Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Labarotomy
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Peritonitis
Stomac and duodenum
Gallbladder
Appendix
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
The Perineum
 





URINARY RETENTION

Acute retention of urine is an indication for emergency drainage of the bladder.
If the bladder cannot be drained through the urethra, it requires suprapubic drainage.

Treatment of chronic retention is not urgent. Arrange to refer patients with chronic urinary retention for further management.

Emergency drainage

Emergency drainage of the bladder in acute retention may be undertaken by:

:: Urethral catheterization
:: Suprapubic puncture
:: Suprapubic cystostomy.

Urethral catheterization or bladder puncture is usually adequate, but cystostomy may become necessary for the removal of a bladder stone or foreign body, or for more prolonged drainage, for example after rupture of the posterior urethra or if there is a urethral stricture with complications.

If a catheter’s balloon fails to deflate, inject 3 ml of ether into the tube leading to the balloon. This will rupture the balloon. Cut it off and remove it. Prior to removing the catheter, irrigate the bladder with 30 ml of saline.

URETHRAL CATHETERIZATION IN THE MALE PATIENT

Technique

1 Reassure the patient that catheterization is atraumatic and usually uncomfortable rather than painful. Explain the procedure.
2 Wash the area with soap and water, retracting the prepuce to clean the furrow between it and the glans. Put on sterile gloves and, with sterile swabs, apply a bland antiseptic to the skin of the genitalia. Isolate the penis with a perforated sterile towel. Lubricate the catheter with generous amounts of water soluble gel.
3

Check the integrity of the Foley catheter balloon and then lubricate the catheter with sterile liquid paraffin (mineral oil). If you are right-handed, stand to the patient’s right, hold the penis vertically and slightly stretched
with the left hand, and introduce the Foley catheter gently with the other
hand (Figure 9.1).

At 12–15 cm, the catheter may stick at the junction of the penile and bulbous urethra, in which case angle it down to allow it to enter the posterior urethra. A few centimetres further, there may be resistance caused by the external bladder sphincter, which can be overcome by a gentle pressure applied to the catheter for 20–30 seconds. Urine escaping through the catheter confirms entry into the bladder.

Advance the catheter 5 to 10 cm before inflating the balloon. This prevents the balloon inflating in the prostatic urethra.

Figure 9.1
Figure 9.1

4 If the catheter fails to pass the bulbous urethra and the membranous urethra, try a semi-rigid coudé catheter.
5 Pass a coudé catheter in three stages. With one hand, hold the penis stretched and, with the other hand, hold the catheter parallel to the fold of the groin. Introduce the catheter into the urethra and bring the penis to the midline against the patient’s abdomen as the “beak” of the catheter approaches the posterior urethra. Finally, position the penis horizontally between the patient’s legs as the catheter passes up the posterior urethra
over the lip of the bladder neck. At this point, urine should flow from the catheter.

If you fail to pass a catheter, proceed to filiforms and followers (Figure 9.2) or use a Foley catheter with a guide. If these procedures are unsuccessful, abandon them in favour of suprapubic puncture. Forcing the catheter or a metal bougie can create a false passage, causing urethral bleeding and intolerable pain, and increasing the risk of infection.

Fixation of the catheter

Figure 9.2
Figure 9.2

1 If you are using a Foley catheter, inflate the balloon with 10 –15 ml of sterile water or clean urine (Figure 9.2). Partially withdraw the catheter until its balloon abuts on the bladder neck.
2 If the catheter has no balloon, knot a ligature around the catheter just beyond the external meatus and carry the ends along the body of the penis, securing them with a spiral of strapping brought forward over the glans and the knot (Figures 9.3, 9.4, 9.5).
Figure 9.3
Figure 9.3

Figure 9.4
Figure 9.4

Figure 9.5
Figure 9.5


Aftercare

:: If the catheterization was traumatic, administer an antibiotic with a gram negative spectrum for 3 days
:: Always decompress a chronically distended bladder slowly
:: Connect the catheter through a closed system to a sterile container (Figure 9.6)
Figure 9.6
Figure 9.6

:: Strap the penis and catheter laterally to the abdominal wall; this will avoid a bend in the catheter at the penoscrotal angle and help to prevent compression ulceration
:: Change the catheter if it becomes blocked or infected, or as otherwise indicated. Ensure a generous fluid intake to prevent calculus formation in recumbent patients, who frequently have urinary infections, especially
in tropical countries.


SUPRAPUBIC PUNCTURE

Bladder puncture may become necessary if urethral catheterization fails. It is essential that the bladder is palpable if a suprapubic puncture is to be performed.

Technique

1 Assess the extent of bladder distension by inspection and palpation.
2 If you are proceeding to suprapubic puncture immediately after catheterization has failed, remove the perforated sheet that was used to
isolate the penis and centre the opening of a new sheet over the midline above the pubis.
3 Make a simple puncture 2 cm above the symphysis pubis in the midline with a wide-bore needle connected to a 50 ml syringe. This will afford the patient immediate relief, but the puncture must be made again after some hours if the patient does not pass urine.
4 It is preferable to perform a suprapubic puncture with a trochar and cannula, and subsequently to insert a catheter. Raise a weal of local anaesthetic in the midline, 2 cm above the symphysis pubis, and then
continue with deeper infiltration (Figure 9.7).

Once anaesthesia is accomplished, make a simple puncture 2 cm above the symphysis pubis in the midline with a wide bore needle. Introduce the trochar and cannula and advance them vertically with care (Figure 9.8). After meeting some resistance, they will pass easily into the cavity of the bladder, as confirmed by the flow of urine when the trochar is withdrawn from the cannula.
Figure 9.7
Figure 9.7

Figure 9.8
Figure 9.8

5 Introduce the catheter well into the bladder (Figure 9.9). Once urine flows freely from the catheter, withdraw the cannula (Figure 9.10).
Figure 9.9
Figure 9.9

Figure 9.10
Figure 9.10

6 Fix the catheter to the skin with the stitch used to close the wound and connect it to a bag or bottle. Take care that the catheter does not become blocked, especially if the bladder is grossly distended. If necessary, clear the catheter by syringing with saline.

This type of drainage allows later investigation of the lower urinary tract, for example by urethrocystography, to determine the nature of any obstruction.

SUPRAPUBIC CYSTOSTOMY

The purpose of suprapubic cystostomy is:

:: To expose and, if necessary, allow exploration of the bladder
:: To permit insertion of a large drainage tube, usually a self-retaining
catheter
:: To allow suprapubic drainage of a non-palpable bladder.


Technique

1 If the patient is in poor condition, use a local anaesthetic, for example, 0.5% to 1% lidocaine with epinephrine (adrenaline) for layer-by-layer infiltration of the tissues. Otherwise, general anaesthesia is preferable. See page 14 – 4 for dose calculation.
2 Place the patient supine. Centre a midline suprapubic incision 2 cm above the symphysis pubis (Figure 9.11) and divide the subcutaneous tissues. Achieve haemostasis by pressure and ligation
Figure 9.11
Figure 9.11

3 Open the rectus sheath, starting in the upper part of the wound. Continue dissection with scissors to expose the gap between the muscles (Figure 9.12). In the lower part of the incision, the pyramidalis muscles will obscure
this gap. Finally, expose the extraperitoneal fat.
Figure 9.12
Figure 9.12

4 Carry the incision in the linea alba down to the pubis, splitting the pyramidalis muscles. With a finger, break through the prevesical fascia behind the pubis; then sweep the fascia and peritoneum upwards from the bladder surface (Figure 9.13). Take care not to open the peritoneum.

The distended bladder can be recognized by its pale pink colour and the longitudinal veins on its surface. On palpation, it has the resistance of a distended sac. Insert a self-retaining retractor to hold this exposure.
Figure 9.13
Figure 9.13

5 Insert stay sutures of No. 1 absorbable suture into the upper part of the bladder on either side of the midline (Figure 9.14). Puncture the bladder between the sutures and empty it by suction (Figure 9.15). Explore the
interior of the bladder with a finger to identify any calculus or tumour (Figure 9.16). Note the state of the internal meatus, which may be narrowed by a prostatic adenoma or a fibrous ring.
Figure 9.14
Figure 9.14

Figure 9.15
Figure 9.15

Figure 9.16
Figure 9.16

6 If the bladder opening must be enlarged to allow you to remove a loose stone, open it 1–2 cm, inserting a haemostatic stitch of 2/0 absorbable suture in the cut edge, if necessary. Close the extended incision partially with one or two stitches of No. 1 absorbable suture, picking up only the
bladder muscle. Inspect the interior of the bladder for retained swabs before you introduce the catheter.
7 For insertion of the catheter, hold the edges of the incision with two pairs of tissue forceps, making sure that the mucosa is included so that the catheter does not slip beneath the mucosa (Figure 9.17):
If you are using a de Pezzer catheter, stretch its head with forceps and introduce the catheter into the bladder between the two pairs of tissue forceps

If you are using a Foley catheter, introduce it into the bladder and inflate the balloon.
Figure 9.17
Figure 9.17

8 Insert a purse-string 2/0 absorbable suture in the bladder muscle to ensure a watertight closure around the tube or, if you have made an extended incision in the bladder, secure the catheter with the final stitch needed to
close the incision (Figure 9.18).
Figure 9.18
Figure 9.18

9 If drainage is to be continued for a long period, fix the bladder to the abdominal wall so that the catheter can be changed. Otherwise, omit this step to allow more rapid healing of the bladder wound. To fix the bladder, pass the traction stitches in the bladder wall out through the rectus sheath
(Figure 9.19). Tie them together after closing this layer.
Figure 9.19
Figure 9.19

10 Close the linea alba with 0 absorbable suture and the skin with 2/0 nonabsorbable suture (Figure 9.20). Connect the tube to a sterile, closed drainage system. Dress the wound every second day until it is healed.
Figure 9.20
Figure 9.20



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  Kep Points  
Acute retention of urine is an indication for emergency
drainage of the bladder

The common causes of acute
retention in the male are
urethral stricture and benign prostatic hypertrophy

 
Other causes of acute retention are urethral trauma and prostatic cancer

 
If the bladder cannot be drained through the urethra, it requires suprapubic drainage

 
In chronic retention of urine, because the obstruction develops slowly, the bladder is distended (stretched) very gradually over weeks, so pain is not a feature

 
The bladder often overfills and the patient with chronic
retention presents with
dribbling of urine, referred to as “retention with overflow”

 
Treatment of chronic retention is not urgent, but drainage of the bladder will help you to determine the volume of residual urine and prevent renal failure, which is associated with retention. Arrange to refer
patients with chronic urinary retention for definitive management.