Difficulties with strictures

Here are the difficulties you may meet in dealing with a stricture. Most of them are characteristically a problem of gonococcal strictures. Extravasation of urine is described in the next section, and impassable strictures in Section 23.11.

EARLY DIFFICULTIES [s7]WITH STRICTURES If BOUGINAGE FAILS but the patient CAN PASS URINE, it is not a disaster. Let him go home and wait a week or two. When he returns, bouginage may be easier. If you again fail to dilate him, and cannot refer him, see Section 23.11.

If BOUGINAGE FAILS and he CANNOT PASS URINE, admit him for some method of suprapubic cystotomy, preferably small- bore suprapubic puncture (23.6). As soon as the acute episode has resolved, he can leave hospital with his suprapubic tube, and reattend the bougie clinic a week or so later. You will probably be able to pass a bougie, if not at the first visit, then at a later one when his stricture has settled down. If necessary, try again at weekly or 2-weekly intervals. With patience and perseverance most strictures will yield. Once you have passed a 7 or 8 Ch bougie, his urine flow will be adequate, and you can remove his suprapubic tube. Or, you can spigot it, and make sure he can void adequately, before you remove it. If his urethra is of adequate calibre, his suprapubic puncture track will rapidly close. His stricture is now manageable[md]but is not cured!

If on the above regime, his stricture remains impassable, see Section 23.11.

If his STRICTURE BLEEDS stop dilating[md]immediately! You have damaged his mucosa. If you continue, you may create a false passage, and make further treatment more difficult. Try again two weeks later. The corpora cavernosa can bleed briskly, and, to the patient, alarmingly. Bleeding usually stops, but he may return in a few hours with retention of urine. You are much more likely to damage his urethra, if you try to dilate it under general anaesthesia.

If he has PAINFUL RETENTION WITH HAEMATURIA and urethral bleeding, he has CLOT RETENTION. The combination of a painfully distended bladder and blood loss may cause shock, so he may need intravenous fluids or blood. Open his bladder suprapubically (23.7) and remove the clot.

If he develops a FALSE PASSAGE it is the result of: (1) failure in the art of bouginage, (2) doing it when his urethra is acutely inflamed, or (3) under anaesthesia. The bougie goes through the false passage, whereas urine will not, so the his symptoms are not improved, and bleeding, extravasation, and abscess formation may follow. Ideally, a bougie should be passed through the correct route, under the direct vision of an endoscope.

If there is no extravasation, merely drain him suprapubically.

If there is extravasation, see Section 23.10.

If the bougie goes into his RECTUM, which it should never do, drain his bladder suprapubically, give him prophylactic antibiotics, consider doing a temporary colostomy (which is unikely to be necessary), and refer him.

If he has RIGORS, after instrumentation, these are likely to be transient and self-limiting.

If he develops COLLAPSE AND SHOCK after bouginage, suspect Gram-negative septicaemia, which is uncommon, but very dangerous, and may kill him. Take a blood culture, and start parenteral broad-spectrum antibiotics (gentamicin and metronidazole).

Other early complications include transient incontinence (uncommon).

Fig. 23-10 A ''WATERING CAN PERINEUM' is the late result of a complex gonococcal stricture, or rarely a tuberculous one. Multiple chronically infected and epithelialized fistulae have involved this patient's penis, scrotum, perineum and thighs. A sullen ooze of purulent discharge is more usual than the shower of urine shown here. Kindly contributed by Neville Harrison

LATE DIFFICULTIES [s7]WITH STRICTURES If he has CHRONIC RETENTION with a HIGH BLOOD UREA, divert his urine suprabubically by blind (23.6) or open (23.7) cystostomy. But be careful, the relief of chronic obstruction is often followed by an obligatory polyuria, which may amount to several litres a day. See Section 23.5.

If his BLADDER CONTINUES TO EMPTY INADEQUATELY, or not at all, after you have dilated his stricture, try a period of continuous bladder drainage for up to 6 weeks to keep it empty. This may be followed by successful voiding.

If he develops a TENDER PAINFUL SWELLING in his perineum, he probably has a PERIURETHRAL ABSCESS, which may or may not be associated with retention of urine. The diagnosis is not difficult, but you can easily overlook it in the presence of retention of urine[md]see also Section 5.14.

If he develops a FISTULA, it is the consequence of an inadequately treated periurethral abscess, or he may give no history of an acute episode, and his fistula may appear spontaneously. Multiple fistulae may involve his perineum, scrotum, and penis, his perianal region and the inner aspects of his thighs (the ''watering can perineum' in Fig. 23-10). You may be able to demonstrate these fistulae radiologically. Sometimes, a fistula forms between his urethra and his rectum.

If his fistula is recent, give him a course of antibiotics, dilate his stricture, and divert his urine by suprapubic drainage. You will probably have to do this by open cystostomy (23.7), because his bladder will not be distended.

If his fistula is an old one, with epithelialized tracks, treatment is difficult. In theory, excising all the tracks and diverting his urine should allow slow healing. In practice, teatment is prolonged and disappointing.

If his fistula fails to close, suspect tuberculosis or carcinoma, and exclude these histologically.

If chronic fistulae and periurethral sepsis lead to gross ELEPHANTIASIS (uncommon), consider excising his chronically oedematous tissue, and retaining his skin by raising flaps at least 1 cm thick. If necessary, excise his oedematous tissues totally and graft the bare area with split skin.

If his TESTES AND EPIDIDYMES SWELL, he has developed acute epididymo-orchitis. Treat him non-operatively with antibiotics (ampicillin or trimethoprim).

If his PERINEUM, LOWER ABDOMEN, OR PENIS SWELL, he has EXTRAVASATION of urine (23.10).

If HIS BLADDER REMAINS DISTENDED AFTER HE HAS PASSED URINE (he has a high residual urine), this is either due to detrusor failure, or bladder-neck stenosis, or both. Or, he may have a stricture and benign (or malignant) prostatic hypertrophy. Bladder-neck stenosis is probably caused by chronic infection. You may feel it as a prominent lip when you pass a straight metal bougie, or you may see it radiologically (34.5). You can: (1) Refer him for a transurethral resection, if his urethra is wide enough to pass the instrument. Or, (2) open his bladder and either incise his bladder neck, or remove his prostate.

CAUTION ! A prominent bladder neck, felt or seen, does not always indicate stenosis. Only a tight bladder neck can be diagnosed in this way.

If he develops STONES, they are the result of infected stagnant urine, and may form in his dilated urethra proximal to the stricture. They will remain until you remove them by cystotomy or urethrotomy. Then treat his stricture and his infection.

If he BLEEDS FROM HIS URETHRA, and this is not associated with instrumentation, consider the possibility of a BLADDER TUMOUR (32.31), and don't necessarily attribute the bleeding to the stricture, or its treatment. By the time the diagnosis is made, the tumour may have extended beyond his bladder, and may have appeared through a cystostomy track, or a urethral fistula. You will not be able to see the lesion until you have dilated his stricture to at least 18 Ch to take a cystoscope. You may also see it as a filling defect in a cystogram. If it has already extended beyond his bladder, it is inoperable, and palliation merely prolongs his misery.

A FORCED PASSAGE IS A FALSE PASSAGE