|Minor Surgical Procedures in Remote Areas (MSF, 1989, 172 p.)|
|Chapter 5: uro-genital procedures|
Drainage of urine
Acute retention of urine
Urgent procedure is necessary for:
· Narrowing of the
· Adenoma or cancer of the prostate
· Pelvic tumor
· Pelvis trauma
· Sterilised gloves and drapes
· Sterile catheters, generally Foleys n° 12,14,18 for example
· Lubrification with chlorhexidine (+ cetrimide) (see table page 7)
· Sterile compresses
· 10 ml syringe
(Figures 88, 89)
· Careful disinfection of the meatus, the glan and the prepuce, through the hole in the drapes.
· Coat the catheter with chlorhexidine (+ cetrimide) (see table page 7)
· The left hand holds the penis vertically
· The right hand carefully introduces the catheter through the meatus.
· Change the size of the catheter if introduction is difficult.
· When the catheter reaches the bulbar angle (13 to 15 cm), direct it towards the base.
· NEVER FORCE THE CATHETER, it is better to use a suprapubic catheter than to traumatise the urethra.
· Advance the catheter to the hilt before inflating the balloon (5 to 10 ml of liquid).
· Next, gently pull the catheter until the balloon abuts on the bladder neck.
· Always replace the prepuce around the glans, to prevent a paraphymosis.
· If the catheter is to remain in place, connect it to a sterile urine container, otherwise to a perfusion tube attached to a short necked bottle.
· Clean the meatus each day, and eventually, depending on the clinical context, institute antibiotic treatment (cotrimoxazole: 1,600 mg de SMX/day in 2 divided doses x 5 days for an adult.
When urethral catheterisation presents difficulties, and when there is a risk of damage to the urethra with the catheter (trauma to the bladder, trauma to the urethra, and urethral stenosis, etc.).
The bladder must be dilated: A DISTENDED BLADER IS OBLIGATORY.
· A prepared pack exists with a unique "cystocath". If not available, a large trochar and long catheter perforated at one end (at least 14G), can be used.
· Drapes with a hole, and sterile gloves
· Suture material
· Local anesthetic
· Shave and then disinfect the suprapubic region with polyvidone iodine (see table page 7).
· Make a bubble in the skin with lidocaine a finger breadth above the symphysis pubis in the median line. Anesthetise the deep tissue planes (Figure 91).
· With the same syringe ensure that aspiration produces urine.
· Puncture through the anesthetised bubble, asking the patient to cough.
· Introduce the perforated drain: advance 10 to 15 cm of the catheter, remove the trocar and attach the catheter to a sterile urine container.
· Fix the drain to the skin with a non resorbable suture and a dressing.
· Clean the drain at least once a day and institute urinary antibiotic treatment (cotrimoxazo/e: 1,600 mg of SMX/day in 2 doses for adults x 5 days) (Figures 92, 93, 94).
Acute swelling of the retracted prepuce.
Urgent treatment is required to prevent glans necrosis
· It is almost always possible to reduce manually, without anesthesia, depending on the condition of the patient. Light sedation with diazepam is sometimes necessary.
· Compress the glans with the fingers of the left hand, while holding the shaft of the penis with the other hand.
· Daily baths with a solution of chlorhexidine (+ cetrimide) (See table page 7).
· Often, manual reduction is difficult or impossible.
· Place an incision in the axis of the penis on the dorsal surface (the urethra is situated on the ventral surface).
· Incise the two rolls of prepucial skin as far as the deep ligament which is constricting the penis.
· The reduction will then be easy.
· A circumcision is recommanded a few weeks later.
Dissection of the perineum to enlarge the birth canal and to prevent a tear.
· Pushing for more than 30 minutes increases pain and suffering.
· Occipito-posterior, face or forehead presentation.
· All obstetric maneuver, forceps, ventouse and symphysectomy.
· Perineal anomalies, retractile scars from previous deliveries.
In general, it is preferable to repair an episiotomy rather than to suture a perineal tear.
The decision to do an episiotomy comes with experience.
Pair of sterile scissors (for example, Dauphin scissors or 16 cm pointed scissors).
After disinfection of the skin with chlorhexidine (+ cetrimide) (see table page 7), place the scissors between the presenting part and a line postero-lateral to the vulva, with the next contraction cut obliquely and posteriorly for approximately 4 cm.
A tear is complete when it reaches the anal sphincter and is complicated when it reaches the rectal mucosa.
NB: Suture an episiotomy after delivery.
· Sterile "abscess-suture" box containing scissors, toothed dissecting forceps, needle holders and needles.
· Resorbable and non resorbable suture material.
· Sterile drapes and gloves.
· Make a sterile tampon: gauze tied with a large suture and then placed in the vagina to collect uterine secretions.
· Local anesthesia with lidocaine 1% in the tissue layers except for the rectal mucosa, at least 5 ml especially under the skin.
· After cleaning the perineum and vagina with polyvidone iodine, place the sterile drapes under the buttocks, on the abdomen and on the thighs (see table 1).
1st: episiotomy or simple perineal tear
Repair the muco-cutaneous junction and pass the first suture without producing a knot, to produce a good join of the layers.
Suture the mucosa of the vagina from inside outwards with resorbable sutures, sufficiently close and sufficiently deep to allow the passage of lochia during the following days, but not too deep as to prevent evacuation of the rectum.
Next, suture the muscle layer with 2 or 3 resorbable sutures, if possible.
Close the skin ensuring that the sutures are not too close together, if possible use the Blair-Donati method. Begin at a point situated at the apex of the wound and which does not already contain a suture, and control the procedure with a finger placed in the rectum.
2nd: complete perineal tear
Figures 103, 104
Rupture of the anal sphincter, a tear of the muscle fibres, easily identify by touching the anal region.
Suture the sphincter with slowly resorbable sutures, with 2 or 3 X-points. Then proceed as before. Control the procedure with a finger placed in the rectum.
3rd: complicated perineal tear
Protect from the stool with a rectal tampon (similar to the vaginal tampon) and clean with polyvidone iodine (see table page 7).
Suture the rectal mucosa with separate resorbable sutures from the inside outwards, tying the knots on the rectal surface. Then proceed as before. Control the procedure with a finger placed in the rectum.
In all cases, clean the vagina with a diluted solution of chlorhexidine (+ cetrimide) (see table page 7) and dry the wound as often as possible. Remove non resorbable sutures after 8 days.
Breakdown of the suture.
In the case of an episiotomy, the scar may be long and unpleasant: encourage daily vaginal toilet.
In the case of a complete or complicated perineal tear, with anal incontinence, refer, if possible, to a surgeon.
Only prescribe antibiotics when the lochia are purulent, with associated intra-uterine procedures or if there is a post-partum fever.
General precautions (asepsis, antibiotic therapy, anesthesia, preventing trauma)
OBLIGATORY ASEPSTS (clean with chlorhexidine (+ cetrimide) (see table page 7), drapes, gloves, and sterile compresses etc.), ALL INTRAUTERTNE PROCEDURES MUST BE FOLLOWED BY ANTIBIOTIC THERAPY, (PPF 4 million units for example IM for at least 5 days or ampieillin), HEMOSTASIS (ergometrine 0,1 mg IM x 1).
ALL INTRA-UTERINE PROCEDURES MUST BE CONDUCTED UNDER THE AUSPICES OF AN ANESTHETIST, the most rapid general anesthetic is ketamine IM (5 mg/kg).
ALL INTRA-UTERINE PROCEDURES MUST BE AS ATRAUMATIC AS POSSIBLE, for in all parts of the third world, sterility is seen not only as an individual problem but also a family and social problem.
All intra-uterine procedures, and in particular curettage, need practical training. The technique cannot be learn from a manual.
All intra-uterine procedures risk hemorrhage: always ensure a good venous line.
Artificial removal of the placenta
Manual removal of the placenta.
When more than 45 minutes elapses between a normal delivery and the delivery of the placenta.
· Intravenous line.
· Patient in lithotomy position, general anesthetic, clean the vagina with antiseptic, and wear sterile gloves.
· The left hand of the surgeon grasps the fundus of the uterus.
· The right hand pronated is advanced to the fundus and the fingers find the line of cleavage between the placenta and the uterine wall, that is to say the hand is advanced until the forearm is within the genital canal.
· Once the line of cleavage has been found, use the edge of the pronated hand as a knife, to dislodge the placenta.
· Next, explore with the fingers to ensure that the uterine cavity is empty and remove the placenta before the uterus contract.
· Give systemic antibiotics for at least 5 days.
· 1 injection of ergometrlne 0,1 mg IM.
Exploration of the uterus with a finger.
· Any suspicion of a retained placenta (always examine a placenta).
· Hemorrhage following delivery: all hemorrhages occuring within 24 hours of delivery.
Attention: if the placenta is complete and the uterus is contracted, only examine under a general anesthetic.
· Intravenous catheter
· The same procedure and aseptic technique as for artificial removal of the placenta.
· Systematically explore the uterus: the two faces, the two sides, the fundus and the two corners with the finger searching for and removing placental tissue.
· Systemic antibiotic therapy for at least 5 days.
· Ergometrine 0,1 mg IM digital curettage
Digital extraction of placental fragments after a miscarriage.
· Hemorrhage or retention of products of conception.
· Dilate the cervix with one, or two fingers if possible.
· Same preparation and asepsis as for uterine exploration.
· Introduce the index and middle fingers into the uterine cavity if possible.
· Examine systematically and remove residual fragments.
· Antibiotic therapy for at least 5 days.
Removal of the remaining products of conception following a miscarriage.
When dilatation of the cervical neck is insufficient using curette technique: always prefer digital curettage when possible.
ATTENTION: curettage of a febrile patient: treat with antibiotics and wait for a fall in fever before curetting. The decision must be weighed against the risk of hemorrhage.
· Speculum or vagina valve, Muzeux forceps (or Pozzi to hold the cervix, bougies for dilating the neck).
· Blunt curette, without hole, not too small: if too small, there is a risk of trauma. With a large curette, it is less dangerous, the diameter should be approximately the size of a tea-spoon and the limit is the degree of dilatation of the neck obtained with the bougies.
· Place the patient in lithotomy, position the sterile drapes, clean the perineum and vagina with polyvidone iodine (see table page 7), give general anesthesia.
· Introduce a speculum or vagina valve, holding the cervix with certical forceps (Museux forceps).
· Introduce the first dilator into the cervical canal, gently in the axis of the uterus ; there is a sudden loss of resistance when the internal os is reached. This first dilator is pushed as far as the fundus in order to estimate the size. With the following dilators, introduce by increasing sizes, until the cervix is dilated sufficiently to introduce the curette. ATTENTION: do not force: there is a risk of uterine perforation !
· The curette is then introduces as far as the fundus and explored, with the products drawn towards the cervical neck.
· The curette should be held between the thumb and index finger, with the other fingers on the shaft, allowing forward and backward movement: do not place the curette in the palm of the hand.
· Remove the fragments and do not damage the mucosa. Do not wait for the grating sensation, which means that the curette is too deep.
· Systematically explore the sides, walls, fundus and corners and check with the finger that the uterus is empty.
· Systemic antibiotics for at least 5 days.
Complications (Figures 109, 110)
· Persistent hemorrhage: Incomplete curettage, followed by uterine inertia; administer 0,2 mg of ergometrine IM and repeat as needed up to 4 hours. Do not administer more than 1,5 mg.
· Cervical damage by dilatation: Usually partial, lateral or submucosal. Heals by itself.
· Perforation: When this is diagnosed (forced instrumentation producing severe pain), lying the patient down and administering antibiotics (ampicillin: 4 g/day in 4 divided doses for at least 7 days) is usually sufficient. Sometimes, signs of peritonitis appear in the following days (pain, contracture) and surgery is needed.
· Infections: Endometritis, salpingitis, pelviperitonitis, septicemia must be prevented by rigorous asepsis, atraumatic procedures and systemic antibiotic therapy.
· Sterility: Obstruction of the ovarian tubes, infection, incompetent cervix. Uterine adhesions, obstetrical complications (placenta previa, adhesions), ectopic pregnancies.
Cyst or abscess of a bartholin gland
Inflammatory tumor, the size of a small egg, affecting the folds of the labia.
Sterilised drapes and gloves, scalpel, dissecting forceps, scissors, needle holder, hooked needle, resorbable suture material, and sterile compresses.
· A large vertical incision, at the muco-cutaneous junction, rather than on the inside of the labia.
· Clean with polyvidone iodine (see table page 7).
· Marsupialisation of the gland or cyst, that's to say, the walls of the gland is sutured to the skin, to keep it open and to prevent recurrence.