URETHRA (synonym urethra) — the output channel of a bladder, on Krom urine is brought out of an organism outside.
M. to. begins to develop in the form of the general bookmark with other parts of urinogenital system. During the first days of the 2nd month of embryonic development the foul place is divided longitudinal mochepryamokishechny folds (plicae urorectales) into a rectum and an urinogenital tube. The isolated urinogenital tube represents the general laying of a bladder, primary M. to. and urinogenital sine. Primary M. to. the long time remains short. Further development of M. to. at men's and female germs proceeds differently. At a female germ primary M. to. becomes definitivny. At a men's germ primary M. to. represents only laying of an upper part of prostatic part M. to. (pars prostatica urethrae), located kranialno from the place where the ejaculatory channel (ductus e jaculatorius) opens. Other part M. to. at a men's germ develops from an urinogenital sine, to-ry, remaining in the form of a narrow tube, turns in webby and in back spongy parts M. to. A front spongy part of an urethra develops in connection with a sexual hillock. Forming on it an urethral fillet afterwards it is closed and forms the forefront of an urethra. See also Urinogenital system .
Anatomy and histology
M.'s length to. at men can reach 23 cm, it serves also for removal of a seed. M to. (fig. 1) begins at the bottom bladder (see) an internal opening also comes to an end on a head penis (see) an outside opening (ostium urethrae ext.). M to. passes through various educations therefore in it allocate three parts: prostatic (pars prostatica), webby (pars membranacea) and spongy (pars spongiosa). The prostatic part, next to a bladder, passes through a prostate and is the widest and stretched site M. to.; its length apprx. 3 — 4 cm. On a back wall there is a small median eminence — a seed hillock (hillock). Wall of this part M. to. consists of mucous and muscular covers. The mucous membrane in the unextended channel forms longitudinal folds from 0,35 to 0,45 mm thick everyone. The muscular coat is in close connection with muscles of a prostate and a bladder. Thanks to a tone of muscles of a wall of the channel adjoin one to another, and the gleam of the channel represents a narrow crack.
A webby part — site M. to. from a top of a prostate to a bulb of a penis. Its length apprx. 1,5 — 2 cm. This part of an urethra represents the narrowest and least extensible site of the canal that needs to be considered at introduction of a catheter. A webby part is surrounded with cross-striped muscle bundles of any sphincter (m. sphincter urethrae). Passing under an arch of pubic bones, it will be spaced from them on 2 cm; in this space there pass circulatory and absorbent vessels and nerves of a penis. Wall thickness of a webby part apprx. 2 mm. Prostatic and webby parts form the strengthened part M. to., spongy — mobile, hanging down, a part it. Border between them is the sheaf suspending a penis.
Spongy part M. to. length apprx. 17 — 20 cm is in the spongy body spliced with cavernous bodies of a penis. In an initial part it open a large number of channels of glands of a mucous membrane of M. to. and channels of bulbouretralny glands (see. Bulbous and urethral glands ). The most distal part M. to. — the navicula (fossa navicularis) — length apprx. 1 cm, has grozdeobrazny mucous glands (gll. urethrales), or Littre's glands; they meet also on all extent of M. to. A mucous membrane of M. to. in a spongy part it is deprived of a submucosal layer, i.e. directly covers a layer of cavernous fabric M. to. In a webby part the mucous membrane is penetrated by muscle cells. In a prostatic part the epithelium of a mucous membrane proceeds in an epithelium of channels and the ferruterous courses of a prostate. In a prostatic part and on the lower wall of M. to. there is a vesical epithelium of a passage type, in a webby part — a multirow prismatic epithelium, at the beginning of a spongy part — single-layer prismatic, and distalny confluences of channels of bulbouretralny glands — multirow prismatic and in a navicula — a multilayer flat epithelium. In a muscular coat of M. to. distinguish longitudinal and circular layers. M to. at men on the extent forms two curvatures: the first, curved down, bending around an union of pubic bones, and the second, curved up and to a root of a penis.
Women's M to. — urethra feminina — (see tsvetn. fig. 2) passes short distance from an internal opening of M. to. to an outside opening under a clitoris between vulvar lips. Length of its from 2,5 to 4 cm. The outside opening of an urethra at an entrance to an entrance of the vagina is surrounded with valikoobrazny edges. M to. passes on a front wall of a vagina, going from top to down and kpered under pubic bones. The mucous membrane forms numerous folds. Connecting fabric is rich with elastic fibers and numerous veins. Near outlet opening on both sides there are very narrow courses of 1 — 2 cm — paraurethral channels (ductus paraurethrales).
Blood supply. M.'s arteries to. are formed of branches of an internal ileal artery (a. iliaca int.). Different departments of the channel eat from various sources: a prostatic part — from branches of an average pryamokishechny artery (a. rectalis media) and lower vesical (and. vesicalis inferior); webby — from lower pryamokishechny (a. rectalis inf.) and perineal artery (. perinealis); spongy — from an internal sexual artery (a. pudenda int.). Veins fall into veins of a penis and a bladder.
Lymph drainage from a prostatic part passes to limf, to vessels of a prostate, and then to internal ileal nodes, from webby and spongy — to inguinal nodes.
Innervation it is carried out from perineal nerves (nn. perineales) and a dorsal nerve of a penis (n. dorsalis penis), and also from a vegetative prostatic texture (plexus prostaticus).
Methods of a research
Survey of an outside opening of M. to. at men it is necessary to see to the act urinations (see). Pay attention to its location, a form, the sizes, color of a mucous membrane and existence of allocations. At a hypospadias an outside opening of M. to. is located proksimalny usual: on a head, a back surface of a trunk of a penis, in the field of a scrotum or on a crotch. At an epispadiya it opens on a dorsal surface of a balanus. Very seldom outside opening of M. to. is absent at all that can carry both the inborn, and acquired character. Narrowing of an outside opening of M. is more often observed to., a cut can be inborn or develop after inflammatory and ulcer processes. The mucous membrane of an outside opening of M. is normal to. light pink color. At an acute urethritis it edematous and hyperemic. Allocations from an outside opening of M. to. most often are a consequence of inflammatory diseases or its damages and happen purulent, bloody or mucous. Any discharge from M. to. is subject to microscopic examination.
Women have a survey of an outside opening of M. to. also it is necessary to see to the act of an urination; at the same time pay attention to possible loss of a mucous membrane, to allocations from paraurethral channels (channels of glands of the Skin) located on each side an outside opening of M. to. At M.'s diseases to. pay also attention to a form, intensity and width of a stream of urine.
A palpation of front department of M. to. at men make on a lower surface of a penis, and back — the index finger entered into a rectum (see. Rectal research ). At women the palpation is carried out through a front wall of a vagina. The research can be carried out also after preliminary introduction to M.'s gleam to. a metal buzh (a palpation to Bougie). It is normal of M. to. is defined as soft education without any consolidations and thickenings. At a palpation in M. to. it is possible to define stones, foreign bodys, cicatricial changes of its walls, tumors. In the presence of paraurethral abscess fluctuation is felt. For identification of localization of inflammatory process use two - or trekhstakanny test (see. Stakanny tests ).
Apply to a tool research various in a form and diameter Bougie (see). The research is carried out at careful observance of rules of an asepsis, at adults, as a rule, without anesthesia, and at children under anesthetic. A tool research M. to. apply to detection of its passability, localization and extent of narrowing, existence of a stone. At acute inflammatory processes in M. to., a prostate, testicles and their appendages introduction of any tools to M. to. contraindicated. Introduction buzhy in M. to. (see. Bougieurage ) carry out by the technique similar to introduction of catheters. Diameter of the tool, necessary for a research, can be determined approximately on width of a stream of urine. If buzh meets an absolute obstacle on M.'s course to., it is impossible to apply violence, but it is possible to try to carry out the tool of smaller caliber. For prevention of possible complications (an urethritis, an epididymite, prostatitis) after the tool research within 3 — 4 days appoint antibiotics of a broad spectrum of activity.
Treats endoscopic methods of a research uretroskopiya (see), edges it is applied at hron, inflammatory diseases of M. to. for establishment of the topical diagnosis and definition of efficiency of the carried-out treatment, for detection of tumors, a stone or a foreign body, for definition of the reason of a spermatorrhea, a prostatorrhea, a hemospermia, a premature ejaculation, etc. Contraindications to an uretroskopiya the same, as at tool methods of a research M. to.
Importance for diagnosis of diseases of M. to. has rentgenol. research. The survey picture allows to find X-ray contrast stones and foreign bodys of M. to. (fig. 2 and 3).
At damages and various diseases of M. to. contrast was widely adopted uretrografiya (see), edges can be both ascending (retrograde), and descending (miktsionny). It is recommended to combine both of this types of a research because on the ascending uretrogramma above an outside sphincter a gleam of back department of M. to. it is represented narrowed that it is mistakenly possible to take for a stricture whereas on the descending uretrogramma which is carried out during an urination it is possible to receive the clear image only of back department of M. to., however a contrast agent is not late in front department of an urethra and therefore fills its gleam insufficiently. Rentgenol, a research gives the chance to distinguish various malformations of M. to.: diverticulums, doubling, inborn valves and narrowings, paraurethral courses. It is possible to define the nature of damage of M. by an uretrografiya to., its localization and existence of uric infiltration and, therefore, to choose more rational method of treatment. At a complete separation of M. to. a contrast agent flows into surrounding fabrics and forms shadows of irregular shape (fig. 4). The uretrografiya gains especially great value in diagnosis of narrowings of M. to. (fig. 5). The method allows to define quantity of strictures, their arrangement, extent, M.'s condition to. higher than the place of narrowing. Sometimes because of much the expressed obliteration to receive M.'s image to. above the place of narrowing it is impossible. In that case
A. Ya. Pytel and Yu. A. Pytel (1966) recommend to combine the ascending uretrografiya with preliminary introduction of a buzh to an urethra through tsistosty to the place of an obliteration, and A. N. Logashev (1973) — to carry out a counter uretrografiya. Uretrografiya is shown also after elimination of a stricture for establishment of extent of recovery of passability of M. to.
At M.'s stones to. already usual survey picture allows to define their quantity, localization and a form. Uretrografiya who is carried out in two projections specifies the diagnosis — in a picture defect of filling is visible. At a X-ray negative stone, except a contrast uretrografiya, it is possible to use a pnevmouretrografiya, using oxygen or carbon dioxide gas for this purpose. At an acute urethritis the uretrografiya is contraindicated. At hron, M.'s inflammation to., followed by hypostasis and scarring of a mucous membrane, in a picture roughness of contours of a wall of M. is defined to., decrease in its tone and filling with contrast liquid of small paraurethral channels, a reflux in prostatic ductules or a channel of bulbouretralny glands (a kuperova channels). With the help Ur-trografii it is possible to establish existence of a tumor of M. to., at a cut in a picture defect of filling decides on uneven contours (fig. 6).
the Aplasia (inborn absence of M. to.) — the rare anomaly observed usually at the impractical fruits having and other uglinesses of urinogenital bodies. At male fruits M.'s aplasia to. it is sometimes combined with lack of a penis.
Atresia — lack of certain sites of the canal — also rare anomaly (fig. 7). At it the fruit seldom happens viable. Owing to features of an embryogenesis the atresia is observed more often in the field of a balanus and in webby department, i.e. in conjunctions of the sites having a different origin. The true atresia of the channel of a head should be distinguished from closing of an outside opening of M. to. owing to its pasting with a prepuce. If M.'s atresia to. is not followed by vesicorectal or uretrorektalny fistula, clinically it is shown by an ischuria. The newborn child makes an effort, shouts, does not urinate, and over a pubis its protrusion of the crowded bladder is observed. At an atresia of an outside opening of M. to. it is enough to cut a membrane a scalpel. At more expressed M.'s underdevelopments to. make an outside urethrostomy (see. Butonyer ); at an atresia of back department of M. to. impose suprapubic fistula (see. Vesicotomy ).
Inborn strictures meet in the field of an outside opening or in webby part M. more often to. A stenosis of an outside opening of M. to., even considerably expressed, a nek-swarm time remains unnoticed since it is compensated by a hypertrophy of a wall of a bladder. Over time the child begins to complain on complicated, an urodynia. It gradually leads not only to disturbance of the act of an urination, but also to a renal failure and loudspeakers of a mochevyvedeniye. At excretory urography (see) expansion of a pelvis and ureters, trabekulyarnost of a bladder comes to light.
Treatment of strictures of an outside opening of M. to. consists in a section of the narrowed opening (meatotomiya) with the subsequent sewing together of edges of a mucous membrane of M. to. with edges of skin of a balanus. At M.'s narrowings to. other departments make an internal urethrotomy.
Inborn fistulas of M. to. arise because edges of an urethral trench in the course of embryonic development in any point did not connect. These fistulas are always located on a lower surface of M. to. on the centerline. Inborn uretrorektalny fistulas meet more often, to-rye arise owing to insufficiency of development of an urorectal partition and are quite often combined with an atresia of an anus. At the same time urine comes to a rectum, and gases and fecal masses — to M. to. Solution methylene blue, entered into a bladder, after an urination paints the tampon entered into a rectum. The diagnosis is confirmed also uretrotsistoskopiy and uretrografiy.
Treatment operational. It consists in dissociation of a gleam of M. to. and rectum.
Inborn valves are always located in a prostatic part of M. to. (fig. 8) also represent folds of a mucous membrane in the form of cups, funnels or a diaphragm, to-rye interfere with bladder emptying. In most cases valves are connected with the first or rear edge of a seed hillock. Difficulty of an urination leads to dysfunction of a bladder and overlying departments of uric system over time. Since the early childhood note lag in physical development, difficulty of an urination, the dysuric phenomena, pyelonephritis, signs accrue afterwards renal failure (see). Inborn valves of an urethra not always interfere with carrying out on it tools, and the diagnosis is based on data of the anamnesis, an uretrotsistoskopiya, uretrotsistografiya and tsistometriya (see. Bladder ).
At survey of an urethra in the field of a seed hillock it is possible to see cross folds of a mucous membrane of a semi-lunar form, to-rye partially close a gleam of prostatic part M. to. The seed hillock is often increased, sometimes inflamed.
Treatment — a transurethral electroresection or a transcystic resection of valves.
The inborn hypertrophy of a seminal hillock can be a cause of infringement of passability of M. to., and also subsequent complications. The painful erection is characteristic of this malformation during an urination. At catheterization in a back urethra usually meet an obstacle. Distinguish this anomaly by means of an uretrotsistografiya and an uretroskopiya. Treatment operational: make an endovesical or chrespromezhnostny resection of a seminal hillock.
A hypospadias — the lower crevice of M. to., arises because edges of an urethral fillet in peripheral department did not connect and did not form a tube (see. Hypospadias ).
Additional urethra — anomaly, at a cut near the main M. to. another is located, usually less developed. In one cases additional M. to. goes from a neck of a bladder to a balanus, in others — is a branch of the main channel (fig. 9). Additional M. to. arises probably as a result of disturbance of connection of edges of an urethral trench. At the same time can be formed not connected or connected to M. to., but blindly coming to an end additional courses. In case of the complications caused by this defect operational treatment is shown.
Inborn defect of a back wall of M. to. it is observed at women. This anomaly is sometimes described as a female hypospadias, however pathogenetic has nothing in common with it. In case of an incontience of urine operational treatment is shown.
The urethrocele — sacculate protrusion of the lower wall of M. to. at men, arises owing to insufficiency of a wall of the channel in the conjunction of edges of an urethral plate (clinic and treatment see below).
Inborn diverticulums of M. to. — the sacculate protrusions connected to M. to. narrow course. Diverticulums of front department of M. to. have an origin, similar to the urethrocele, whereas in back department of M. to. they come probably from the remains of myullerovy channels. For the urethrocele and inborn diverticulums of M. to. it is characteristic complicated, an urodynia, in time to-rogo in the area M. to. there is a protrusion disappearing after expression of urine a hand. At a retrografiya specifies the diagnosis. Treatment of these malformations operational.
Epispadiya — splitting of an upper wall of M. to., meets much less often than a hypospadias (see. Epispadiya ).
Cysts can develop from the remains of myullerovy channels, on site a prostatic utricle (utriculus prostaticus) or to arise for the same reasons, as additional M. to. Also cysts on site of bulbouretralny glands are described. The disease is shown by difficulty of an urination owing to M.'s prelum to. cyst. Treatment — excision of a cyst.
Distinguish the closed and open damages of M. to., to-rye can be isolated or combined, getting and not getting. Closed call M.'s damages to. without disturbance of an integrity of an integument. At the combined damages along with M. to. the integrity of pelvic bones, a rectum, penis or other next fabrics and bodies can be broken. At not getting (or partial) damages defect is formed not in all layers of M. to., and at getting (or full) all layers of its wall are damaged, and then urine impregnates surrounding fabrics. Sometimes there is M.'s separation to. from a neck of a bladder. Men have M.'s damages to. are observed considerably more often than at women; they are, as a rule, localized in webby and prostatic parts, sometimes in a spongy part.
The reason of damages of M. to. various mechanical influences are; first place (apprx. 65 — 70%) is won by changes of pelvic bones. During the falling the crotch on a firm subject, blow to the area of a crotch usually damages spongy part M. to. At a change of pelvic bones webby is damaged and a prostatic part is more rare that can be as as a result of direct wound of M. to. the displaced bone fragments, and because of the shift of bone fragments and increase in distance between points of fixing of an urethra to walls of a basin. To the closed M.'s damages to. carry also the so-called false course. This tool damage of a wall of M. to. with education in paraurethral space of the additional course. The false courses arise owing to rough carrying out the tool (a catheter, a buzh, the urethroscope, the cystoscope); they can be formed in any site of an urethra, but to a thicket are observed in spongy and webby its parts.
Open damages of M. to. subdivide on chipped, cut, fragmentary, bitten and fire. Chipped wounds are localized preferential in perineal (i.e. fixed) M.'s department to. At the same time the bladder, a rectum and adjacent soft tissues are quite often injured. Cut wounds are more often localized in spongy part M. to. and usually are followed by an injury of cavernous bodies, and sometimes and bodies of a scrotum. Extreme extent of such damage — a traumatic peotomy. Avulsive and bite wounds of M. to. meet seldom, are localized in its spongy part and are always combined with injury of a penis.
Gunshot wounds of M. to. in wartime make apprx. 40% of all damages of uric and generative organs. In peace time they are extremely rare. Their feature are extensive defects of a wall of M. to. on site wounds. In addition to direct damage, the so-called secondary rupture of M. can take place to. after fire damages of pelvic bones.
M.'s damages to. at women can be also a consequence of a birth and surgical trauma. In obstetric practice of damage of M. to. are observed at rodorazreshayushchy operations (at an application of forceps, use of vacuum extraction of a fruit), and in gynecologic — during removal of paraurethral cysts and fibromas of a vagina, a front colporrhaphy, operations for an incontience of urine, etc. by M. to. at women it can be damaged also during sexual intercourse of per urethram in case of an atresia of a vagina, and also at introduction to M. to. various foreign bodys.
A wedge, the course of damages of M. to. depends on localization and the nature of an injury. Patognomonichna following symptoms: local pain, a delay of an urination (see), an urethremorrhagia, a hematoma (or an urohematoma) in a crotch. Pain in the area M. to. at damages appears right after an injury, amplifies in attempt to an urination and becomes especially intensive at penetration of urine into the damaged fabrics.
The delay of an urination can be caused as the shift of the ends of M. to. at a complete separation, and a prelum of its gleam a hematoma or an urohematoma, and also obstruction by a clot. The impossibility of an urination can be temporary — during an urination pains on the course of the damaged M. sharply amplify to., and the patient reflex stops urinating. At nek-ry patients only difficulty at an urination is observed, the stream of urine at the same time is thinned.
An urethremorrhagia (release of blood from M. to. out of the act of an urination) it is more expressed at damage of front department of an urethra. It can be very insignificant and short-term. At simultaneous injury of a cavernous body, urethra or prostate bleeding from M. to. can accept the menacing character.
At getting M.'s ruptures to. blood streams in paraurethral fabrics and the hematoma is formed, and at simultaneous flowing of urine — an urohematoma. Especially big urohematoma is formed at the getting complete separations of back department of an urethra, at the same time urine gets to surrounding fabrics only in attempt to any bladder emptying. Blood and urine from paraurethral fabrics spread to area of a crotch, a scrotum, an inner surface of hips, sometimes to inguinal and pubic areas. At ruptures of back department of M. to. urine infiltrirutsya pelvic cellulose. The urine which streamed in cellulose leads to a necrosis of fabrics, and accession of an infection — to phlegmon. Uric became numb (see) in many respects the wedge, courses of damages of M. defines features to.
Weight of a condition of the patient at the combined damages of M. to. depends on a type of a change of pelvic bones, a damage rate of a rectum and other bodies, blood loss and prevalence of an uric zatek.
Diagnosis of damages of M. to. in the presence of characteristic symptoms comes easy. At survey pay attention to release of blood from an outside opening of M. to. Determine by a palpation overflow of a bladder and uric infiltration of tissues of external genitals. A rectal research at damage of back department of M. to. allows to define a swelling in a prostate gland, and pressing on it a finger causes release of blood from an outside opening of an urethra. Introduction of tools to M. to. for establishment of the place of damage it is inexpedient since it can be the cause of an additional injury and infection. The main method of recognition is the uretrografiya, edges allows to establish degree, character and localization of damage.
Lech. tactics at M.'s damages to. depends on the nature of an injury. Not getting gaps treat conservatively: appoint a bed rest, cold to a crotch, diuretics and antibacterial drugs. At a delay of an urination resort to a capillary puncture or constant catheterization of a bladder within 2 — 5 days (see. Catheterization of uric ways ). At the getting gaps surely take away urine by an epicystostomy (see. Vesicotomy ), the urohematoma is opened and drained (see. Drainage ). At small changes of pelvic bones without shift, satisfactory condition of the victim, his early hospitalization and in the absence of considerable uric infiltration and a paraurethral hematoma along with an epicystostomy carry out primary uretrouretroanastomoz (primary seam of an urethra). Operation is made perineal access; excise the damaged tissues of an urethra and sew its end in the end. During operation for finding of the point of fracture through a bladder enter into an urethra buzh. If primary plastics cannot be executed, then resort only to an epicystostomy, and recovery operation is made not earlier than in 2 — 3 months after an injury. At critical condition of the victim it is temporarily possible to be limited to a trocar epicystostomy or a capillary puncture of a bladder.
At open damages of M. to. make the EPICYSTOSTOMY), then carry out a careful hemostasis and primary surgical treatment of a wound, cut and drain an urohematoma and if there are no contraindications. make primary uretrouretroanastomoz. In other cases are limited an epicystostomy and drainage of a wound after its processing. If uric infiltration extends in cellulose of a small pelvis, then resort to drainage through a locking opening across Buyalsky — Mac-Uortera. In case of the combined damage which is followed shock (cm), at first carry out all antishock actions and a capillary puncture of a bladder, and after removal of the patient from shock — an epicystostomy), emptying of an urohematoma and other operative measures.
Stricture — permanent narrowing of a gleam of M. to., the urination caused by education in walls of the channel of cicatricial fabric and complicating. The disease occurs generally at men. Distinguish the strictures passed for buzhy. passable only for urine, and obliterations.
About 80% of strictures of M. to. it is localized in webby and prostatic parts M. to. In length they make 0.5 — 1,5 cm. Strictures of big extent are found approximately in 15% of patients, multiple meet seldom.
Among causes of illness the closed and open damages of M. are in the first place (80%) to., to-rye at 60% of patients accompany a change of pelvic bones. The second place (17%) on frequency is taken by the inflammatory strictures developing after gonorrheal and nonspecific uretrit.
The pathogeny of strictures and expressiveness of pathoanatomical changes depend on the nature of damage, extent of crush of fabrics, contamination of urine and on a condition of defense reactions of an organism of the victim. Inflammatory and necrotic process in fabrics comes to an end with formation of the dense kallezny hems inclined to wrinkling. Traumatic strictures and M.'s obliterations to. form in 2 — 3 weeks after an injury that corresponds to terms of maturing of the hem which is formed at a wound repair. At uric zateka and phlegmons when destructive process is dragged out, and also at treatment of a rupture of M. to. on a catheter the term of formation of a stricture is extended and narrowing begins to form only after completion of purulent process or removal of a catheter. Cases of late formation of traumatic strictures — within a year and more are known. Inflammatory strictures develop slowly, sometimes within several years.
Range of pathoanatomical changes at M.'s strictures to. it is very wide: from small pristenochny hems to the extensive cicatricial conglomerates taking sometimes all crotch and which are complicated by a pyonephrosis and a renal failure. The mucous membrane about a stricture is thickened, uneven, sometimes with small warty growths. At gistol, a research find proliferation of an epithelium, to-ry becomes multilayer flat with dystrophic changes and the phenomena of a parakeratosis (fig. 10).
The main background gistol, pictures of strictures of M. to. the dense fibrous connecting fabric which is characterized by powerful development of collagenic fibers and extensive sites of a hyalinosis creates. Irrespective of duration of a disease in cicatricial fabric signs hron, the inflammation (extensive cellular infiltrates, granulyatsionny fabric) which is a potential source of progressing of cicatricial process in places are found.
Small narrowings of M. to. clinically long are not shown, and the inflammation which only joined in the field of a hem causes difficulty of an urination.
The main symptom of a stricture of M. to. disturbance of an urination is: narrowing of a stream of urine, its spraying or allocation by drops at a strong natuzhivaniye. Time of bladder emptying is extended. Sharply expressed stricture leads to emergence of a residual urine that is followed by feeling of incomplete bladder emptying, increase of an urination and an involuntary effluence of urine. Pozadistrikturny expansion M. develops to. At an obliteration the act of an urination is impossible in the natural way and release of urine is carried out through suprapubic or perineal fistula. Symptomatology of a stricture of M. to. supplement signs of complications. from to-rykh are most often observed pyelonephritis (see), an urolithiasis (see. Nephrolithiasis ), paraurethral abscesses and fistulas.
Recognition of a stricture of M. to. comes easy. The great value is attached to studying of complaints of the patient and the anamnesis of a disease. From objective methods of a research the greatest value have a research buzhy and an uretrografiya. If prostatic and webby parts, a research buzhy quite often are struck combine with a manual rectal research that helps to gain a better understanding about localization and extents of hems, to define borders of a stricture, a condition of a prostate and walls of a rectum. Uretroskopiya is applied at not clear a wedge, a picture when M.'s survey to. or a biopsy are necessary for differential diagnosis. Uretrografiya allows to define localization, expressiveness and extent of a stricture, to reveal fistulas, the false courses, diverticulums etc.
Treatment of strictures includes bougieurage and surgeries. Bougieurage the strictures of small extent passed for buzhy treat. It will be out carefully, without any violence and begun with buzhy, easily passing a stricture. Buzh leave in M. to. for 2 — 3 min. then enter buzh the following number. It is possible to carry out Bougie to one session of three-four numbers. Bougieurage is carried out daily or every other day depending on a condition of the patient and reaction to bougieurage. At badly passable strictures with the gyrose course use thin elastic bougies, to-rye carry out through the narrowed site by means of the endoscope. Buzh leave in M. to. on 1 — 2 day, then replace it with an elastic bougie No. 8 — 12 then bougieurage is continued in the usual way. Improvement of results of bougieurage is promoted by local introduction of a lidaza and cortisone, physiotherapeutic procedures.
At operational treatment of strictures of small extent (to 2 cm) in spongy part M. to. operation of the choice is the resection of the narrowed site. Operation was for the first time executed by E. E. Klien in I860 of, in the subsequent it was improved V. Rochet, K. M. Sapezhko, B. N. Holtsov, etc. For carrying out operation of the patient stack in situation for a lithotomy (situation on spin with the legs and the moved apart hips bent in knees). The bladder is opened over a pubis, and in the presence of suprapubic fistula it is excised. Retrogradno to a stricture is entered metal buzh or an elastic catheter. Through an outside opening of M. to. bring the second to the distal end of a stricture buzh. Over a stricture on the centerline of a crotch a section 5 long — cm would bare M. to., separate it from cavernous bodies throughout 4 — 5 cm and cross in transverse direction above and lower than a stricture. There and back M. to. enter a silicon drainage tube or a catheter. M.'s ends to. sew noose sutures so that threads passed in a submucosa, and nodes remained out of a gleam (fig. 11). The anastomosis is strengthened paraurethral seams. The bladder is drained.
Resection of prostatic and webby parts M. to. it is developed in 1955 by I. Rusakov. After opening and audit of a bladder retrogradno to a stricture enter buzh. On a crotch a pinnacled section (fig. 12) cut fabrics to bulbous and spongy muscles and together with them will mobilize M. to. till the distal end of a stricture also cross it. Excise hems till not changed proximal end of M. to., to-ry then sew noose sutures with the distal end. In M. to. carry out a catheter with multiple openings on the vesical end and seams consistently, since a front wall, tie. The mobilized M.'s end to. together with the bulbous and spongy muscles surrounding it it is tightened up and occupies the space formed after excision of hems. For unloading of an anastomosis put paraurethral stitches. The wound of a crotch is taken in tightly or drained on 1 — 2 day. Suprapubic part of operation is finished as well as after a resection of spongy part M. to.
Often apply also the operation offered in 1932 by P. D. Solovov. Open a bladder, to a stricture retrogradno enter buzh. A slit on a crotch bare M. to., will mobilize it throughout 5 — 6 cm and cross about a stricture. Being guided on buzh, in hems create the tunnel passing an index finger. On edges of the distal end of M. to. impose long ligatures and fix them to the short rubber tube which is put on the end of the buzh removed in a wound from a bladder. By means of a buzh the tube with ligatures is removed through a bladder outside and tighten the mobilized M.'s end to. in the created tunnel, trying to establish it on the level of the central end. Ligatures tie up to a gauze ball or to a short rubber tube on an abdominal wall. Other operations (tunnelization, outside and internal urethrotomy, etc.) apply very seldom.
At M.'s strictures to. big extent the best results are yielded by substitution by flat and tubular rags from skin of a scrotum. At total strictures of spongy part M. to. it is cut together with a spongy body and skin from an outside opening to not changed site (fig. 13, a). Free edge of not changed M. to. sew in a bottom corner of a wound with skin. On a front surface of a scrotum find the corresponding length and not less than 1,5 — 2 cm of width a skin rag; after a preliminary epilation a rag sew it edges with dissect M. to. (fig. 13,6). The first stage of operation is completed sewing together of edges of a skin wound of a penis and a scrotum and drainage of a bladder a double tube (fig. 13, in, d). In 4 — 5 weeks two meeting cuts which are carried out at distance of 1 — 1,5 cm from a postoperative hem, the penis is released from a scrotum (fig. 13, d, e).
Similar operation is carried out also at incomplete strictures of this part. Depending on localization and the extent of a stricture change the size, a form and an arrangement on a scrotum of the found rag. Options of operation are shown in the figure 14, and. At an obliteration of spongy part M. to. cut lengthways through all fabrics throughout an obliteration and cross at the proximal end of a hem. From skin of a front surface of a scrotum find a rag 3 — 4 cm wide, create a tube, anastomose it from M.'s end to. and the penis is sewed in a scrotum. In 4 — 5 weeks release a penis.
Plastic surgeries at strictures and obliterations of big extent of back department of M. to. complete in two or three phases. At the first stage create a tubular rag of skin of a scrotum, is longer than estimated defect of M. to. on 3 — 4 cm, immerse it in depth of a scrotum and leave to the following stage or sew the distal end with M. to., previously crossed below a stricture. The second phase is completed in 2 — 3 months. If operation was made by the first option, delete a stricture, will mobilize a skin tube and the end it sew with the central end of M. to., leaving imposing of a distal anastomosis on the third stage. If operation is carried out by the second option, then the second stage becomes completing.
In the postoperative period active suction of urine and constant washing of a bladder solution of Furacilin is necessary. A catheter from M. to. delete in 4 — 6 days, a tube from a bladder — in 9 — 10 days. In 2 — 4 days carry out control bougieurage and delete a suprapubic drainage. Later 1 — 3 day after that fistula is usually closed and recovered a normal urination.
Strict performance of methods of treatment of strictures of M. to. provides recovery of patients in 97% of cases.
Fistulas. The most frequent reason of fistulas of M. to. at men damages are, but they can be formed and as a result hron, inflammatory process, after opening outside of abscess of an urethra or a prostate, germination of a tumor of M. to. and a penis, decubitus from a stone or a foreign body, it is long being in M. to. At women M.'s fistulas to. also most often damages result at ginekol, operations (removal of a uterus and cysts of a vagina), operational delivery, at destructive diseases of M. to. (an actinomycosis, syphilis, germination of a tumor), at abscesses of skiniyevy and bartolinovy glands etc. The internal opening fistula can open in M. to., and outside — on skin of a penis or a scrotum, a crotch, inguinal area, a buttock, in a rectum (fig. 15), and at women in a vagina. They can be single or multiple, have the forward or twisting stroke of various length and width.
Symptomatology of fistulas of M. to. depends on localization and the sizes of an outside and internal opening, length and tortuosity of the fistular course. The most characteristic symptom is the expiration of urine through fistula at the time of an urination. At small uretrorektalny fistula urine comes in the small portions to a rectum, but at the wide message of M. to. with a gut urine almost completely follows through an anus. If also the sphincter of a bladder is at the same time struck, then urine is constantly involuntarily emitted through fistula. At wide uretrorektalny fistula in M. to. from a rectum the fecal masses and gases get, to-rye then are allocated through an outside opening of an urethra. At uretroperinealny fistulas urine gets on skin of a scrotum and hips. Skin around an outside opening of fistula of a matserirovan.
Diagnosis of fistulas of M. to. it is based on data of the anamnesis, survey, performance of colourful tests, tool and rentgenol, researches. At survey pay attention to allocation during an urination of urine from an outside opening of fistula. For detection of dot fistula in M. to. enter intensively painted liquid and watch its allocation from the fistular course. Short and wide fistula manages to be distinguished by means of the probe (see. Sounding ). For diagnosis at a retro of rectal fistula carry out a rektoskopiya (see. Rektoromanoskopiya ), at the same time it is possible to see the fistular course and to enter the probe in a leg, and also to execute fistulografiya (see). At suspicion on existence of uretrovlagalishchny fistula resort to survey of a vagina by means of mirrors that allows to find a fistular opening, to define its localization and to execute sounding of the fistular course. Uretroskopiya not always helps to find an internal opening of fistula. At a retrografiya is of great importance in diagnosis of fistulas of M. to., it allows to define an anatomic condition of M. to., whistling for localization, extent, diameter and the course that helps to choose the most rational way of treatment.
Independent healing of fistulas of M. to. meets seldom since it is interfered by cicatricial fabric in the field of fistula. Seldom it is possible to achieve healing of fistula by means of a constant urethral catheter, cauterization by chemical substances and diathermocoagulations. Closing of fistula of M. to. as a rule, perhaps only in the operational way. Make full removal of the cicatricial changed fabrics together with Fistula for closing of fistula and closing of defect of M. to. At most of patients previously carry out an epicystostomy), and take in defect of fabrics over entered into M. to. catheter. At the same time apply various techniques urethroplasties (see). See also Urinogenital fistulas .
Stones in M. to. happen primary (formed in an urethra) and secondary — gone down from upper uric ways and got stuck throughout M. to. Secondary stones are more often observed. Primary stones occur almost only at men and form in the presence of a stricture, fistula or M.'s diverticulum to. The form of a stone corresponds to a configuration of that part M. to., in a cut it is with the growth. The largest stones are formed in M.'s diverticulum to.
Symptoms and a wedge, the course of a disease are various and depend on localization of a stone, its form, size and duration of stay in M. to. Patients have a pain and the complicated urination, change of a form and weakening of a stream of urine is observed, sometimes there is an acute ischuria. Long stay of a stone in M. to. causes urostasis (see) in upper uric ways, an inflammation of a mucous membrane of M. to., decubitus with development of paraurethral abscess and urethral fistula is more rare. At the uretropuzyrny stone which is partially in M. to., partially in a bladder, can nablyudattsya an incontience of urine.
For recognition of stones of M. to. apply a palpation, a tool research M. to. and uretrografiya. At a palpation, especially through a rectum, it is possible to find a stone not only in spongy part M. to., but also in its back department. Tool and rentgenol, researches specify the diagnosis.
Stones of front department of M. to. can be removed with urethral nippers and if a stone mobile with a smooth surface, it it is necessary to try to advance the massing movements to an outside opening. If the stone is in a navicula, then it can be taken tweezers, at a narrow outside opening of M. to. this procedure is made after its preliminary section — a meatotomiya. Stones of back department of M. to. it is possible to push the tool in a bladder and then to make lithotripsy (see). At unsuccessfulness of tool manipulations carry out lithotomy (see) way of an outside urethrotomy. Removal of a stone from back department of M. to. it is better to make through the opened bladder. At a part of patients M.'s stones to., especially secondary, after the conservative actions (water loading, antispasmodics, to lay down. bathtubs, etc.) depart independently.
See also Nephrolithiasis .
Benign tumors. Among new growths distinguish tumors, coming from a mucous membrane and - its glands, and also muscular and connecting tissue. Caruncles, condylomas, papillomas, polyps concern to the first; to the second — fibromas, myomas, fibromyomas, neurofibromas. Also angiomas belong to benign tumors.
A caruncle is a kind of polyps of female M. to. It is small (in the diameter from 0,3 to 0,5 cm) rounded shape the tumor, is located on the wide basis or on a short leg, has bright red or bluish color, easily bleeding velvety surface. A caruncle happens, as a rule, single. Most often it is localized on a mucous membrane of the lower half of an outside opening of M. to., consists of the friable connecting fabric containing many vessels. Emergence caruncles is promoted by venous stagnation and hron, an inflammation. The main symptoms are release of blood, pain during the walking, an urination and sexual intercourse, the urination sometimes complicated. Differentiate to a caruncle with loss of a mucous membrane of M. to., polyps of other nature and malignant tumors. At long existence it can malignizirovatsya.
Condylomas usually have the cone-shaped form, are located in the form of separate educations or accumulations around an outside opening of an urethra, easily bleed. They resemble a cauliflower superficially.
Polyps (see. Polyp, polyposes ) — tumorous formations of a softish consistence, usually have a long leg.
Angioma (see) has characteristic bluish-crimson color, a soft consistence, an uncertain form, in some cases happens in the form of considerable vascular growth.
Fibromas, myomas, fibromyomas occur extremely seldom, especially at men, at a palpation — dense, with accurate contours, rounded shape, grow slowly.
A long time benign tumors of M. to. can proceed asymptomatically. Most often patients complain of an itch, pains, burning in an urethra, release of blood from it. Polyps and papillomas quite often cause difficulty at an urination. Due to often found accompanying inflammation purulent discharges from an urethra are possible. Men can have a hemospermia, disturbances of an ejaculation and an erection are possible.
Diagnosis usually does not cause difficulties. At an arrangement of a tumor in the field of an outside opening of M. to. the diagnosis is made already at survey and a palpation, at an arrangement of a tumor in the above-located M.'s departments to. — by means of an uretroskopiya and at a retrografiya.
Apply electrothermic coagulation to treatment (see. Diathermocoagulation ), an electroresection (see. Electrosurgery ), various cauterizing solutions, a cryolysis (see. Cryosurgery ). However after these methods of treatment quite often there is recurrence. The resection of the struck part M. is considered more radical intervention to. Fibromas and myomas delete by enucleating. Radiation therapy at benign tumors of M. to. it is inefficient.
Malignant tumors. M.'s cancer to. occurs seldom, at the same time at women more often than at men. On gistol, to a structure in 85% of cases is planocellular cancer (see), the adenocarcinoma is much more rare.
Among the first complaints patients note the pains and an itch on the course of an urethra amplifying at an urination, the complicated release of urine; from M. to. appear serous, and in the subsequent — purulent and bloody discharges. In process of growth of a new growth metastasises in regional limf, nodes appear. At an arrangement of a tumor in front department of M. to. are surprised inguinal limf. nodes. If the tumor is localized in back department of an urethra, then metastasises appear in ileal limf, nodes, passing inguinal.
The diagnosis quite often manages to be made already at survey. The big density of a tumor, infiltration of the subject fabrics, bleeding, increase regional limf, nodes is characteristic of cancer. Helps to specify the diagnosis tsitol, a research separated from M. to., scrapings and prints from a tumor. In doubtful cases resort to a biopsy. Make an uretroskopiya for specification of extent of distribution of tumoral process, at a retrografiya, a tsistoskopiya. A state regional limf, nodes specify them by a puncture, limfografiya (see) and flebografiya (see).
Cancer therapy of M. to. can be operational, beam or combined.
Operational treatment at women at an arrangement of a tumor in distal department of M. to. consists in its resection, if necessary with a vulva, a wall of a vagina and small pudental lips. In the presence of metastasises in inguinal limf, nodes carry out also Dyuken's operation (see. Dyukena operation ). At localization of a tumor in uretrovezikalny department of M. to. delete together with a neck of a bladder and ileal limf, nodes. After operation carry out radiation therapy. At small tumors radiation therapy interstitial, remote or application by methods is possible.
Men at an arrangement have tumors in front department of M. to. make a peotomy, to-ruyu at metastasises in inguinal limf, nodes combine with Dyuken's operation. After operation radiation therapy is shown. At patients with defeat of bulbokavernozny or prostatic parts of the canal together with M. to. delete completely a bladder or only his neck.
Bibliography: Warsaw S. T. Uretro-venozny reflux and its clinical value, Tashkent, 1963, bibliogr.; In and-silyeva. I. Uretroskopiya and endoure/g-ralny operations, L., 1955; In an eyner ov I. V. and P about and N with to and y L. M. Diseases of urinogenital bodies at men, Kiev, 1961, bibliogr.; Gekhmanb. S. Uretro-grafiya and prostatografiya (atlas), Kiev, 1967; Zadorozhny B. A. and Petrov of B. R. Uretrita, Kiev, 1978, bibliogr.; And in and N about in G. F. Fundamentals of normal anthropotomy, t. 1, page 720, M., 1949; Ilyin I. I. Not gonococcal uretrita at men, M., 1977, bibliogr/; To and D. V N. Guide to obstetric and gynecologic urology, page 184, M., 1978, bibliogr.; A clinical onkourologiya, under the editorship of E. B. Marinbakh, page 177, M., 1975; Krayevskiyv. Ya. Atlas of microscopy of an urocheras, M., 1976; Logasheva. H. A counter uretrografiya at a posttraumatic obliteration of an urethra, Urol, and nefrol., No. 6, page 53, 1973; JI I x about in and the Central Committee and y N. S. Uretroskopiya and vnutriuret-ralny interventions, M., 1969, bibliogr.; Damages of bodies of urinogenital system, under the editorship of. And. G1. Shevtsova, page 101, L., 1972, bibliogr.; Pytel A. Ya. and Pytel Yu. A. Radiodiagnosis of urological diseases, page 128, 392, M., 1966; The Guide to clinical urology, under the editorship of A. Ya. Pytel, page 344, etc., M., 1970, bibliogr.; V. I hares. Strictures of an urethra, M., 1962, bibliogr.; Rusanov A. A. Ruptures of an urethra, M., 1953, bibliogr.; A camp to I. Embriologiya of the person, the lane with slovatsk., page 268, Bratislava, 1977; Injuries and surgical diseases of bodies of a basin and external genitals, under the editorship of M. N. Zhukova, page 171, L., 1969; Chukhriyenko D. P. of an ilyulko. B. The atlas of operations on bodies of urinogenital system, page 194, M., 1972; Bracken R. and. lake of Primary carcinoma of the female urethra, J. Urol. (Baltimore), v. 116, p. 188, 1976; Klinische Urologie, hrsg. v.C. E. Aiken u. W. Staehler, S. 129 u. a., Stuttgart, 1973; Mayor G. u. Z i n g g E. J. Urologische Operationen, S. 373, Stuttgart, 1973.
G. P. Kulakov, V. I. Rusakov, V. H. Tka-chuk; B. P. Matveev (PMC.), I. I. Novikov (An.)