Ischuria

Description:

The ischuria - impossibility to independently empty a bladder - is one of the most frequent reasons of the emergency hospitalization of patients in a hospital. Distinguish an acute and chronic, full and incomplete delay of an urination.

At an incomplete delay of an urination in a bladder after an urination there is a certain amount of urine (more than 20 ml). The residual urine can be found by introduction of a catheter or at X-ray inspection, a radio isotope renografiya and ultrasonography. The incomplete delay of an urination quite often passes in full, especially at patients with adenoma, a prostate cancer or a stricture of an urethra, and also at children with various inborn diseases of a vesical and urethral segment.

The acute delay of an urination comes suddenly, as if among full wellbeing, for example at hit of a stone or polyp on a long leg with urine current in an urethra.

Ischuria symptoms:

Diagnosis of an acute delay of an urination does not cause difficulties (impossibility to empty independently a bladder, acute arching pain in the bottom of a stomach). At survey find the spherical protrusion over a pubis which is especially accurately defined at thin patients and children. At a palpation reveal dense elastic education over a bosom.

Ischuria reasons:

The urethra injury, foreign body can cause an acute delay. It develops also against the background of a chronic delay of an urination. The reasons causing an urination delay can be divided into two groups:

  1. Pathological changes in uric bodies or their prelum:
        1. Traumatic damages (injury, crush, urethra separation).
        2. Obstruction of a gleam of an urethra:
              1.na the level of a vesical and urethral segment (one - or bilateral to an ureterotsela, a stone, a polyp, bladder cancer, inborn disturbances of passability of a vesical and urethral segment);
              2.na urethra level (valve, diverticulum, foreign body, stone, tumor, post inflammatory strictures of an urethra).
        3. An urethra prelum patholologically the changed bodies of urinogenital system (at adenoma, cancer, a cyst, abscess, a prostate sclerosis, prostatitis, a phymosis, a paraphimosis, a balanoposthitis).
        4. An urethra prelum patholologically the changed bodies of a cavity of a small pelvis (rectum cancer, a paraproctitis, uterus tumors, inguinal hernias, aneurism of a hypogastric artery, a crotch hematoma, etc.).
  2. Diseases of a nervous system (neurogenic dysfunction of a bladder).

Carry tumors, inflammatory diseases, injuries to causes of infringement of processes of reduction and relaxation of a detruzor and a vesical and urethral segment back and a brain, hernia of a spinal cord, disturbance of a peripheral innervation of a bladder after operations on bodies of a small pelvis. In the same group of the reasons it is necessary to carry also a reflex delay of an urination after surgeries, childbirth, spinal anesthesia. At the same time it is necessary to remember that not everyone even the healthy person can urinate in horizontal position.
At a prelum of an urethra or obturation of its gleam the urination becomes frequent and sokratitelny ability of a detruzor increases. The uneven myopachynsis of a bladder therefore there is a so-called trabecular bladder is observed. This eminence of separate muscle fibers over a bladder cover mucosal surface. At a hypertrophy of a detruzor blood circulation and a trophicity of a bladder are broken, there can be false and true diverticulums. The quantity of a residual urine increases, and further there is a full ischuria. If the cause breaking urine outflow is not removed there is an inconscience with overflow. In this case urine, having overcome the stretched vesical and urethral segment, irrespective of a will of the patient constantly with drops it is allocated from an urethra, that is against the background of a full delay of an urination the urine incontience is observed. The rupture of the bladder at the patients who are in alcohol intoxication at blows to the area of a bladder is possible, falling. At a full and incomplete delay of an urination there are all conditions promoting development of inflammatory process in a bladder - cystitis. In initial stages the mucous membrane, and further - submucosal, muscular and all layers of a bladder is involved in inflammatory process. Such development of inflammatory process is especially often observed at patients with damage of a head and spinal cord.

In most cases the reasons causing an urination delay at the same time cause also disturbance of outflow of urine from kidneys. A bright example - patients with prostate adenoma. Hypertrophied paraurethral glands squeeze at the same time both an urethra, and mouths of ureters. On the roentgenogram find the narrowed gleam of the raised distal department of an ureter. It has the form of a fishing hook, and in these cases disturbance of outflow of urine from ureters is caused by pressure of both adenomatous nodes, and urine which large amount is in a bladder. Patients with prostate adenoma as it is paradoxical, can have also a vesicoureteral reflux that is characteristic as well of children with contractures of a vesical and urethral segment, a hydronephrosis and a megadolikhoureter.

Disturbance of outflow of urine from kidneys, vesicoureteral, and further and a lokhanochno-renal reflux break microcirculation, reduce the level of glomerular filtering and a canalicular reabsorption and create conditions for penetration of the ascending infection, developing of pyelonephritis. And in these conditions serous pyelonephritis quickly passes in purulent (апостематоз, an anthrax, карбункулез) and leads to death of kidneys, to an urosepsis and a renal failure.

Patients with prostate adenoma already in the 1st stage (when the person is almost healthy) have a pyelonephritis and a latent renal failure. Patients with it is long not treated delay of an urination, as a rule, perish from a renal failure and an urosepsis.

Treatment of the Ischuria:

Treatment of patients with a delay of an urination includes two moments. This removal of urine from a bladder and elimination of the reasons which caused an urination delay. Patients with an acute delay of an urination it is also long suffering from its incomplete delay, weakened by chronic pyelonephritis and a renal failure, need immediate removal of urine from a bladder. Bladder emptying can be carried out by catheterization, a suprapubic capillary puncture, trocar cystostomy and an epicystostomy.

The most widespread way of removal of urine is bladder catheterization. It will be out in aseptic conditions. For prevention of inflammatory processes and urethral fever appoint antibiotics. For catheterization of a bladder use metal and rubber catheters. Position of the patient on spin, is better in a gynecologic chair. The doctor becomes near a couch or a chair on the right side. Three fingers of the left hand takes a penis for a head, the right hand enters a catheter into an urethra, pulling the last on the tool to an outside sphincter of a bladder. Then the penis together with a catheter is led to a front abdominal wall and gradually lowered towards a scrotum from top to bottom. At this moment, having overcome the easy resistance of a vesical and urethral segment, the catheter enters a bladder. Use of a metal catheter, especially in the absence of skills, does not exclude danger of formation of the false courses in an urethra, a prostate that can lead to development of urethral fever, an orkhiepididimit, uric zateka. It is safer to enter Nelaton and Timman's rubber catheters into an urethra. The last has a coronoid bend on the distal end and better passes on a back wall of an urethra in a bladder. Advantage of rubber catheters is also that it is possible to leave them in an urethra on 2-3 days, and sometimes and to 2 weeks. Existence in urine of slime, blood, pus, salts complicates drainage of a bladder a catheter, especially at its leaving for a long time.

Catheterization complications. Even at single catheterization infection of the lower uric ways (an urethritis, cystitis), a microtrauma of a mucous membrane of an urethra are possible that can lead to development of pyelonephritis, an urosepsis. Catheterization, especially metal catheter, can cause an urethremorrhagia that forces to refuse attempt to empty a bladder.

Contraindications to catheterization: urethra injury, acute prostatitis.

The second way of removal of urine from a bladder at a delay of an urination is the capillary puncture of a bladder which is made the patient when introduction of a catheter is impossible or it is contraindicated. It is desirable to carry out a capillary puncture of a bladder at patients with adenoma of a prostate of the second stage (a full ischuria) for inspection and the solution of a question of expediency of carrying out a single-step adenomectomy. Punktirut a bladder over a bosom, having receded 1-2 cm from the average line. A puncture it is possible to carry out 2 - 3 times a day.

Complications of a capillary puncture. According to many authors, at a capillary puncture are observed extensive uric flow, especially at patients with the thinned bladder wall. The capillary puncture at persons with excess body weight is complicated. It is ineffective in the presence in urine of clots, pus, salts, etc.

When carrying out catheterization of a bladder and a suprapubic puncture it is necessary to remember that bystry bladder emptying leads to blood redistribution, that is outflow of blood from a brain that causes a collapse, bleeding from a bladder.

Suprapubic epicystostomy. Operation is applied long ago and technology of its performance is well-known. Create the suprapubic vesical fistula providing sufficient drainage of a bladder by means of Pettser's catheter, Foley, rubber drainages. Being rather small on volume and low-traumatic, cystostomy nevertheless is hard transferred by the weakened patients and patients of advanced age who quite often have associated diseases.

Drainage of a bladder by a suprapubic puncture a trocar with leaving of a rubber catheter deserves attention. The equipment of a puncture is simple, painless, the malotravmatichna also does not demand special conditions. It can be executed in a dressing room, chamber. On a midline of a stomach of the 2 cm higher palpated pubic joint carry out anesthesia, cut skin and enter a trocar in front back and several from top to bottom. Small diameter of a tube and considerable reduction of a bladder with shift lead to sliding of a bubble from a drainage. The tube excess, adjournment in it of salts is possible that it breaks urine outflow. Arise uric flowed, paracystitis. Now are issued one - and double-thread troakara which use for fixing of a bladder and its simultaneous washing. The demountable tube trocar is developed (two semi-tubes up to 130 mm long and with a diameter of 8 mm). At introduction of a trocar these semi-tubes are moved apart then enter Pettser's catheter. Advantages of this method following: the catheter itself keeps in a bladder, it elastic, its gleam has bigger diameter that creates more favorable conditions for drainage of a bladder.

At constant and long drainage of a bladder the reflex on stretching is broken. The bladder detrenirutsya and irreversible changes in its intramural nervous device develop that is the reason of decrease and even full loss of functional capacity of a detruzor.

Existence of an infection and long free outflow of urine causes formation of the small wrinkled bladder which loses elasticity, so necessary for its normal functioning. Therefore the bladder needs to be washed out constantly antiseptic agents, to fill and detain periodically in it liquid. In 1935 Monroe and Guy offered the device of automatic filling and bladder emptying.