膀胱肛管直肠穿通伤的诊断与治疗

Diagnosis and treatmant of a through-and-through injury of urinary bladder-rectoanal canal

目的 总结膀胱肛管直肠穿通伤的诊治经验。 方法 回顾性分析 13例膀胱肛管直肠穿通伤患者的资料。均为男性 ,平均年龄 37岁。均为外伤所致 ,伤后就诊时间 <6h 4例 ,6～ 12h5例 ,>12h 4例。 13例均行膀胱探查及膀胱造瘘术。其中 1例因前列腺损伤行前列腺切除 ,1例行尿道吻合术 ,术后均持续导尿。肛管括约肌清创缝合 3例 ,经肛门行直肠修补 8例 ,未修补 4例。骶前间隙置双套管引流 7例 ,沿原创口引流 4例 ,放置肛管 6例。行乙状结肠造瘘 12例。 结果 13例均治愈。 2例术后并发骶前间隙感染 ,经充分引流痊愈 ;1例肛门括约肌修补失败 ,行二期修补治愈 ;1例发生直肠膀胱瘘 ,保守治疗痊愈。无排尿困难、阳萎、肛门直肠狭窄等并发症。随访 12例 ,失访 1例 ,随访时间 10个月～ 6年 ,1例轻度大便失禁 ,经提肛肌训练半年后恢复正常 ;1例 1年后发现膀胱结石 ,经膀胱镜下碎石痊愈。余 10例排尿、排便正常 ,1例曾定期尿道扩张 6次。 结论 掌握膀胱肛管直肠穿通伤的临床特点 ,作到早期正确诊断 ,选择合理手术方案 ,加强围手术期治疗 ,是提高疗效的关键。

Objective To outline the diagnosis and treatment of a through-and-through urinary bladder to rectum-anal canal injury. Methods To review and summary 13 cases of through-and-through urinary bladder to rectum-anal canal injury.All patients were male and average age of 37 years old.Among them 4 cases reached hospital in 6 hours after injury,5 cases during 6～12 hours and 4 cases over 12 hours.Debridment and suture of urinary bladder to rectum-anal canal injure,effective revolution of urine and stools and full drainage in anterior sacrum space were performed.All of the 13 cases experienced operation of bladder exploration and drainage.1 among them underwent prostate gland cuting off because of the prostate gland injury.Another received the operation of urethra anastomoses.Both of them keep on catheterizing after operation.The management of anus and rectum hurt:3 cases received clearing and sewing up the wounnd of anus sphincter.8 cases received the repair of rectum passing through the anus.4 cases were not given remedy.7 patients received placing double thimble in the gap before sacrum.4 patients recieved placing eduction tube in the original wound.12 patients were given the operation of making sigmoid flexure fistula. Results All the 13 cases were cured.2 cases had postoperative infection in anterior sacrum space and were cured by full drainage.1 case was cured by secondary repairment after anal spincter repaired unsucessfully.1 case with rectovesical fistula was cured by conservative treatment.None suffered from dysuria,importence or anal stenosis.12 cases were visited and 1 was lost.Follow up was conducted from 10 months to 6 years.1 case with mild bowels incontinence recovered after training of lifting the anus for half a year.1 patient suffered from bladder calculi after a year and healed through lithotrity under cystoscope.The remaining 10 urinate and defecate normally,amonmg them 1 experienced urethra extends 6 times. Conclusions It was the key of improving treatment effect to master the clinical feature of a through-and -through urinary bladder to rectum-anal canal injury and diagnose correctly in the early stage and select reasonable operative procedure.