URETHRAL STRICTURE Urethral strictures are becoming more prevalent secondary to the rising incidence of STDs. Increasingly, in teenagers and young adults, gonococcal and chlamydial infections have resulted in bulbous urethral obstruction ( Fig 91-11), while trauma and urethral instrumentation are less common and tend to be localized to areas where a traumatic event has occurred. In the older population, postendoscopy meatal stenosis or localized urethral strictures are more common.

Urethral Sphincter Endoskopy

If a patient requires measurement of his residual urine, has difficulty voiding, or is in urinary retention, and a 14F or 16F Foley or Coudé catheter cannot be easily placed into the bladder, the differential diagnostic possibilities include urethral stricture, voluntary external sphincter spasm, bladder neck contracture, or BPH. If time permits, retrograde urethrography can be done, which will define the location and extent of a urethral stricture. Only endoscopy can confirm a bladder neck contracture or the extent of an obstructing prostate gland. Suspected voluntary external sphincter spasm can be overcome by holding the penis upright and encouraging the patient to relax his perineum and breathe slowly during the procedure ( Fig 91-12).

Prostatic Balloon Dilation Catheters

FIG. 91-12. Foley catheter placement. Holding the penis upright will help eliminate urethral folding and reduce external sphincter spasm, both of which can impede catheter placement.

When a urethral stricture is encountered, copious anesthetic lubrication is placed intraurethrally after the foreskin has been controlled with a folded 4 * 4. This latter maneuver is especially important in uncircumcised patients (Fig 91-13). A 12F or 14F Coudé catheter may negotiate the strictured area, since this catheter has an angled bend near its tip (Fig 91-14). If there are previous false passages from attempts at dilation or unsuccessful instrumentation, passage of the Coudé catheter may be difficult. Further urethral manipulation may create new false passages, leading to unnecessary hemorrhage and possible gram-negative bacteremia. If two or three gentle attempts to pass the catheter fail, urologic consultation is indicated. Under no circumstance should a catheter guide or urethral sound be used by anyone other than a urologist (F,i,g ,,,,9,1:1,5).

Catheter False Passage
FIG. 91-13. Foley catheter placement. Improper foreskin retraction and immobilization leads to difficulty with catheterization. The uncircumsized patient's foreskin should be fully retracted and immobilized with a folded 4 * 4.
Supra Pubic AspirateUrethritis Medicine

In an emergency situation, suprapubic cystostomy, utilizing the Seldinger technique, can be performed with the least amount of morbidity. The infraumbilical and suprapubic area is prepped with povidone-iodine solution. A 25- to 27-g spinal needle is used to locate the bladder ( Fig 9.1-16.). This step is especially important in cases of previous lower abdominal surgery where normal anatomic relationships may be distorted. Commercially available introducer cystostomy kits are readily available and utilize the Seldinger technique, which allows easy access to the bladder with a balloon catheter for temporary drainage. After the bladder has been accessed with a syringe and needle, the syringe is removed and a guidewire is passed through the needle into the bladder. The needle is then removed and the fascial dilator with an overlying 14F to 18F peel away sheath is passed over the wire into the bladder. The wire and dilator are then removed leaving the hollow peel-away sheath. An appropriate-sized Foley balloon catheter is passed through the peel-away sheath into the bladder, urine is aspirated from the catheter to assure proper placement, and the balloon is inflated with water. The sheath is then removed from the bladder and peeled away leaving the indwelling catheter, which should be withdrawn until it snugly approximates the cystostomy site. Appropriate urologic follow-up is necessary in two to three days.

URETHRAL FOREIGN BODIES Patients of all ages, but especially young children, may be victims of innocent urethral exploration or attempts to heighten sexual experiences utilizing a variety of foreign bodies such as bobby pins; long, thin paint brushes; or ball point pens. Bloody urine combined with infection and slow, painful urination should suggest a possible foreign body in the lower urinary tract. An x-ray of the bladder and urethral areas may disclose the presence of a foreign body.

Foreign bodies often require endoscopic removal or even open cystotomy. Occasionally a gentle milking action of the proximal end of the urethral foreign body by an experienced examiner will allow its retrieval from the distal urethral meatus. Even then, retrograde urethrography or endoscopic confirmation of an intact, nontraumatized urethra is indicated.

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