(Disclaimer: This article is for scientific use only, and the relevant information in the following content has been processed to protect patient privacy)
Abstract: In this article, a 68-year-old old man with unbearable urethral pain and bleeding after self-extraction of a urinary catheter without emptying the balloon was unable to urinate on his own. After treatment in our department, a urinary catheter was successfully retained along the guidewire under cystoscopy, 24-hour bladder irrigation was given, and hemostatic drugs were also applied, and the hematuria disappeared and the pain was relieved after 3 days. After 8 days of anti-infection treatment, he was discharged with a urinary catheter and was able to urinate smoothly after removal of the catheter in 1 month.
Basic information】Male, 68 years old
Disease Type】Urethral injury, urinary retention
Hospital】Harbin First Hospital
Date of consultation】March 2022
Treatment plan】Urinary catheter (F18 ultra-slip triple-lumen urethral catheter) + intravenous injection (spearhead viper hemagglutinase + cefotaxime sodium for injection) + bladder irrigation
Treatment period】Inpatient treatment for 8 days, outpatient follow-up after 1 month
Treatment effect] The patient’s hematuria disappeared, pain symptoms were reduced, and he could urinate smoothly after removal of the urinary catheter.
I. Initial consultation
Two days ago, the patient was unable to urinate on his own after drinking alcohol and had a urinary catheter placed in a local hospital. He went to the pharmacy and bought Yunnan Baiyao, but after 4 hours, the bleeding did not ease, and he was unable to urinate on his own. He came to our hospital urgently. The emergency department failed to place a urinary catheter and asked our department to consult him. The patient had a painful expression and a bulging lower abdomen, which was painful on pressure. There was no bruising or butterfly swelling in the perineum. The prostate gland was not elevated and displaced by rectal palpation, and there was no blood in the finger sleeve. The preliminary diagnosis was urethral injury and urinary retention.
II. Treatment history
After the patient was transferred to our department, he was given chest X-ray, routine blood tests, and retrograde urography, which showed posterior urethral stricture without extravasation of contrast. The patient was considered as a possible posterior urethral contusion or laceration, and the patient’s indwelling urinary catheter failed in the emergency department. Treatment option 1: we can choose to try urination for 2-3 weeks after cystostomy, and if normal urination is not possible or there is urinary extravasation, then we can perform surgery; treatment option 2: we can choose to perform cystourethroscopy, and if the injury is not serious, we can leave the urinary catheter under the guidance of guidewire for 1 month. after 1 month, the urinary catheter is removed to observe urination.
After communication with the patient and family, the patient and family considered option 2. Subsequently, cystoscopy was performed under intravenous anesthesia, and the patient was found to have significant prostatic hyperplasia, two lacerations of the posterior urethra, multiple contusions of the bladder neck opening and prostate mucosa, and local mucosal swelling. An ultra-slip guidewire was left in place, and an F18 ultra-slip triple-lumen urethral catheter was smoothly left in place along the guidewire, and continuous bladder irrigation was performed, while hemostasis with injectable spearhead viper hemagglutinase and anti-infective treatment with injectable cefotaxime sodium were applied.
III. Treatment effect
After retention of the urinary catheter, urine was immediately drained out and the patient’s lower abdominal bulge disappeared; after 1 day of treatment, the patient’s bleeding symptoms were relieved and bladder irrigation and spearhead viper hemagglutinase for injection were stopped. After continuing anti-infection treatment for a few days, the patient’s symptoms improved, pain was significantly relieved, no blood oozing from the urethra or causing infection occurred, and the patient was discharged with a urinary catheter on the 8th day of hospitalization. The patient was discharged from the hospital one month after removal of the urinary catheter, and no carnal hematuria was observed.
IV. Notes
We are glad that the patient’s urethral injury healed successfully. Since the patient has a history of prostatic hyperplasia, which is aggravated by alcohol consumption and urinary retention, the patient was advised to reduce alcohol consumption after discharge and to pay attention to his diet with a light and easy-to-digest diet to promote recovery from the disease. The patient was also advised to observe urination daily and to review urinary ultrasound, bladder residual urine measurement and PSA after six months, and was instructed to listen to the doctor’s advice and not to act recklessly in the future.
V. Personal insight
Urethral injury includes posterior urethral injury and anterior urethral injury, which is usually treated with indwelling urinary catheter, prevention of infection and shock, and hemostasis. If the indwelling urinary catheter fails, cystostomy is performed, and the condition is stabilized and then treated with second-stage surgery. However, the difficulty in the treatment of urethral injury is how to reduce and treat long-term complications such as traumatic urethral stricture.
Reviewing the treatment of this patient, this patient’s posterior urethral injury had three advantages of an indwelling catheter under cystoscopy, the first being that the patient was spared the pain of a cystostomy and the twists and turns of secondary examination and treatment. The second is that the urethra is supported by a urinary catheter after placement, which reduces the risk of fibrous tissue proliferation and scar formation causing urethral stricture during the stricture period. The third is that ureteral traction and compression has a hemostatic effect, but at the same time, cystourethroscopy in the early stage of patient injury also has the risk of aggravating urethral injury in patients. My perception is: firstly, we should try to choose a thinner cystoscope, such as a good field of view can choose ureteroscopy, if the field of view is poor, we can also choose F14, F16, F18 cystoscope to reduce the risk of secondary injury. Secondly, we should stop at the right time and not get too entangled. If we find that the urethral injury is serious and the matter is not feasible, we should give up decisively and choose cystostomy and second stage treatment.