URETHRAL RUPTURE.
When laceration of the urethra is met with soon after the injury, a sterilised and well-lubricated soft rubber catheter should be passed down the tube and coaxed into the bladder if possible; failing in this attempt, the patient should be put under chloroform and a rigid instrument tried. After the catheter has been introduced into the bladder it should , he tied in for a week, and a long piece of rubber attached to siphon off the urine into a vessel placed beneath the bed.
When the bladder cannot be entered in this manner, a full-sized staff should be passed down to the laceration, and the skin and tissues freely divided in the perineum, so as to fully expose the ruptured tube and admit of the discovery of the proximal end of the torn portion. The staff being withdrawn, a full-sized rubber catheter is passed through the meatus and guided through the proximal opening into the bladder, after which the laceration should be sutured over the catheter and the perineal wound closed, a drain being left in and the catheter retained for to days with a rubber siphon to continuously drain off the urine as it flows into the bladder from the ureters.
Often, however, it will be found that the bladder end of the rupture escapes detection, and the only resource open to the surgeon is to do suprapubic cystotomy, and guide an instrument from above through the neck of the bladder into the urethra, and out through the perineal wound, or a perinea] section down to the seat of the rupture will prevent extravasation and allow the urethral mucous membrane to heal. If
division has been complete, an attempt should be made to unite by means of fine catgut sutures the torn ends of the urethra.
Ultimately a suitable plastic operation may be indicated when the patient survives the cystotomy and the sloughing caused by extravasated urine. Sapiejko has obtained success by transplanting grafts taken from the mucous membrane lining the lower lip, with the view of restoring the destroyed portions of the urethra; grafts as large as r inch by E inch were sutured to the ends of the divided urethra.
If extravasation of urine has already occurred when the case comes under observation, perinea] section should be performed without attempt ing catheterisation, and a number of deep incisions should be made into the boggy area, one of these passing down to the site of the rupture, and these should be thoroughly irrigated by warm Saline solution.
Ruptured urethra is invariably followed by stricture, for which systematic dilatation will be required, and the patient should be taught to pass a full-sized Bougie at regular intervals, as in the treatment of ordinary organic stricture.