Small Ani. Sx- Urinary 4

kelseyfmeyer's version from 2016-03-05 14:35

Urethra (intro, cath, lithiasis)

Question Answer
how can you insert a cath with just your hands?simple method- insert finger and feel external urethra meatus and slide cath near your finger and insert it right away. use friendly and easy to perform
if you use a vaginoscope (speculum) to perform a cathatarization, how do you use it to visualize the urethra? how must you be mindful of removing it?insert at 6o'clock and then rotate upside down to 12 o'clock and then open to see urethral meatus. You must remove it while it is still open, because closing it might pinch the mucosa of the vulva and cause damage
which is the blind spot in the female repro tract- the clitoral fossa or the external urethral meatus?clitoral fossa blind spot- CAN see the urethral meatus
If you are absolutely unable to visulize the urethral meatus, what sx procedure can you do to try to see it?episiotomy (opening of the vulva going dorsally to level of anus- but no damage the anus)
explain the episiotomyopening of the vulva going dorsally to level of anus- but no damage the anus. Cut at raphe at vulva-use two hemostats- leave for a bit and then make incision btwn hemostats- can give direct access of view if have to do special catheterization or if regular methods not working. Also used to increase diameter of passage of fetus, or access other vaginal dzs to fix them. close w/ simple continuous of mucosa and submocosa. then close muscularis and something layer, then finally close skin.
Before you decide which cath to use, you need to..PREMEASURE the cath externally! (estimate where bladder is from tip of prepuce)
why don't you want your cath too long?might keep pushing and rupture wall of bladder, or might kink the cath and it'll be useless
how might you be able to place a clean cath if you don't have any gloves?cutting paper sheath of cath to make a butterfly. *make sure you don't cut cath when cutting the paper!!
why should you be careful about choosing an instrument to advance a cath?might crush cath/cause partial occlusion or weaken the cath
If cath a male, how do you start it?first retract prepuce, or use fingers like in a v shave, push prepuce back and grab penis with rest of hand. Put cath in slowly with lots of lube
what is hypospadia?failure of fusion of urogenital folds--> this means that it can include urethra, skin, prepuce....cleft that divides scrotum in 2. usually have infantile penis and os penis might not be developed.
what might you be able to do sx for a hypospadia pt?can do plastic reconstruction, move skin forward or from side to make new prepuce. castrate so dont pass down prob to descendents
where do stones tend to be in the urethra?often get stuck on os penis, esp in this little "v" part (trough)
average age for lithiasis of the bladder/urethera?3-7yrs
top 9 breeds for lithiasis of the bladder and urethraSchnauzer - Dalmatian - Bull dog - Dachshund - Basset - Terriers - Beagle - German shepherd- Poodle
If there is lithiasis in the urethra, what are the 2 sx procedures you can use?urethrotomy (cut open), urethrostomy (create opening)

Urethra (sx procedures)

Question Answer
**** suture what to what?MUCOSA TO SKIN
what are the 4 locations at which you might perform your urethrotomy/urethrostomy?(1) prescrotal (2) scrotal (3) perineal (4) prepubic (salvage)
how common is a Perineal urethrostomy?avoided in dogs because of difficulty of procedure and complications of urine scald and urinary tract infection
what might make a prescrotal urethrostomy difficult?If they were castrated before, the prescrotal area might be scarred already
what are some reasons a scrotal urethrostomy is desirable? urethra is wider and more superficial, and less tension on skin so less chance of dehiss (scrotal best, but prescrotal more common bc easiest)
explain the procedure for a urethrotomy (step one- prep and opening)Clip WIDE and LONG, scrub, place drapes. look for median raphae. incision about 4-5cm long, through skin and SQ-- under that is fascia, then the retractor penis mm. grab with forceps and bluntly dissect to separate. Pass suture or umbilical tape around the retractor penis mm (wet so its not too much friction) to keep it displaced towards one side. Then you see the corpus cavernosum (often penis tends to twist, so careful, might not be easy to find retractor and then cut corpus cavernosus penis. Cutting cavernosum= lots of bleeding. It'll f**k up your surgical field. so ID RETRACTOR PENIS MM, HOLD PENIS BETWEEN FINGERS and have trough of V facing upward- thats where urethra is, nestled between the cavernosuses. Stabalize penis when cutting! When you cut urethra, might bleed bc inflamed (esp if caths have been passed). use #11-12-15 blade (very sharp and little- no 10s or 21s) if lucky, can cath penis up to where youre making your incision... Make incision between obstruction and base of scrotum. Remove stones, after removal, cath to make sure urethra is clean and that there are no other stones that might have been displaced. if you think that's the case, leave open and let heal 2nd intention. (pic is showing how to ID retractor penis mm so you don't cut it on accident)
explain the procedure for a urethrotomy (step two- active part of procedure)by opening urethra you can sometimes relive part of obstruction and can pass cath. Or, opening might dislodge stones and they might come though incision. Dont lose them! Empty bladder or pass cath from incision and aspirate bladder content. In retrograde manner, try to pick up stones carefully with delicate instruments like alligator forceps.
If you are unable to remove the stones during your urethrotomy, what are some things you could do?can leave catheter to see if going to get dislodged later, or turn urethotomy into urethostomy
explain the procedure for a urethrotomy (step three- closure)sew with simple continuous and try not to get into lumen. small suture size. Reposition retactor penis, close SQ, close skin. If you let it heal by 2nd intention (would do this if you think there are other stones around), there might be a stream of blood when peeing bc passing clots, warn owners of this. After closure, if clean urethra, can leave in cath for 24-48 hrs to facilitate passage of urine and reduce some irritation on edges of incision. monitor urine output to make sure kidneys working well!!!
When is a urethroStomy indicated? (4)(1) non displaceable stones (2) chronic stone formation (3) urethral stenosis (4) penile trauma
how does a prescrotal urethrostomy incision look? (pic)
Explain how you go about creating the stoma in the prescrotal urethroStomy procedure (*how do you suture??)make sure place cath before starting is at all possible (thats what tube is in pic) and then incise urethra-- then gonna sew the urethra to the edges of the incision into the body wall. **suture inside out-- starting with urethral mucosa always going out towards skin~!! never the opposite! want to overlap, don't want inward folding. First stitches at 1, 12, 11 o'clock are important- so flap of mucosa doesnt fall down and occlude the lumen- this is to maintain good urethra opening. Then place sutures staggering a few on each side until complete whole opening. if skin incision is longer than urethrostomy, can suture remnants of skin together at ends. (first pic is first sutures where they should be placed, second is how more advanced closure is looking)
*what should the MINIMUM size of the opening be for your urethroStomy?not less than 3.5-4cm long, longer if bigger pt...IF YOU DON'T MAKE IT AT LEAST THIS LONG, WHEN IT HEALS, IT SHRINKS, AND CAN BECOME SMALL ENOUGH WHERE URINE CANT BE PASSED
*When you want to suture mucosa of urethra to skin, what fashion must you always do it in?always- urethra mucosa towards skin- sutring inside out!!!!**** never opposite- want to overlap and prevent inward folding.
briefly explain SCROTAL urethroStomyremove scrotum and castrate if needed. if already castrated- eliptical incision on remnant of scrotum, and remove skin. ID retractor penis mm, make incision through urethra, etc (See prescrotal for details).
Explain how you suture urethral mucosa to skin, in detail. How can you use this to your advantage?(dont forget you go from mucosa to skin, never skin to mucosa) sometimes tissues inflamed..might have bleeders or oozers. To prevent, make stitch going through mucosa, bridging over corpus cavernosum, fascia, and skin.... will lock tissue and will block blood from coming out by bridging, you assure line of tissue will not bleed too much in immediate post op. (if this is not done, you risk blood extravasing under suture and causing swelling/damage/tension on sutures. Also risk urine doing between layers if not done right)
are you worried about urethra mucosa which has never been exposed to the outside world suddenly being out there? why?No, bc will undergo metaplasia bc exposure, become more resistant epithelium
which suture patterns can you use to close a urethrostomy?simple continuous (can use double needled suture if you want), or simple interrupted
if you are going to do simple interrupted sutures for your urethrostomy, how can you reduce irritation?leave tails LONG so you don't create bristles that are irritating against the skin
how can you help prevent the skin around your new urethrostomy from getting urine scalded? (esp if you're doing perineal)put baby oil on skin
why might you want to leave a cath in your new urethrostomy after sx?prevent urine stream from flushing away clots/ irritating incisions (fingertrap the cath so it doesnt just fall out)
what is the process for a perineal urethrostomy like? (pic)((dont forget to place purse string in anus during procedure to prevent fecal contamination- and DONT forget to take it out!)
about how many days would you expect it to take for a urethrostomy to heal?about 14-21 days, plus or minus.
what are the 4 stages of wound healing? why do we care?inflammatory stage-->debridement stage-->healing(apposition of collagen)-->remodeling. We care bc we know each stage of this takes a certain amt of time, so if a stage is taking too long, you know there must be a prob (inflammation is 24-72 hrs, and simultaneous to debriding.)
what is the Wilson & Harrison technique?AKA perineal urethrostomy used for blocked CATS this also includes PARTIAL AMPUTATION of penis
5 main clinical signs of urethral trauma?dysuria, anuria, hematuria, pain, hematomas (can try walking to dec hematomas)
4 most common causes of Urethral Laceration and Rupture(1) Pelvic fracture (2) Fracture of the os penis (canine) (3) Penile trauma (4) Iatrogenic injury (Catheter-induced)
what is something you need to be very careful of post-op with urethral sx?MAKE SURE BANDAGES AREN'T KINKING THE CATHETERS
how do you tx a minor contusion/laceration?If minor, can usually heal spontaneously
how can you help improve healing of Urethral Laceration and Rupture (not sx)healing improves by placement of a soft catheter (urethral splint)
how would you sew a urethra back together? (pattern, type of suture)simple apposition, 3/0-5/0 suture. Sew the back wall first. If continuous, only 180* at a time
what is going on in a prepubic anastomosis? for trauma so severe cant reconstruct or anastomose the urethra ...move penis under pubis, then anastomose neck of bladder to penile urethra (salvage procedure)
prepubic urethrostomy is most commonly done in who?cats
what is/what are you doing in a prepubic urethrostomy?Creation of a urethrostomy on the ventral body wall, cranial to the pubis
A prepubic urethrostomy is a salvage procedure done bc of what problems?stricture, neoplasia, or trauma of pelvic, perineal or abdominal urethra, OR a recurrent stricture of perineal urethrostomy
So in the prepubic urethrostomy, you aren't opening up part of the urethra longitudinally and sewing it to the side of your 1* incision so it can be as big as you want are taking the transversely transected uretha and placing it to empty outside of body do you keep this from not being so tiny it closes up?you FISHMOUTH it! (pic is finished procedure with fishmouthed urethra exiting from ventral body wall (note it's not through 1* incision)
DISADVANTAGES of a prepubic urethrostomy?Urine scalding, Ascending urinary tract infection, Potential for urinary incontinence!!
how might you be able to minimize the risk of urinary incontinence in a prepubic urethrostomy?instead of piercing through abd wall, you can tunnel through mm layers, so sorta mimics how like the ureters goes through walls of the bladder and the pressure works with you