Extravasation of urine complicating a stricture

The effects of extravasated urine are dramatic. The combination of urine and infection produces severe oedema of a patient's scrotum and abdominal wall. If this is not treated, the skin over his scrotum, penis, and anterior abdominal wall may slough. He may be very ill, toxic, febrile, dehydrated, anaemic, or uraemic, or all of these things. If his renal function is impaired, as it often is after a long standing stricture, extravasation may kill him.

Urine can extravasate from a stricture spontaneously, through a periurethral abscess, or as the result of bouginage. The other important cause is trauma (68.7). The attachments of Camper's (Buck's) and Colle's fascia limit its spread so that: (1) From a hole in his bulbous urethra it can track into his scrotum, up over his pubis and into his lower abdominal wall. (2) From a hole in his penile urethra the swelling is limited to his penis.

Fig. 23-11 EXTRAVASATION OF URINE. A, the fascial planes concerned with the superficial extravasation of urine. B, incisions for drainage. C, a dissected drawing (not an operation!) showing the directions in which urine can track (C, Fig. 68-6 shows another way to drain extravasated urine).

1, and 2, incisions for drainage. 3, Colles' fascia. 4, Camper's fascia. 5, the transversus perinei muscle. 6, Denonvillier's fascia. 7, the triangular ligament. A, from ''Hamilton Bailey's Emergency Surgery', edited by HAF Dudley, Fig. 50.11 (John wright). With the kind permission of Hugh Dudley.

EXTRAVASATION OF URINE Exclude cardiac, renal, and hepatic causes of oedema.

Assess the patient's fluid and electrolyte state before surgery. He will probably benefit from intravenous fluid replacement, which may be life-saving.

Control infection with antibiotics. Chloramphenicol will probably be suitable.

DIVERT HIS URINE FLOW so that it no longer leaks into his tissues. His bladder will probably not be palpable because: (1) his urine has ''passed' into his tissues, and (2) oedema may obscure his swollen bladder, even if it is distended. You will probably have to do an open cystostomy (23.7), because: (a) his bladder is unlikely to be dilated enough for a blind one, and (b) you are unlikely to be able to negotiate his stricture with a urethral catheter. Make a formal suprapubic cystostomy, and divert his urine through a high, oblique, midline track.

Later, treat his stricture (23.8). Remove his suprapubic catheter, as soon as regular progressive dilatation has opened up his urethra enough to provide an adequate flow (7 or 8 Ch). If his urine flow is adequate, the high, oblique, midline, suprapubic track that you have made should close satisfactorily.

If you have to continue suprapubic drainage for more than a month, change the suprapubic catheter at 4- to 6-week intervals[md]see Section 23.7.

DRAIN THE URINE OUT OF HIS TISSUES. Lay him supine, give him a general anaesthetic and perioperative antibiotics (ampicillin, trimethoprim, or gentamicin). Clean his abdomen, penis, and scrotum, and the upper half of his thighs with 1% cetrimide, followed by 1% alcoholic iodine.

(1) Make 5 cm incisions on each side of the base of his penis. Insert your index finger, and open up the tissue planes widely towards his abdomen, and down the shaft of his penis. (2) Make 5 cm incisions on the inferolateral aspects of his scrotum, and use your finger to open up the tissue planes as far as possible. Place two long corrugated rubber drains into the depth of each wound in each direction, and suture them in place. Dress the wounds with gauze and cotton wool. Bath him in a bowl of salt water each day. The swelling will usually settle in about 5 days. Shorten the drains 5 cm a day. Areas of necrotic skin and subcutaneous tissue will form. These will take a long time to separate spontaneously, so excise them. When infection has subsided, close the skin incisions by secondary suture, and graft the bare areas (57.2). Don't attempt bouginage again until he is much improved, say at 4 to 6 weeks.