Research articles
 

By Dr. Manu Gupta
Corresponding Author Dr. Manu Gupta
Dept of Surgery, Subharti Medical College, Meerut, R-23,Subhartipuram,Meerut - India 250005
Submitting Author Dr. Manu Gupta
GENERAL SURGERY

Retrogradeurethrogram(RGU),Micturating cystourethrogram(MCU)

Gupta M. Clinical and radiological Study of Urethral Injuries and Stricture Urethra. WebmedCentral GENERAL SURGERY 2011;2(10):WMC002389
doi: 10.9754/journal.wmc.2011.002389
No
Submitted on: 30 Oct 2011 07:04:53 AM GMT
Published on: 31 Oct 2011 05:27:34 PM GMT

Abstract


Objective:-
To study clinical and radiological evaluation of urethral injuries and stricture urethra and evaluation of various methods used in the treatment of urethral injuries and stricture urethra .
Methods :-
After thorough history , Physical and local examination , RGU,MCU,Uroflowmetry, USG was done in all 55 patients after that suprapubic cystotomy and later on urethroplasty was done in urethral injury cases.Urethral dilatation was done as primary treatment in one patient of stricture urethra, in rest of the patients urethroplasty was done as a definitive treatment.
Result:-
Most common etiology of urethral injury and stricture urethra was trauma with membranous  urethra  being the most common site. Suprapubic cystotomy followed by urethroplasty in the patients of urethral injuries and urethroplasty as a primary definitive treatment in stricture urethra  has better results.
Conclusion:-
RGU and MCU are good diagnostic modalities to localize the site of urethral injury and stricture urethra .Suprapubic cystotomy with delayed repair of urethral injury gives better results than primary catheter repair . In cases of stricture urethra , urethroplasty have better result than urethral dilatation.

Introduction


Urethral injuries are common and occur most often in men usually associated with pelvic fracture or straddle type falls .They are rare in women .Urethral distraction injuries are the result of blunt pelvic trauma and accompany about 10% of pelvic fracture injuries and are all intents unique to the membranous urethra.
The use of aligning catheters actually is some what controversial but most agree that the aligning catheter of the very worst facilitates subsequent reconstsuction and at best often leaves the patient with an endoscopically manageable stenosis.  Primary anastomosis is unquestionably the goal in all these patients and if possible it is desirable to proceed within 4-6 months.
Today Most urethral stsictures are the result of trauma. With the advent of prompt and effective antibiotic treatment, gonococcal urethrities now progresses less often to strictures.
Urethral dilation is oldest and simplest treatment for stricture but seldom used curatively .internal urethrotomy should be served for strictures of bulbar urethra that should be less than 1.5 cm in length and should not be associated with dense deep spongy fibrosis .A number of lasers have been used for anterior urethral stricture with mixed result. Excision with primary anastomosis has proved to be the “gold standard”.
The present study had been under taken to establish a full clinical and  radiological evaluation of urethral injuries and stricture urethra and evaluation  of various methods used in the treatment of stricture urethra and urethral injuries.

Materials and Methods


The present study was carried out in patients attending the out patient department of surgery or admitted to the emergency ward of SVBP Hospital ; L.L.R.M Medical College Meerut.
The study include one year of prospective evaluation of 35 patients of urethral injuries and stricture urethra from August 2006 to July 2007. The study also includes one year of retrospective evaluation from 2005 to 2006 of 20 patients of stricture urethra .After thorough history taking, complete physical and local pelvic examination ,retrograde urethrogram,  micturating cystourethsogram, USG case  was done in all cases. Patient either of urethral injury or stricture urethra who presented with retention of urine, suprapubic  cystotomy either with percutaneous  supracath or using open method was done . Later on in these patients urethroplasty was done.
Urethral dilatation was done in one patient of stricture urethra as a primary treatment. Urethrsoplasty was done as a definitive procedure in most of the patients of stricture urethra or urethral injury.

Observation & Results


The various observations made during study are-
- Out of 20 patients of urethral injuries , maximum no. of patients belonged to the age group of 11 to 40 years 13 patients; 65 % and in stricture urethra also  out of 15 patients maximum no.of patients were in the age group of 11 to 40 years (11 patients; 73.33%) (Illustration - 1)
- Out of 20 patients of urethral injury , 10 patients had haematuria ,16 patients had blood at meatus ,18 patients with retention of urine and 19 patients had difficulty in micturition (Illustration -2)
- Out of 15 patients of stricture urethra ,12 patients presented  with thin stream,13 had difficulty in urination,  6 had retention of urine, discharge per urethra and burning micturition  were present in 5 (33.3%) and 12 (80.0%) patients respectively (Illustration -3)
- Maximum no. of cases (13 out of 15 ) of urethral injury were due to road traffic accidents associated with pelvic fracture. Straddle injuries and  instrumentation were etiological factor in 4 (20.0%) and 2 (10.0%) cases respectively (Illustration -4)
- Maximum no. of cases of urethral stricture (9, 60.3%) were caused by trauma , 3(20.1%) cases were caused by urethritits , one case by indwelling catheter one  postoperatively and one by balanitis xerotica obliterans (Illustration -5)
- Out of 20 cases of urethral injury , urine culture was positive in 11 (55%) cases .Most common organism found was Escherichia coli in 4 case (20%) (Illustration -6)
- Out of 20 cases of urethral injury bulbomembranous  junction was most commonly involved in 12 cases . Penile and bulbar urethra was involved in  2 and 3 cases respectively (Illutration -7)
- Out of 15 patients of stricture urethra bulbomembranous junction was involved in 8 cases, membrano – psostatic junction was involved in 4 cases (Illustration -8)
- Out of 20 patients of urethral injury, in 18 patients suprapubic cystotomy with delayed urethroplasly was done. Urethral catheter alignment was done in one patient and in another patient primary urethral repair was done  (Illustration -9)
- Out of 15 patient of stricture urethra , urethroplasty was done in 10 cases , supra pubic cystotomy followed by urethroplasty was done in 4 patients and urethral dilatation was done in 1 patient (Illustration -10)
- In retrospective study of 20 urethral stricture patient following observation made- Trauma was etiology in 12 cases four patient had H/o urethrititis , Balanits xerotica oblitrans was associated with 2 cases of urethral stricture (Illustration -11)
- Out of 20 patients of urethral stricture membranous urethra was involved in 8 patients, membrano –postatic junction in 5 cases and bulbar in 4 cases (Illustration -12)
- Out of 20 cases urethroplasty was done in 12 cases , suprapubic cystotosmy followed by urethroplasty in 7 cases and urethral dilatation was done in one case (Illustration -13)

Discussion


In the present study maximum number of urethral injuries and stricture urethra patients were in the 10-40 years of age group. similarly Beard and Goodyear (1948)1 found stricture urethra most common in the age group of 30—50 years.
In this study most common mode of presentation of patents of urethral injury was haematuria (95.0%) and difficulty in micturition Shalmovitz and McCullough (2007) 2  reviewed all cases of urethral trauma and concluded that gross haematuria was the most sensitive sign for the presence of urethral injury.
In the present study maximum no of cases of posterior urethral injuries were due to road traffic accidents with pelvic fracture in 13 (68%) cases. Straddle injury was most common etiological factor in the injury to anterior urethra.  similarly, Rosenstein at al (2006)3 found that injuries to posterior urethra were classically associated with pelvic fracture secondary to road traffic accidents while anterior urethral trauma usually was secondary to straddle injury or injudicious instrumentation.
In the present study ,membranous urethra is the most common site involved . similarly Colapinto and McCallum (1977)4 and Brandes and Borelli (2001) stated that bulbomembranous junction was more vulnerable to injury during pelvic fracture.
In the present study suprapublic cystotomy with delayed repair gives better results. Cass (1984)5 in his study of 74 patient with urethral injury showed that above treatment gives better result

Conclusion


After analyzing the result obtained , following conclusions were derived-
1.Maximum number of patient of urethral injuries and stricture urethra were in 10-40 years of age. As this age group seems to be more exposed to trauma
2.Most common mode of presentation of patient of urethral injuries was haematuria (95.0%) and difficulty in micturition (95.0%)
3.Most common presenting symptom in patients of urethral stricture was difficulty in micturition (86.6%) followed by thin stream (80.0%)
4.Maximum numbers of cases of posterior urethral injuries were due to road traffic accidents associated with pelvic fracture (65.0%).  Straddle injury was most common etiological factors in the injury of anterior urethra.
5.Most common cause of stricture urethra in both prospective and retrospective study was trauma . Urethritis was next common cause of stricture.
6.On retrograde urethrography and micturating cystourethrography , most common site involment in both urethral injuries and stricture urethra was membranous urethra
7.Urethroplasty was performed in maximum numbers of patients of stricture urethra as a primary treatment modality.
8.Most of the patients of urethral injuries in the present study were treated  with suprapubic  cystotomy with delayed repair (90.0%)  . Primary catheter alignment and primary urethral repair was done in one patient each.
Thus we conclude that retrograde urethrography and micturating cystourethrography are good diagnostic modality to localize the site of urethral injury and stricture urethra . supra pubic cystotomy with delayed repair of urethral injury gives better result than primary catheter alignment and immediate primary urethral repair. In case of stricture urethra , urethroplasty have better results the urethral dilatation.

Refrences


1.Beard DE , Goodyear WE. Urethral Stricture. Pathological study . Urology 1948;59:619.
2.Shlamovitz GZ, Mc Cullough L. Blind urethral catheterization in trauma patients suffering from lower urinary tract injuries .J Trauma 2007;62(2):330-35.
3.Rosenstein DI, Alssikafi NF. Diagnosis and classification of urethral injuries . Urol Clin North Am 2006;33(1)73-85.
4.Colapinto V, McCallum RW. Injury to the male posterior urethra in fractured pelvis . A new classification . J Urol 1977;118:575-580
5.Cass AS. Urethral injury in the multiple injured patients . J Trauma 1984;24(10):901-6

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Competing Interests


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