By Y. Ressel. Middlebury College.

The stricture may take a form of a shelf at the junction of the bladder with the prostatic bed discount 25 mg clomiphene overnight delivery. While doing suprapubic or retropubic prostatectomy buy clomiphene 25mg, such shelf may be resected with a pair of scissors and then the margins are carefully sutured buy discount clomiphene online. Postoperative stricture may also follow partial or complete amputation of the penis. This usually follows injury or inflammation to the urethral mucosa Gradually there is scar formation in the periurethral tissue. This gradually encroaches the mucous membrane and narrows the lumen of the urethra. The peculiarity is that in the bulbous urethra the fibrosis is most evident in the roof, whereas in the penile urethra it is more seen in the floor. The major complication of stricture of urethra is obstruction to the outflow of urine. This gradually causes dilatation of the urethra proximal to the stricture, compensatory hypertrophy of the bladder musculature with formation of diverticuli. Because of stasis infection occurs which causes prostatitis, cystitis and pyelonephritis. Due to infection of the stagnant urine just proximal to the stricture periurethral abscess may develop. Patient complains of pain in the perineum with high temperature and rigor and rapid pulse rate. On examination, a tender swelling may be felt in the perineum in case of bulbar periurethral abscess and on the undersurface of the penis in case of penile periurethral abscess. When periurethral abscess occurs just proximal to a tight urethral stricture, the patient passes most of his urine through many such urinary fistulae. Urethral diverticulum may develop due to increased intraurethral pressure proximal to the stricture. Such diverticulum may also develop due to long standing presence of a urethral calculus or it may be congenital 5. Retention of urine is due to obstruction to the flow of urine by the urethral stricture. Hernia, haemorrhoides or rectal prolapse may occur due to straining to overcome obstruction to the flow of urine by the urethral stricture. Sudden urinary retention may occur if an infection or oedema occurs at the site of stricture. Careful history taking may suggest previous urethral injury or severe untreated gonorrhoea Symptoms of cystitis e. In contradistinction to obstruction due to an enlarged prostate, the patient is considerably younger. Excretory urograms may reveal urinary calculi or calculi within the diverticulum of the bladder or changes compatible with pyelonephritis. The urethra may be centrally situated or towards the roof or the floor The stricture may take the form of a crescent. Before dilatation is performed, the patient should pass urine The glans penis and urinary meatus are cleansed with antiseptic solution. There are three types of instrumental dilatation — intermittent, continuous and rapid dilatation. This dilatation, at first, is done biweekly and every time the largest bougie is inserted. After this, dilatation is done weekly for a month Then dilatation is done fortnightly for 3 months Then once a month for 6 months. What is done is that two or three Filiform bougies are passed through the urethra and by to and fro movement, one will pass through the stricture. When such a bougie is passed, it is left in position for 12 hours for sufficient dilatation to facilitate subsequent intermittent dilatation to be continued. Wheelhouse’s staff is passed into the urethra down to the stricture, its grooved surface should face the surgeon. An incision is made at the midline of the perineum and the urethra is opened on the groove of the staff for about an inch. About a quarter of an inch of the urethra just distal to the stricture is left uncut. The staff is now rotated and withdrawn till the terminal hook is made to retract the upper angle of the opened urethra. Through the lower angle of the opened urethra, a fine probe-pointed director is inserted through the stricture. The floor of the stricture is cut by running a knife along the groove of the director. Being guided by the groove of the director, a Teale’s gorget is passed towards the bladder until a flow of urine comes out. The Wheelhouse’s staff is removed and a large polythene catheter is passed through the penile urethra till its tip appears through the opened urethra. The tip of the catheter is then pushed towards the bladder being guided by the trough of the Teale’s gorget. The gorget is taken out only after interrupted stitches are passed through the normal urethra distal to the stricture. The floor of the urethra is formed by granulation tissue after which the usual intermittent dilatation regime is started throughout the patient’s life. Under direct vision down the panendoscope the filiform guide is introduced through the stricture. The obturator of the urethrotome is now removed and the stricture is then cut under vision with a sharp knife blade that can be projected from the tip of the instrument. By a sharp thrust of the knife the roof (12 o’clock position) of the stricture is divided. If this gives unsatisfactory opening of the stricture a second cut is performed at the floor (6 o’clock position). The catheter is retained for 3 days, after which intermittent dilatation should be continued. The advantages of this method are that the cutting of stricture is done under direct vision minimising the chance of false passage formation and the stricture is cut in one position without causing generalised trauma to it. The procedure can be repeated if necessary after 3 months when urethroscopy should be performed to know the condition of the stricture. If there is a short stricture in the bulbous urethra, it may be excised and end-to-end anastomosis is performed. Long strictures particularly in the anterior urethra are best treated by splitting the urethra and suturing the edges of the open urethra to the adjacent skin. A perineal skin flap may be constructed (technique devised by Blandy) or a scrotal tunnel is taken up to be sutured to open edges of the urethral defect (Turner-Warwick technique). Tubed scrotal flap pull-through urethroplasty devised by Mr Innes Williams has also been satisfactory as reported by a few centres. The end of the scrotal flap is fastened to a catheter, which is pulled up in the Badenoch-fashion into the bladder. After 3 weeks the catheter is withdrawn and the scrotal tube is found to have healed.

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This condition should be suspected if the patient complains of pain down the forearm after the fracture has been reduced and plastered order generic clomiphene online. Only antero-posterior view may not be able to detect such injuries as fracture of olecranon generic 25mg clomiphene with amex, posterior dislocation of the elbow and even the supracondylar fracture without lateral displacement discount clomiphene line. While interpreting a skiagram of the elbow joint after injury one must have a clear conception of time of appearance, the size, the shape, the position and time of fusion of all the epiphyses in the region of the elbow. Cases are not uncommon when epiphyseal line was erroneously diagnosed as fracture line and there was no real bony injury. The first centre of ossification appears in the capitulum in the first year and extends medially to form the chief part of the articular surface. In the fourth year in case of females and in the sixth year in case of males ossification begins in the medial epicondyle. At the same age the disc-like centre of ossification appears at the upper end of the radius. The centre for the medial part of the trochlea appears in the ninth year in females and tenth year in males. At about the same age or a year later a thin scale-like epiphysis appears on the top of the olecranon process. The centre of ossification in the lateral epicondyle appears at about the twelfth year in both sexes. The centres for the lateral epicondyle, capitulum and trochlea fuse around puberty and the large epiphysis thus formed unites with the shaft of the humerus in the fourteenth year in the females and the sixteenth year in the males. The upper epiphysis of the radius fuses with the shaft at the same age as the previous one (14th to 16th year). An additional centre sometimes appears in the tuberosity of the radius at about the fourteenth or fifteenth year. This fact can be verified by drawing a line which is drawn downwards along the anterior surface of the humerus which divides the circular trochlea into anterior l/3rd and posterior 2/3rd in the lateral X-ray film. The following conditions are to be considered in injury around the elbow :— 1) Supracondylar fracture. This is due to the fact that the lower epiphysis of the humerus after it has fused with the shaft is bent 8) Fracture of the olecranon process. Note also the position and shape of the epiphysis 9) Posterior dislocation of the elbow forming the olecranon. This must not be mistaken for a with or without fracture of the coronoid fracture which usually occurs at the base of the olecranon process. The mechanism of backward supracondylar fracture is a fall on the hand with bent elbow, when the distal fragment is pushed backwards and twisted inwards as the forearm is usually full pronated. The displacement of the distal fragment is backwards, upwards, backward angulation with a slight internal rotation. The victims are usually children and present with a gross swelling at the elbow which is supported by the patient with his other hand. On examination there may be bruising and the posterior prominence of the elbow which requires differentiation from the posterior dislocation of the elbow. The possibility of an injury to the brachial artery as well as three main nerves should be foreseen and properly examined to exclude such possibility. An immediate reduction of the displaced fracture is essential and the elbow joint is kept flexed in collar and cuff in such a position as the radial pulse is well palpated. The mechanism of forward supracondylar fracture which is very much rarer than its previous counterpart is caused by a fall on the stretched hand with fully extended elbow so that the lower fragment is tilted forward. The patient presents with a more extended elbow than its previous counterpart and swelling around the elbow. The lower fragment is displaced laterally for a considerable distance which is obvious in anteroposterior film. The centre of ossifcation for the capitulum is likely to be mistaken for that of the head of the radius in anteroposterior view but not in the lateral view. In fact the centre of ossification for the head of the radius has not yet appeared. The elbow remains slightly flexed supported by the other hand and movement is extremely painful and restricted. Swollen elbow and tenderness on the lateral condyle are the usual clinical features. The mechanism of injury is usually a severe abduction force and young children between ten and fifteen years of age are the usual victims (before the medial epicondylar epiphysis fuses with the shaft). The peculiar feature of this fracture is that besides slight rotational displacement the medial epicondyle may be included into the joint by the forced abduction which momentarily opens up the medial side of the joint and thus sucks in the fractured medial epicondyle. The anterior half of the capitulum and the trochlea are broken off and displaced proximally. It is actually an epiphyseal separation with a triangular metaphysis attached to it. There is tenderness at the upper end of the radius with a lateral projection of the head of the radius which can be palpated. X-ray shows fracture of the neck of the radius with the head tilted forwards, outwards and distally. On examination there will be localized tenderness on the head of the radius and rotation of the forearm i. X-ray will confirm the diagnosis by showing either a vertical split in the radial head or a lateral major fragment of the head broken off and displaced laterally or a comminuted fracture with multiple fragments. The fracture line is at the narrowest point of the olecranon almost where it joins with the shaft of the ulna and must not be confused with the epiphysial line which lies near the tip of the olecranon process. If the triceps muscle goes in action during the injury a gap is expected between the two fragments of the olecranon process. If there is just a crack fracture, slight swelling, bruising, localized bony tenderness and bony irregularity will be the clinical features. Whereas in more severe injury with separation of fragments there will be more swelling, oedema and bruising at the fracture site. X-ray examination is obligatory not only to know the details of the fracture and displacement but also to assess the type of treatment which would be best suited for the particular case. The mechanism of posterior dislocation is a fall on the outstretched hand with the elbow in slightly flexed position. The coronoid process may pass posteriorly below the distal end of the humerus intact or may be fractured by the thrust against this part of the humerus. Very often the posterior dislocation is associated with lateral displacement of varying range. Clinically this condition may mimic the supracondylar fracture and the differentiating points between these two conditions should be borne in mind.

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So in this group the liver and not the gallbladder appears to be responsible for producing stones purchase clomiphene online pills. Reflux of pancreatic enzymes into the gallbadder is also considered to be the cause of cholesterol precipitation discount clomiphene 25 mg overnight delivery. Trypsin disturbs colloidal balance and pancreatic phospholipase A may convert lecithin into toxic lysolecithin generic clomiphene 100 mg. Interruption of bile flow into the intestine is associated with interruption of enterohepatic circulation, which in turn is accompanied by a decrease in the output of bile salts and phospholipids reducing the solubility of cholesterol. Stasis is usual during pregnancy and this may cause increased incidence of stones in multipara. Moy- nihan’s aphorism that a gallstone is a tomb stone erected in the memory of the organisms within it’ is still true today. Slow growing actinomyces have also been recovered in over half the gallstones examined in one series. These organisms reach the gallbladder via the blood stream from a focus of infection elsewhere in the body. Majority of the stones have particularly high content of cholesterol averaging 70%. A pure cholesterol stone is pale yellow in colour, but more often bile pigments are deposited within it. On section a cholesterol stone shows radiating lines which cross the circular strata. Sometimes a stone starts as a pure cholesterol stone, but ultimately receives mixed covering of pigment and cholesterol. Pure pigment stones are black or dark brown in colour and found almost exclusively in the gallbladder. Calcium bilirubinate stones are earthy brown to orange in colour and soft in consistency. Recurrent pyogenic cholangitis or Oriental cholangiohepatitis often cause to precipitate calcium bilirubinate stones. Increased alkalinity of the bile may favour precipitation of calcium carbonate with slow build up of stones over the course of a few years. Combined gallstones are those in which either the central core or external layers are pure and the remainder of the stone is a mixture of constituents. Combined stones are sometimes solitary but mixed gallstones are invariably multiple, often the gallblader is seen to be literally stuffed with hundreds of stones. What would be the colour of such stones is determined by the predominence of the stone-forming constituent. When it is cholesterol, it is yellow, when it is bilirubinate it is black and when it is calcium carbonate it is greyish white. The laminations are composed of cholesterol, calcium bili­ rubinate and calcium carbonate. Presumably the chemical inflammatory changes prepare the soil for bacterial invasion. What is the cause of association of these three conditions is difficult to elicit. But obesity may be the single common factor which initiate all the three conditions. But it must be confessed that there must be some disorder ofthe heart previously which was latent. Early cholecystectomy is advised to avoid operation at a later date when the cardiac condition may be less favourable. Such asymptomatic gallstones after a long follow-up 50% has turned symptomatic and serious complications have occurred in 20% of cases. The most dreaded complication of asymptomatic gallstone is carcinoma of the gallbladder. Incidence of cancer of gallbladder in patients with symptomatic gallstones range between 1 and 15%. It is yet to be established what is the real incidence of carcinoma in asymptomatic cholelithiasis. Slight jaundice may be seen if the oedema cons­ equent upon impacted stone may encroach the common bile duct. T reatment is early cholecystectomy to avoid complications such as infection, perforation of the gallbladder and even gallstone ileus. This symptom includes a feeling of fullness after food, belching and heart bum which becomes worse after a large or fatty meal. Such symptom in a patient should arouse suspicion of presence of stone in the gallbladder. One should exclude oesophageal hiatus hernia and chronic pancreatitis which also give rise to flatulent dyspepsia. It usually occurs at night when the patient goes to bed and in the horizontal position calculi find easier to accumulate at the neck or at the entry of the cystic duct. Such colic gives rise to excruciating pain at the upper and right quadrant of the abdomen. The pain may shoot to the back towards the inferior angle of the right scapula or may complain of referred pain at the right shoulder The patient tosses on the bed in agony to get some relief of pain in different postures, but in vain. Such attack is often accompanied by nausea and vomiting and even retching This colic lasts for about 2 hours and it passes off as suddenly as it came with great relief to the patient. If the patient is excep­ tionally co-operative one may find an enlarged gallbladder on palpation. Jaundice may follow an attack of gallb­ ladder colic in 20% of cases due to stone obstructing the common bile duct. Oral cholecystogram is not advised at the stage of gallstone colic as the liver function is depressed. Other investigations are more or less similar to those performed in acute cholecystitis. T reatment of gallstone is cholecystectomy, but in acute cases treatment is same as that of acute cholecystitis. If gallstone has migrated into the common bile duct — treatment is cholecystectomy with choledoch- olithotomy. In about 60% cases of acute cholecystitis bile culture is positive which shows bacterial cause of cholecystitis. Even in the absence of stones at surgery or autopsy, obstructive factor cannot be excluded since the stones might have passed into the common bile duct and G. Kinking of gallbladder or duct or pressure from anomalous vessel or from adjacent structures may cause non-calculous obstruction. Oedema or erosion caused by the stone may also cause obstruction of outlet of gallbladder. Obstruction will cause stasis of bile leading to progressive concentration of bile and chemical irritation of the gallbladder wall It must be remembered that hydrops of the gallbladder, in which the outlet is obstructed by a stone, produces marked distension, but acute inflammation does not follow. In animals, ligation of the cystic duct alone does not produce acute cholecystitis. So simple outlet obstruction cannot cause acute cholecystitis until and unless it is added with some other factor or factors.

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