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 Male Urethra
 


> URETHRAL STRICTURE
> THE PREPUCE
> PARAPHIMOSIS
> TORSION OF THE TESTIS
> SCROTAL HYDROCOELE
> VASECTOMY





URETHRAL STRICTURE

Urethral dilatation is indicated for urethral stricture, a problem which is common in certain parts of the world.

Technique

1 Administer appropriate analgesia and sedation before beginning the procedure and start antibiotic treatment, to be continued for three days. Carefully clean the glans and meatus, and prepare the skin with a bland
antiseptic. Instil lidocaine gel into the urethra (optional) and retain it for 5 minutes. Drape the patient with a perforated towel to isolate the penis.
2

In the acute stricture, begin by introducing a small filiform; leave it in the urethra and continue to insert filiforms until one passes the stricture. Then progress to dilatation with medium-size followers and gradually work up
in size (Figure 9.21).

For a post-inflammatory stricture that starts in the anterior urethra, always introduce a straight bougie first; this will minimize the risk of urethral damage (Figure 9.22).

After the acute stricture is dilated with filiforms and followers, bouginage can be undertaken at regular intervals, using metal bougies. Perform dilatation with straight bougies of increasing size, and finally
introduce a curved bougie (Figure 9.23). Remember that the small sizes of metal bougies are the most likely to lacerate the urethra. Therefore, in this situation, filiforms and followers should be used.

Figure 9.21
Figure 9.21

Figure 9.22
Figure 9.22

Figure 9.23
Figure 9.23

3 Introduce a curved bougie in three stages:
Bring the bougie parallel to the crease of the groin and hold the penis taut (Figure 9.24)

While raising the taut penis to the midline towards the patient’s abdomen, slip the bougie into the posterior urethra and let it progress by its own weight (Figure 9.25)
Finally, bring the penis down to the midline, horizontally between the patient’s legs, as the curve of the bougie carries it up the posterior urethra and over the neck of the bladder (Figure 9.26).


Figure 9.24
Figure 9.24

Figure 9.25
Figure 9.25

Figure 9.26
Figure 9.26

4 Initially, dilate the patient’s urethra at least twice a week, using two or three sizes of bougie successively at each session. Begin with the smallest sizes (for example, 12) and stop at about 24 Ch. If there is urethral bleeding, skip a session to give the mucosa time to heal. Perform follow-up dilatation:
Weekly for 4 weeks
Twice monthly for 6 months
Every month thereafter.

Possible complications

:: Trauma – bleeding or creation of a false passage
::

Bacteraemia

:: Septicaemia and septic shock.

Minimize complications by asepsis and the use of antibiotics.

> URETHRAL STRICTURE
> THE PREPUCE
> PARAPHIMOSIS
> TORSION OF THE TESTIS
> SCROTAL HYDROCOELE
> VASECTOMY



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  Kep Points  
Filiforms and followers are the safest means of dilating acute strictures

Chronic strictures can be
managed safely with repeat
dilations using metal bougies

 
Suprapubic puncture or
cystostomy should not be
thought of as the last resort
and are much preferable to
continued instrumentation,
which can lead to urethral
traumatization.