Page 1353 - TNFlipTest

Toronto Notes 2019 Infertility Urology U35 Urethral Injuries
Etiology
• posteriorurethra
■ common site of injury is junction of membranous and prostatic urethra due to blunt trauma, MVCs,
pelvic fracture
■ shearing force on fixed membranous and mobile prostatic urethra
• anteriorurethra
■ straddle injury can crush bulbar urethra against pubic rami
• othercauses
■ iatrogenic (instrumentation, prosthesis insertion), penile fracture, masturbation with urethral
manipulation
• alwayslookforassociatedbladderrupture
Clinical Features
• bloodaturethralmeatus
• high-ridingprostateonDRE
• swellingandbutterflyperinealhematoma • penileand/orscrotalhematoma
• sensationofvoidingwithoutU/O
• distendedbladder
Investigations
• mustperformRUGorcystoscopypriortocatheterization
Treatment
• simplecontusions ■ no treatment
• partialurethraldisruption
■ very gentle attempt at catheterization by urologist
■ with no resistance to catheterization → Foley x 2-3 wk
■ with resistance to catheterization → suprapubic cystostomy or urethral catheter alignment
• periodicflowrates/urethrogramstoevaluateforstrictureformation • completedisruption
■ immediate repair if patient stable, delayed repair if unstable (suprapubic tube in interim)
Complications
• stricture
Infertility
Definition
• failuretoconceiveafteroneyearoffrequent,unprotectedandproperlytimedintercourse • incidence
■ 15% of all couples (35-40% female, 20% male, 25-30% combined)
Female Factors
• seeGynecology,GY22 Male Factors
Male Reproduction
• hypothalamic-pituitary-testicularaxis(HPTA)
■ pulsatile GnRH from hypothalamus acts on anterior pituitary stimulating release of LH and FSH ■ LH acts on Leydig (interstitial) cells → testosterone synthesis and secretion
■ FSH acts on Sertoli cells → structural and metabolic support to developing spermatogenic cells
■ FSH and testosterone support germ cells (responsible for spermatogenesis)
■ spermroute:epididymis→vasdeferens→ejaculatoryducts→prostaticurethra
Etiology
• idiopathic(40-50%infertilemales) • testicular
■ varicocele (35-40% infertile males)
■ tumour
■ congenital (Klinefelter’s triad: small, firm testes, gynecomastia, and azoospermia) ■ post-infectious (epididymo-orchitis, STIs, mumps)
■ uncorrected torsion
■ cryptorchidism(<5%ofcases)
All patients with suspected urethral injury should undergo RUG