Chapter 13. Urology

Table of Contents
Equipment for urology
Catheters and how to pass them
Retention of urine
Emergency (''blind') suprapubic cystostomy, suprapubic puncture (''SPP')
Open suprapubic cystostomy
Postgonococcal urethral strictures
Difficulties with strictures
Extravasation of urine complicating a stricture
Impassable strictures
Stones in the urinary tract
Nephrostomy for calculous anuria or hydronephrosis
Ureteric stones
Bladder stones in adults
Bladder stones in children
Urethral stones in children
Prostatic obstruction
Freyer's transvesical prostatectomy
Other causes of urinary obstruction[md]dyskinesia and bladder-neck fibrosis
Ghadvi's lateral perineal prostatectomy
Undescended or maldescended testes
Phimosis and paraphimosis
Meatal strictures
Other urological problems
The general method for the eye
Operating on an eye
The red painful eye
Loss of vision in a white eye
Uveitis; iritis and iridocyclitis (anterior uveitis), and choroiditis (posterior uveitis)
Refractive errors, difficulty reading, and presbyopia
Disease of the neuromuscular system of the eye (squints, amblyopia, and diplopia)
Diseases of the lids and nasolachrymal apparatus
Tarsal cysts (chalazions or Meibomian cysts) and granulomas
Destructive methods for the eye
Other eye problems
Otitis media and externa
Acute mastoiditis
Foreign bodies in the ear
Blocked nose and the general method for sinusitis
Frontal sinusitis
Maxillary sinusitis
Nasal polypi
Foreign bodies in the nose
Bronchoscopy: inhaled foreign bodies in the larynx and tracheobronchial tree
Foreign bodies in ''the throat'
Corrosive oesophagitis, and oesophageal strictures
Other problems in the ear, nose, and throat
Gum disease
Extracting teeth
Impacted third molars (''wisdom teeth')
Cancrum oris
Jaw swellings
Cleft lip and palate
Other dental and oral problems

Equipment for urology

Disease of the urinary tract can be very distressing, so much so that some sufferer in the Middle Ages is said to have prayed ''O Lord, take me not through my bladder''. You may not always be able to prevent the Creator taking your patients this way, but you can do much to help them. Urological cases are among the ''smelliest and dirtiest' in the wards. Because it is usually considered sensible to start making rounds at the ''clean' end, you and your staff are likely to arrive tired at the urological patients, and can easily neglect them.

You can treat acute, chronic, and ''acute on chronic' retention (23.5), and urethral strictures, whether they are passable (23.8) or not (23.9). You can remove the prostate, and take stones from the bladder in adults (23.15) and children (23.16) and from the urethra (23.17) and ureter (23.14), but not from the kidneys. You can treat carcinoma of the penis (32.33) and prostate (32.32), but not the bladder (32.31). You cannot do much about the congenital anomalies of the urinary tract, except to remember that the absence of a kidney is the most important one.

The most useful urological investigations are urinalysis, microscopy and culture, and a blood urea, followed, when necessary, by a urogram and cystoscopy. We have included methods for both the latter, although you can usually do without a cystoscope if you have to.

The commonest urological procedure is to pass a catheter to let a patient's urine flow out of his bladder. Catheters are graduated according to the Charri[gr]ere gauge, which is their circumference in millimetres. If there are two numbers, for example, 18/22 Ch, the smaller one refers to the circumference of the tip, and the larger one to the circumference of the shaft. Think of catheters in three sizes[md]8 or 10 Ch for simple drainage, 14 or 16 Ch Foley self-retaining catheters for the relief of retention, and large 20 or 24 Ch catheters for postoperative drainage or evacuating blood clots.

CATHETERS, latex or plastic, Jacques, 380 mm, (a) 8 Ch, ten only. (b) 10 Ch, twenty only. (c) 14 Ch, ten only. (d) 16 Ch, ten only. (e) 20 or 24 Ch, ten only. These are the cheapest, simplest, softest, and safest general purpose catheters. You will be wise to start with them before trying any others.

CATHETER, Tiemann, rubber or plastic, olive-tipped, (a) 16 Ch, twenty only. (b) 18 Ch, fifty only. (c) 20 Ch, fifty only. These have bent, olive-tipped ends, and you may succeed in passing one round a prominent prostatic middle lobe when you cannot pass a Jacques or a Foley catheter. A ''coud[ac]e' catheter is any catheter, like a Tiemann, with a bend near the tip.

CATHETER, Gibbon, simple polythene, with removable nylon stylet, 10 Ch, twenty only. The nylon stylet of a Gibbon catheter makes it easy to pass, but when it is removed the catheter is soft. It has a tube which you can lead straight into a collecting bottle, and flanges to strap to the penis.

CATHETERS, Foley, latex rubber, self-retaining, double channel, 30 ml balloon, (a) 14 Ch, twenty only. (b) 16 Ch, forty only. (c) 18 Ch, forty only. (d) 20 Ch, forty only. (e) 22 Ch, forty only. These have a balloon at the end which you can blow up through the second channel, and so keep the catheter in the bladder.

CATHETERS, Foley, silicone rubber, self-retaining, double- channel, 30 ml balloon, (a) 14 Ch, five only. (b) 22 Ch, five only. Keep these expensive silicone Foley catheters for long-term drainage and stricture management.

CATHETER, plastic, Foley balloon, three-channel for continuous irrigation, 75 ml balloon, straight tip, 22 Ch, twenty only. This catheter holds itself in place and allows you to irrigate the bladder. One channel is for the balloon, one is for irrigating fluid going into the bladder, and one for fluid and urine coming out. Use these for Freyer's prostatectomy (23.19).

CATHETER, Malecot, self-retaining, rubber or plastic. (a) 20 Ch. (b) 26 Ch. (d) 32 Ch. Twenty of each size. These are very similar in function to a de Pezzer catheter; which you use is a matter of personal preference. For suprapubic drainage, you can use a Foley as easily as a Malecot or a de Pezzer catheter.

Alternatively, CATHETER, de Pezzer, self-retaining, rubber or plastic, 20 Ch, 26 Ch, and 32 Ch. Twenty of each size. This self-retaining rubber catheter has a circular flange. You can put it on to an introducer, pull it straight to flatten the flange, insert it, and then remove the introducer, whereupon it will regain its original shape, and stay in place in the bladder (or in a caecostomy, 9.5). [f10]Malecot and de Pezzer catheters are only for suprapubic use.[f09]

INTRODUCER, catheter, two only. Keep one of these straight for introducing suprapubic catheters, and bend the other one into a smooth curve for introducing urethral catheters. If you use the same introducer for both purposes and keep on bending and unbending it, it will soon become so kinked that you cannot withdraw it. An introducer can be a dangerous instrument in the urethra, so use it with great care, and only when absolutely necessary.

SPIGOTS, plastic, for catheters, (a) small, fifty only. (b) large, fifty only. If a patient has a spigot in his indwelling catheter, he can walk about with it in, and remove it to drain his bladder. If you don't have plastic spigots, make wooden ones.

BOUGIES, neoplex, Porges (POR), filiform, (a) smaller sizes olive-tipped, (b) larger sizes plain, sizes 1 to 20 Ch, two only of each size. (c) Follower to fit, two only. Use these for dilating strictures, for which they have many advantages over metal bougies[md]except that they are much less durable. You can control their passage through the anterior urethra more easily, they follow the curve of the posterior urethra, and you will less easily cause false passages, even with small sizes. Cheatle's forceps can crush plastic bougies when they are hot, so tie them into bundles, and handle them only with tapes. Lift them out of the sterilizer and put them into cold boiled water. They will then be the right consistency for use.

SOUNDS, metal, large, blunt, straight, plain-end, Powell's, sizes 12 to 20 Ch, one only of each size. Historically, a ''sound' refers to a metal instrument used to locate stones in the bladder by the sound of the instrument hitting the stone. The terms ''sound' and ''bougie' are now used synonymously. If you are going to use a metal sound, Powell's straight sounds are the safest[md]a large one is much too large to be led down a false passage.

SOUNDS, metal, Otis[nd]Clutton urethral, curved with olive ends, 9/14 Ch, 11/15 Ch, 12/17 Ch, 14/18 Ch, 15/20 Ch, 17/21 Ch, and 18/23 Ch, one only of each size. Use these for dilating a strictured urethra. The set is deliberately incomplete, because small sounds are dangerous, and can too easily cause a false passage.

TROCAR and cannula, gall-bladder, Ochsner, with metal piston and side branch, medium size, one only. Although this is intended for draining a patient's gall-bladder, it is even more useful for draining his urinary bladder suprapubically.

SYRINGE, bladder washout, 50 ml, plastic, boilable, two only.

RETRACTOR, Thomson[nd]Walker, with two pairs of detachable abdominal wall blades, and a long blade for posterior wall, one only. Use this for a suprapubic prostatectomy. It is designed to reach into the floor of the bladder.

URINE BAGS, simple pattern, with drainage outlet at the bottom, plastic, reusable, five hundred only. Although these bags are intended to be disposable, you can boil them and reuse them many times. Put 20 ml of cetrimide into the bag to help prevent infection, especially in long-standing cases. If you don't have any urine bags, you can wash blood-giving bags and blood-giving sets, cut them, and adapt them.

CLAMP, penile with rachet, twenty only. If a patient is incontinent, he may find a penile clamp useful. You can also use one to retain local anaesthetic before you pass a catheter.

BIOPSY NEEDLE, Travenol ''Tru-cut' (TRAV) code 2N2704, one only. This is for the operative treatment of priapism (23.29). Several punctures with a large ordinary needle or a sharp trocar may be effective.

Fig. 23-1 EQUIPMENT FOR UROLOGY. Each catheter has its own special purpose. The Charri[gr]ere scale shows the actual diameter of each catheter.