The 'watering-can' perineum: presentation and management.

OBJECTIVES: To assess the frequency of 'watering-can' perineum among patients with post-inflammatory urethral strictures, to evaluate methods of anatomical location and to assess the efficacy of direct-vision internal urethrotomy (DVIU) in this condition. PATIENTS AND METHODS: From 1990 to 1996, 216 patients with post-inflammatory urethral strictures were evaluated; all underwent ascending urethrography and urethroscopy and 44 were found to have a 'watering-can' perineum. These patients were evaluated further for the presence of associated urethral pathology. e.g. calculi and diverticulae. DVIU was performed as the primary method of treatment and any associated urethral pathology treated at the same time. The follow-up ranged from 3 to 36 months (mean 20). RESULTS: Ascending urethrography and urethroscopy located the site of the stricture in all 44 patients: 12 had associated urethral calculi. In 28 patients, the fistulae healed completely after a single DVIU, a further 11 required two urethrotomies, while the remaining five required more than two urethrotomies to treat the stricture. CONCLUSION: DVIU can be used to treat strictures complicated by urethrocutaneous fistulae, and for detecting associated urethral pathology. It has the advantage of requiring a minimal hospital stay, provoking minimal morbidity and the procedure can be repeated as a day-case if the stricture recurs.

Internal fistula formation: an unusual complication of mycetoma.

This paper reports 2 hitherto undescribed complications of mycetoma, urinary extravasation and expectoration of mycetoma grains due to cutaneo-urethral and cutaneo-pleuro-bronchial fistulae, respectively. The first patient had an infection with Actinomadura madurae which started in the foot and had spread progressively to involve the whole limb, anterior abdominal wall, perineum and urethra. The second patient had Madurella mycetomatis infection of the hand and, in spite of extensive treatment, the infection had spread to the axilla, chest wall, lung and bronchial tree. Both patients died of the sequelae of these complications. The pathogenesis of these unusual complications is discussed.

Evaluation of haematuria in Khartoum.

Four hundred and fifty patients with haematuria were studied over 10 years. Their mean age was 35 years. 103 (23%) patients had past histories of urinary bilharziasis. 207 (46%) patients had associated loin pain at presentation. Intravenous urography could detect the cause of the haematuria in 251 (56%) patients. Cystoscopy was diagnostic in 131 (29%) patients. Other methods of investigation included ultrasonography, selective renal angiography and renal biopsy. The commonest causes of haematuria were urinary calculi in 206 patients (46%), and carcinoma of the bladder in 47 (10%) patients. Twenty patients had squamous cell carcinoma of the urinary bladder in association with urinary bilharziasis, and all were under the age of 40 years, Other causes of haematuria included glomerular diseases in 31 patients, malignant renal tumours in 11, benign renal cysts in five, while it was due to benign prostatic hyperplasia in 31 patients, vesical calculi in 16, cystitis in nine and urethritis in nine patients. Forty two (9%) patients with undiagnosed haematuria were followed for five or more years. Repeat investigations in those with recurring haematuria were negative; except in four patients. Two of those were found to have hyperuricaemia, one renal tuberculosis; and one arterio-venous fistula. None of the patients labelled as having undiagnosed haematuria was found to have developed malignancy in the urinary tract over the subsequent five years. Accordingly, it seems that in the absence of significant signs and symptoms of urological or renal disease other than recurrent haematuria, the probability of finding a significant lesion is quite small.

Ureteric injuries during gynaecological surgery.

Thirty-two patients with 35 ureteric injuries encountered during gynaecological surgery are presented. Their mean age was 41 years. Eight ureteric injuries were recognized during surgery, the nature and sites of injury were diagnosed peroperatively using an illuminated size 5 F ureteric probe (Storz) passed through a cystoscope. Three ureteric injuries were diagnosed during convalescence as continuous drainage of urine or urinoma collection, while three patients developed total anuria due to ligation of both ureters. Eighteen patients presented with late urinary fistulae, being uretero-uterine in 8 and ureterovaginal in 10. The ureteric injury occurred during emergency Caesarean section in 15 patients, the indication for Caesarean section being obstructed prolonged labour in 70% of them. Twelve urinary fistulae followed hysterectomy. Intravenous urography, antegrade and retrograde ureterography were useful methods of locating the sites of the fistulae. Ureteroneocystostomy was performed in 18 patients, utilizing a Boari flap in 3 and a bladder psoas hitch in 2. Other methods of treatment are discussed. The mean follow-up was 3 years.

Acute idiopathic scrotal oedema in association with diabetic septic foot.

Acute idiopathic scrotal oedema was observed in three adult diabetic patients with septic foot following life saving above knee guillotine amputation. This is a previously unreported association as far as we know and no clue to the pathogenesis could be obtained.

Squamous cell carcinoma of the urinary bladder.

A series of 52 patients with squamous cell carcinoma of the urinary bladder were studied over a 6-year period. They constituted 27% of all bladder tumours. The male:female ratio was 12:1; 62% of the patients were below the age of 50 years (mean 47) and 31% had a previous history of urinary bilharziasis. Associated stigmata of Schistosoma haematobium, as sandy patches, were detected in 69% of patients. Fourteen had bilharzial ureteric strictures as seen on intravenous urography and most of the tumours occurred in the region of the trigone; 60% had T3 NO MO tumours at presentation. Eighteen patients received radical radiotherapy and 16 patients under the age of 55 years underwent radical cystectomy with diversion of urine to an isolated rectum. The 5-year survival rate in the radical cystectomy group was 75%. Other modalities of treatment and their results are discussed.

Presentation and management of urethral calculi.

A total of 36 patients with urethral calculi are presented; 34 were males, aged 2 to 65 years (mean 43). Eight patients were under the age of 6 years and presented with retention of urine. Calculi were in the posterior urethra in 56% of the patients, 33% had associated urinary tract calculi, and 47% had other diseases of the lower urinary tract, the commonest being posterior urethral stricture (42%). Of these calculi, 58% could be manipulated endoscopically into the urinary bladder, then crushed. Associated urethral strictures were dealt with by visual internal urethrotomy before manipulating the calculi. Other methods of treatment and their complications are discussed.

Clinical aspects of hydronephrosis in Khartoum.

Two hundred and thirty two patients with hydronephrosis were managed during the period 1982 to 1987. The peak incidence occurred between 20 and 30 years of age. 29% of the patients had history of urinary bilharziasis at presentation. Intravenous urography (IVU) was performed in 227 (98%) patients and it was diagnostic in 83% of them. Ultrasonography, retrograde and antegrade pyelography were among other methods of investigations. Hydronephrosis was bilateral in 56 patients. The commonest cause of hydronephrosis were idiopathic pelvi-ureteric junction obstruction, urinary bilharziasis and retroperitoneal fibrosis. 206 patients required surgical intervention to relieve obstruction. 184 patients attended the follow-up clinics for 6 months or more. The findings of the post-operative follow-up IVU are discussed.

The continuing challenge of bilharzial ureteric stricture.

The commonest urologic complication in 176 cases of chronic urinary bilharziasis was ureteric stricture (87 ureters in 55 patients), with the lower third of the ureter affected in 87% of the cases. Other complications included squamous-cell carcinoma of the bladder, urinary calculi and bladder calcification. Intravenous urography and cystoscopy were the most useful diagnostic methods in 76% of the cases. Post-micturition erect urography and frusemide intravenous urography gave great help in distinguishing between true mechanical and non-mechanical ureteric obstruction in patients with dilated pelvicalyceal system on conventional urograms. Only 17 of 68 dilated ureters were truly obstructed and required excision and ureteroneocystostomy. Postoperative vesicoureteric reflux developed in four of these cases. No deterioration of renal function occurred in the remaining, conservatively treated patients.

Complicated male urethral strictures: presentation and management.

Among 104 patients with urethral strictures treated over a period of 3 years, sixty-five (63%) had complications such as inflammatory periurethral mass, watering-can perineum with discharging sinuses and fistulas, associated urethral calculi, periurethral abscesses and urethral diverticula. Seventy-four per cent of the strictures were of inflammatory origin and they predominated in the region of the bulbar urethra. Thirty-two patients were treated by visual internal urethrotomy, 11 had two-stage urethroplasty and 9 had perineal urethrostomy. Other methods of treatment and their results are discussed.