Infections of urogenital system are characterised by the following symptoms: dysuria, urgency in micturition, colic pain in either flanks or the loins, pain on the lower abdomen due to inflammation of the urinary bladder (cystitis), poor urinary stream, dribbling and hesitancy, nocturia, urinary incontinence, urinary retention, haematuria and renal failure.

These symptoms overlap over many specific conditions hence a thorough examination is required:

• Ask and check for urethral discharge

• Palpate the urethra for areas of induration (stricture)

• Palpate the lower abdomen for tenderness, masses in the urinary bladder

• Bimanually palpate the kidney for masses or tenderness

• Do rectal or vaginal examination:

- manually palpate the urinary bladder for masses

- feel for the prostate in a man (size, consistency, nodularity, tenderness, fixation of rectal mucosa to it, etc).

URINARY RETENTION

Inability to pass urine while the urinary bladder is full. There is an urge to micturate and if not relieved, there is severe pain with straining.

Common Causes

Children Meatal Stenosis; Phimosis or paraphimosis; Posterior urethra valves; Ruptured urethra after trauma, constipation.

Adult - 20-50 years Urethral stricture; Calculi (bladder and urethral stones); Bladder tumours; Ruptured urethra (trauma); Post-operative (any perinea! operation); Clot retention.

After 50 years Prostatism (Benign prostatic enlargement Ca. prostate, prostatitis, prostatic fibrosis); calculi; urethral strictures; bladder tumours; ruptured urethra (trauma); clot retention.

Females Bladder tumours; calculi; pelvic tumours (Cancer cervix, etc); urethral stenosis; clot retention (severe haematuria).

NB Cord compression with paraplegia/quadriplegia will result in urinary retention.

Management

• Relieve Acute retention

- pass a size 16FG foley's catheter in adults or 8FG in children, if it passes and bladder is emptied retain it.

• If catheterisation fails, do a Suprapubic puncture 2-3 cm above pubic crest

- after urine is drained, the anteverted bladder returns to normal position. Try catheterization again if fails use cystofix or suprapubic cystostomy and refer.

NB All catheters must be well lubricated with gel (Xylocaine, K-Y gel, etc).

Management - Definitive

• Do circumcision for phimosis or paraphimosis [see circumcision].

Refer If

• Prostatectomy and urethroplasty are indicated.

URETHRAL STRICTURE

Causes Congenital, traumatic (usually follows fracture of pelvis); inflammatory (follows gonorrhoea infection usually earlier in life); instrumentation: Indwelling catheter following endoscopy; post-operative following prostatectomy; after amputation of penis.

Clinical Features

Usually younger patient (below 50 years). Early symptoms: Passage of flakes in urine with early morning urethral discharge, later; difficulties in micturition (narrow prolonged stream, dribbling, straining). Urine retention with a distended urinary bladder.

Ask for any history of urethral discharge in the past, history of pelvic injury, history of instrumentation. Palpate urethra for induration. Do a rectal examination in all patients.

Investigations

• Urinalysis and C&S

• Urea and electrolytes

• Micturating cystourethrogram (MCU) and ascending urethrogram.

Management

• Suprapubic cystostomy or insert cystofix if there is retention of urine

• Basic investigations as above and treat for urethral discharge before any further treatment

Refer Patient for definitive surgical treatment.

URETHRAL INJURIES

May result from:

• A fall astride a projecting object

• A loose manhole cover

• Cycling accident

• Fracture of pelvis in road traffic accident

• Penetrating wounds (bullet wounds, etc)

• latrogenic.

Clinical Features

Urethral bleeding. Retention of urine. Perineal haematoma. Signs of fractured pelvis.

Management - Preliminary

• Do not catheterize the patient per urethra

• Give morphine or pethidine

• Empty bladder if full through a suprapubic cystostomy, but if the patient has passed urine “leave him alone”

• Start antibiotics

• Group and cross-match blood

• Do plain pelvic X-ray.

Definitive treatment will depend on which part of the urethra is ruptured, anterior (bulbous) or posterior (membranous). This is specialised treatment for which the patient should be referred to a surgeon. As this may not always be possible, the alternative is to do a suprapubic cystotomy and insert a catheter and refer.

Procedure for Suprapubic Cystotomy

This is done under strict aseptic precondition.

• Clean the abdomen and hypogastrium well with an antiseptic and drape with sterile towels

• Feel for the distended bladder and 2-3 cm above the upper pubic margin, infiltrate local anaesthetic

• Make a 2 cm transverse incision and dissect the tissues with a haemostat

• Open the bladder under direct vision and introduce a 16F Foley's catheter

• Close the layers around the catheter with stitches

• Balloon the catheter and leave it to drain for 14 days (in the meantime refer the patient)

Admit For

• Resuscitation and suprapubic catheterization.

Complications of Ruptured Urethra

Subcutaneous extravasation of urine and urethra stricture. This is made worse by infection or iatrogenically by inadvertent attempts to catheterize or do urethrography and urethroscopy, early.

RUPTURE OF BLADDER

This usually follows:

• A blow, kick or fall on a distended bladder

• Gunshot wounds/stab wound

• Passage of instruments

• Endoscopic resection of prostate or bladder tumour

• Diathermy coagulation of bladder tumour

• Operative procedures in the pelvis (e.g. C/S, tubal ligation, hysterectomy).

Clinical Features

The bladder may be injured intraperitoneally or extraperitoneally. Intraperitoneal Rupture Sudden agonizing pain in the hypogastrium. Severe shock, abdomen is rigid and distends slowly. Patient passes no urine. Rectal examination reveals a bulge in the pouch of Douglas. Extraperitoneal Rupture Similar symptoms like in rupture of posterior urethra described above.

Investigations

• Blood stained urine

• Plain erect X-ray of the abdomen show “ground glass” appearance of fluid in the lower abdomen

• Intravenous urography will demonstrate a leak from the bladder

• If there is no fracture pelvis, pass a 14F Foley's catheter and a little blood stained urine will drain out.

Management

• Laparotomy is done after resuscitative measures are taken

• The rupture in the bladder is repaired in two layers of catgut

A catheter is left in situ for ten to fourteen days.

Complications

Severe peritonitis if not attended to within 12 hours. If left unattended the mortality rate is 100%.

CIRCUMCISION

This is excision of the prepuce (fore skin of penis).
indications includes ritual (religious, traditional, personal), phimosis, paraphimosis, recurrent herpes genitalis restricted to the prepuce, recurrent balanitis (inflammation of prepuce), balanoposthitis (inflammation of prepuce and glans penis), tight frenulum, long and adherent prepuce.

Method:

• Clean and drape the perineum

• Local anaesthesia is used

• Dilate the prepucial meatus with artery forceps

• Retract foreskin and clean with warm saline

• Make circular incision on inner skin ~ 3 cm from the corona taking care not to injure the urethra and the glans penis

• Pull foreskin over glans penis and make incision with surgical knife over the coronal sulcus. Leave adequate penile skin

• Complete circumcision with scissors

• Control all bleeders with Bipolar Diathermy or ligatures.

• Suture incision with 4/0 plain catgut.

Use of Plastibel in circumcision of neonates is not recommended due to frequent urethral injuries and is best left for experienced surgeons.

Methods for infants, adolescent and adults is as described above. It can be safely performed under local anaesthetic. DO NOT USE ADRENALINE.