Acquired male urethral diverticulum
Description
◉ Patient Profile & Background
• Age and sex: male, 54
◉ Chief Complaints:
• When voiding, the penile mass becomes tense (tumescence).
• Several urinary tract infection (UTI) incidents
• To finish urinating, the penile bulk must be physically compressed.
• Duration: Over the past 12 months, symptoms have gotten progressively worse.
• Previous Medical and Surgical Experiences
• Perineal fistula: A complicated posterior perineal fistula that was previously treated in the general surgery department with several unsuccessful procedures.
• Transanal fistulotomy (intersphincteric and trans-sphincteric tracts) is the first treatment.
• After three unsuccessful attempts, the issue was resolved with intestinal diversion (colostomy).
• After surgery, MRI shows persistent fibrosis and no new fistula tracts.
• HIV positive: Has good virological control and is on a triple HAART treatment.
• No more noteworthy comorbidities.
◉ Clinical Examination
• Normal position and appearance of the urethral meatus.
• At rest, there is no felt or apparent penoscrotal bulk.
• functional lower abdominal colostomy on the left side.
• No evidence of an active illness, redness, or pain.
• typical results of a general examination.
◉ INVESTIGATIONS
▶ Lab Results
• Blood and urine cultures showed no signs of an active infection.
• E. Coli and Klebsiella pneumoniae were cultivated in earlier cultures during recurrent UTIs.
▶ Functional Test
• Flowmetry without charge:
• 18 mL/s is the peak flow (Qmax).
• extended, sporadic pattern that is compatible with manual compression to remove any remaining urine.
• Endoscopic Results
• Cystourethroscopy:
• In bulbar urethra, a little ostium (opening) is visible.
• No blockage or urethral stricture.
▶ Imaging Findings
• Retrograde urethrogram:
• saccular outpouching, or bulbar urethral diverticulum, 4 cm.
• No indications of stricture or fistula.
• Pelvic MRI:
• Urethral saccular dilatation was confirmed.
• No new fistulous tracts or abscesses.
◉ DIFFERENTIAL DIAGNOSIS CONSIDERED:
• Urethral stricture was ruled out since imaging showed no narrowing.
• There is no fecal or pneumaturia, therefore urethral fistula (urethrorectal or urethrocutaneous) is improbable.
• Obstruction of the bladder outlet is ruled out (normal flow following compression).
• The diagnosis of urethral diverticulum has been confirmed.
◉ DISCUSSION AND LITERATURE INSIGHTS
• Male urethral diverticulum is uncommon and can be acquired or congenital.
• Trauma, infection, stricture, or prior urethral/perineal procedures are examples of acquired causes.
• In this instance, the urethral wall protruded due to fibrosis and scarring after several perineal fistula procedures.
▶ Typical signs and symptoms include:
• recurring urinary tract infections
• Dribbling after a void
• bulk or swelling in the penoscrotal area
• Sometimes having trouble voiding
• A common appearance is penile enlargement during urination, as in this instance.
• The diagnosis is confirmed by imaging using an MRI or retrograde urethrogram.
• When there are symptoms or an infection that keeps coming back, surgical excision is recommended.
• Excellent outcomes with diverticulectomy and end-to-end urethroplasty are demonstrated in the literature (Cinman et al., Alphs et al.) when the defect is less than 4 cm.
• With full excision and appropriate repair, the prognosis is excellent.
Protocol
◉ MANAGEMENT
▶ Care Before Surgery:
• Before surgery, it was made sure there was no active urinary infection.
• Urine culture results before to surgery were negative.
• Broad-spectrum preventive antibiotics were introduced.
• Patient education on potential complications, postoperative catheter care, and surgery.
• accurate assessment of colostomy performance.
▶ Surgical Intervention:
• Method: Perineal approach in lithotomy position with an inverted U-shaped incision.
• Because of the thick fibrosis surrounding the urethra, a careful dissection was done.
• To clearly identify the urethral mucosa, methylene blue was added.
• The process carried out:
• Total removal of the urethral diverticulum.
• urethral anastomosis from end to end for reconstruction.
• After surgery, a Foley catheter was placed and maintained for three weeks.
• For ten days, broad-spectrum antibiotics were used.
• No problems during or after the procedure
◉ Management of Nursing (DETAILED POINTS)
▶ Nursing Care Prior to Surgery
• Examine past infection history and urine symptoms.
• Before surgery, make sure the urine culture is sterile.
• To avoid infection, practice good perineal hygiene.
• Inform the patient about catheter management, postoperative care, and the operation.
• Due to HIV status and previous surgical failures, offer psychological support.
• Physically prepare the patient (consent, hydration, and bowel management).
▶ The role of intraoperative nursing:
• Help with placement (severe lithotomy) while making sure there is padding and safety.
• Take careful aseptic precautions at every stage of the process.
• Assist the surgeon while handling tissue and applying dye.
• Avoid pressure injuries or nerve compression during extended operation.
▶ Immediate Postoperative Nursing Care:
• Keep an eye on wound drainage, urine production, and vital signs.
• Monitor catheter function to guarantee ongoing drainage.
• Check for wound infection, bleeding, or leaks.
• Give analgesics and antibiotics as directed.
• To keep urine flowing and avoid blockage, promote hydrated.
▶ Care for Catheters and Wounds:
• Keep your catheter clean and avoid unintentional pulling.
• To prevent contamination, clean the stoma site and the perineal area separately on a regular basis.
• Keep an eye out for symptoms of a wound or urinary tract infection.
• Inform the patient of any infection symptoms or blockage reports right away.
• To cleanse the urinary system, promote the consumption of enough oral fluids.
• After the catheter is removed, instruct the patient in pelvic floor muscle exercises.
• To encourage bladder reconditioning, teach timed voiding.
• Encourage good hygiene and ways to avoid getting a UTI.
• To lessen worry about complications or recurrence, offer continuous emotional support.
Notes
FOR MORE DETAILS VISIT https://pmc.ncbi.nlm.nih.gov/articles/PMC5174757/?utm_source=chatgpt.com
