The injuries to a patient's penis and scrotum are discussed in Section 68.8. Here we describe the foreign bodies that can enter his lower urinary tract, and some urological problems.
OTHER UROLOGICAL PROBLEMS For a periurethral abscess, see Section 5.14.
If a patient says that a FOREIGN BODY body has entered his urethra, try to remove it with as little damage as possible. Give him a general anaesthetic. Ideally, identify it with a cystoscope with a 0[de] telescope to look down his urethra. Failing this, locate it in his penis by palpation and with X-rays. Try to disimpact its distal end from the wall of his urethra. Use alligator forceps and, perhaps, a large bore cannula. If necessary, do a urethrotomy, and cut down on his urethra through the ventral surface of his penis.
If the foreign body is far back in his urethra, try to dislodge it into his bladder, and if you cannot remove it endoscopically, do so through a small suprapubic cystotomy.
If it is a pin, you will have to remove it head first, so put its point through the wall of his urethra, and turn it round.
If the opposing SURFACES OF HIS GLANS AND PREPUCE ARE ACUTELY INFLAMED, he has acute BALANITIS. Test his urine for sugar to exclude diabetes. The primary treatment of balanitis is better hygiene, and the application of an antiseptic. Show him how to retract his foreskin. Ask him to do this at least 3 times daily, to wash with soap and water and to apply a mild antiseptic, such as chlorhexidine or ''Savlon' (cetrimide and hexachlorophene). Systemic antibiotics should not be needed. If he has associated phimosis, circumcise him or make a dorsal slit when the infection has subsided.
If PAIN AND SWELLING DEVELOP WITH EXPLOSIVE RAPIDITY in his penis or scrotum, and he becomes very ill, suspect that they are about to slough as the result of FOURNIER'S GANGRENE (more appropriately called acute necrotising subcutaneous infection). This is more common in diabetics, and may follow surgery to his scrotum or penis, or extravasation of urine. It resembles cancrum oris, and may follow ]]measles. It is caused by a synergistic combination of organisms, including anaerobes. Cl. Welchii is sometimes responsible, and may form gas in his scrotum. It may spread rapidly, eat away much of his scrotum, penis or abdominal wall, and end in Gram-negative septicaemia and death.
Control the infection with gentamicin, or a cephalosporin and metronidazole. Apply wet dressings of saline or povidone iodine. Alcoholic iodine is effective, but very painful. The sloughs will probably separate rapidly to expose his testes. Excise all dead tissue as soon as possible, sacrificing some living tissue if necessary. If necessary expose his testes and the shaft of his penis. When the infection has settled, attempt secondary suture (54.6) or split skin grafting as appropriate. You may have to bury his testes in his abdominal wall.
If he passes MILKY URINE, he has CHYLURIA due to a fistula between his lymphatics and his urinary tract. Sometimes he passes chyle and blood (haematochyluria). The endemic form of chyluria is due to W. bancrofti (but not W. malayi ) blocking his lymphatics and promoting fistulae between his lymphatic system and his urinary tract. Where W. bancrofti is endemic chyluria is not uncommon, elsewhere it is rare. Chyluria debilitates, through a persistent loss of fat in the urine, but does not kill. Treatment is medical, with diethyl carbamazine 2 mg/kg (''Heterazan') three times a day for 14 days, repeated at intervals. Don't ask him to restrict his diet. He has a 50% chance of remitting spontaneously. No surgical method is effective, or simple enough, to be described here.
24 The eye