain film can diagnose pelvic fracture, and contrast medium can be injected into the urethral orifice for urethral angiography, showing that the contrast medium leaks out from the damaged area, thus knowing the location and extent of the urinary extravasation.

　　3. Diagnostic catheterization:When the catheter is obstructed at the injury site and a small amount of blood is discharged, and the catheter is partially broken, the catheter can be slightly obstructed, but it can still be inserted, and blood urine appears in the anterior section and clear urine in the posterior section. If the catheter can be inserted into the bladder, it should not be removed and can be left in place as one of the treatment measures for urethral trauma.

　　1. Corn water

　　Boiling corn to make water is a good beverage, with the effects of diuresis, anti-inflammatory, and preventing urinary tract infection.

　　2. Celery and red date soup

　　About 250 grams of celery (with roots), 100 grams of red dates, washed and placed in a pot, add an appropriate amount of water to make a soup for drinking. It has the effects of lowering blood pressure, diuresis, and nourishing the middle and blood. It is suitable for hypertension, urinary pain, and other symptoms. Celery is sweet and pungent, cool in nature, and has an auxiliary therapeutic effect on urethral infection, hepatitis, hypertension, and other conditions.

　　3. Boiled pork small intestine with plantain seed

　　First, treatment

　　First, shock should be corrected, and then the urethral injury should be treated. The basic principle of treating urethral injury is to drain urine and reconnect the urethral ends.

　　1. Drainage of urine

　　If the catheter can be inserted smoothly under strict aseptic conditions and satisfactory anesthesia, it indicates that the continuity of the urethra is still intact. If there is no severe hematoma and urine extravasation, the catheter can be retained for 10 to 14 days to drain urine and support the urethra, waiting for the injury to heal. If catheterization fails, immediate surgical exploration should be performed. If the condition is severe and does not allow for major surgery, a simple suprapubic bladder stoma can be performed. Bladder stoma can prevent urine extravasation, reduce local irritation and infection, promote the absorption of inflammation, hematoma, and fibrous tissue, thereby reducing the severity of possible urethral stricture and surrounding scars, facilitating second-stage repair. Bladder stoma can also be completed by puncture method. It is suitable for cases of posterior urethral injury. Due to its simplicity, it is particularly suitable for primary medical units.

　　2. Urethral repair

　　(1) Retrograde urethral repair is suitable for scrotal urethral injury caused by injuries such as straddle injuries. The perineal incision exposes the bulbous urethra. If the urethra is not completely ruptured, a catheter is inserted from the urethral orifice to the bladder under direct vision and finger palpation. The incision is sutured along the catheter, and generally, transverse rupture is more likely to cause postoperative stricture than longitudinal rupture. When the urethra is severely contused or completely ruptured, a catheter can be inserted from the urethral orifice to find the distal end, or a catheter can be inserted from the suprapubic bladder incision through the urethral internal orifice to find the proximal urethral end, thoroughly removing necrotic tissue and hematoma, and then using absorbable sutures for interrupted exterior flip缝合 the two ends. The anastomotic site should avoid tension. The urine extravasation should be drained completely according to anatomical relationships, and multiple skin incisions should be made in the area of urine extravasation to drain the extravasated urine, the incisions should extend below the superficial fascia. The catheter should be retained for at least 3 to 4 weeks after surgery. If urination is smooth after catheter removal, the suprapubic bladder stoma tube can be removed. To prevent postoperative urethral stricture, regular urethral dilation can be performed after surgery. It is also possible to irrigate the urethra 1 to 2 times a day with 10ml of urethral irrigation fluid as soft dilation (formula: dexamethasone 0.15g, neomycin 25g, procaine 10g, 5% sodium naproxen 10ml, glycerin 400ml, Tween-80 5ml, add double-distilled water to 1000ml). At the same time, audio therapy can be used to prevent stricture.

　　(2) In cases of urethral injury after retrograde urethral catheterization, it is often due to severe外伤 to other organs, the condition is critical, and the patient cannot tolerate major surgery. At this time, a suprapubic incision can be made to perform a urethral reimplantation through the bladder. A female and male probe rod is placed at the urethral orifice and the urethral internal orifice of the bladder, respectively, and a Foley catheter is introduced after the reunion. After inflating the balloon, the catheter is pulled to align the two ends. If there are no female and male probe rods, a finger can also be inserted into the posterior urethra from the bladder neck, and it will meet with the metal probe inserted from the urethral orifice. If there is too much tension, one suture can be placed on each side of the prostate tip using nylon thread, and then a straight needle is brought out from the perineum and tied on a small gauze pad to aid in traction and fixation. The sutures are removed 2 weeks later. Although there is still a possibility of urethral stricture after surgery, due to the close proximity of the two ends and the consistent axis, it facilitates the second-stage repair.

　　(3)One-stage repair of urethral rupture via the suprapubic approach is difficult due to the fact that posterior urethral rupture often accompanies pelvic fracture, the patient is near shock, and there is a large amount of bleeding around the pubic bone and bladder. If repair is performed, it is necessary to remove the hematoma and bone fragments, which may lead to more severe bleeding, so there is a certain degree of difficulty. However, if the patient's condition allows, blood supply is sufficient, and experienced doctors can choose it and achieve good results.

　　II, Prognosis

　　The prognosis of urethral injury depends crucially on the correctness of emergency treatment. It is禁忌 to repeatedly attempt catheterization, which may worsen the injury, even leading to the progression of partial urethral laceration to complete urethral rupture. As for the choice of surgical method, it should be based on the patient's overall condition, the location, extent, associated injuries, the experience of the attending physician, and the current medical conditions, and should not be generalized.

　　Regardless of the method of repair for urethral injury, there is a possibility of urethral stricture due to scar contraction after surgery. Regular urethral dilation after surgery may not always be effective. In addition, infection and fistula are common complications.

　　1, Anterior urethral injury

　　(1)General measures: Straddle injuries often do not result in significant hemorrhage; otherwise, local compression and hemorrhage control may be required during resuscitation.

　　(2)Special treatment:

　　①Urethral contusion: Urethral contusion patients do not show signs of urinary extravasation, and the urethra remains intact. After urethrogram, patients can be instructed to urinate; if urination is normal without bleeding or pain, no further treatment is required. If there is persistent bleeding, a catheter can be used for drainage.

　　②Urethral laceration: After urethrogram, it should be avoided to perform instrumental examination. A median lower abdominal incision should be made to expose the bladder neck for the placement of a cystostomy tube. During the healing period of urethral laceration, the urine should be completely diverted and drained, of course, percutaneous cystostomy can also be performed. If urethrogram shows only a small amount of extravasation, a voiding examination can be performed 7 days after suprapubic catheter drainage, to observe for extravasation. If the injury is more extensive, drainage through the suprapubic catheter is required for 2-3 weeks before voiding examination. Strictures may occur after healing, most of which are not severe and do not require surgical reconstruction. After confirming there is no urinary extravasation, the cystostomy tube can be removed, and then the urinary flow rate can be measured to determine if there is obstruction caused by stricture.

　　③Urethral laceration with extensive urinary extravasation: After severe laceration, urinary extravasation can extend to the perineum, scrotum, and lower abdomen. Drainage of these areas is required, and suprapubic cystostomy should be performed. Effective antibacterial treatment should be administered in cases of infection or abscess.

　　(4) Emergency Repair: Urethral lacerations can be repaired in an emergency, but the surgical operation is difficult, and the incidence of postoperative stricture is high.

　　(3) Treatment of Complications: If the stricture range at the injury site is extensive, the reconstruction surgery should be postponed.

　　2. Posterior Urethral Injury

　　(1) Emergency Treatment: Treat shock, control bleeding.

　　(2) Surgical Treatment: Avoid performing catheterization.

　　(1) Bladder Stoma: If the bladder is distended, suprapubic bladder puncture stoma can be performed. If the bladder is not distended or combined with bladder rupture, exploration and treatment are required. After 3 months of bladder stoma, if urethral stricture or atresia occurs, surgical treatment for urethral stricture in the second stage should be performed.

　　(2) Urethral Convergence: The method is to incise the bladder above the pubic bone, insert the index finger from the bladder neck into the posterior urethra, and introduce the probe inserted into the urethra from the external urethral orifice into the bladder. Put a catheter on the tip of the probe, withdraw the probe, and pull the catheter out of the urethral orifice, then tie it with a silk thread to the tip of the F18-20 balloon catheter and pull it into the bladder, fill the balloon, and use it as a urethral stent and urine drain. Properly pull the catheter to help the proximal urethra reduce. Leave the catheter for 4 to 5 weeks. Most cases have unobstructed urination and can avoid the second stage urethral stricture surgery.

　　(3) Urethral Reduction under Scope: Under the scope, the urethroscope is inserted into the damaged site, and the distal urethral end enters the bladder through the posterior urethra. Leave half of the urethroscope sheath in place, withdraw the urethroscope, insert a Foley catheter through the half-ring sheath, fill the catheter balloon, and leave the catheter for 3 to 5 weeks. This method can restore the continuity of the urethra in the early stage, and the recovery is satisfactory in most cases.

　　(4) Posterior Urethral Repair: After finding the two ends through an incision above the pubic bone and perineum, urethral anastomosis is performed. This method can cause uncontrollable bleeding and concurrent infection after incising the hematoma, and the incidence of urethral stricture and impotence is higher in the future, and it is now less commonly used.

　　(3) Treatment of Complications: About one month after the second stage urethroplasty, the catheter is removed and voiding cystourethrography is performed. If there is no leakage of contrast medium, the suprapubic stoma tube can be removed; if there is leakage or stricture, the stoma tube should be retained. If stricture occurs, it is often very short and easy to perform urethral incision under direct vision, and healing is also fast. After the second stage urethroplasty, impotence may occur for several months, and those with impotence two years later should undergo penile prosthesis implantation surgery. There is rarely urinary incontinence after the second stage urethroplasty, and it can usually be gradually recovered.