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and by faulty position of the patient in bed. In patients with pressure sores over the
sacrum who have to be nursed in prone position, great care has to be taken to ensure that
the penoscrotal area is free from pressure by being positioned in the gap between the
adjacent pillow—or sorbo rubber packs.
One patient admitted during the war to the Centre, with extensive pressure sores and
suprapubic drainage, had a vesico-rectal fistula which healed spontaneously, and in 2
patients vesico-rectal fistulae developed as a result of penetrating cancer of the bladder.
Both died. One female patient developed a vesico-vaginal
fistula which healed
spontaneously.
Treatment
The treatment of urethral fistulae consists in combined conservative and surgical proce
dures. Actually fistulae, especially those in the bulbous urethrae, may heal spontaneously.
Success of the surgical treatment depends largely on the condition of the fistula, i.e.
whether the fistula is associated with a stricture or not. Griffiths & Walsh (1961) described
eleven cases of urethral fistulae without an associated stricture, and all healed eventually
although two and even three surgical closures were necessary. However, in eight of these
patients excision of the fistulous track resulted in development of a diverticulum. Various
surgical techniques have been described in the literature for the closure of fistulae
associated with strictures but not a single one has proved to be reliable for all cases. In
one of the patients, described by Griffiths & Walsh, Donovan, urologist in Birmingham,
successfully closed the fistula and at the same time opened the large urethral stricture
with bougies and carried out a split-skin inlay. The fistula recurred a year later and
eventually healed after 4 surgical attempts. In a case operated in two stages by Griffiths,
using the Denis Browne technique, the fistula closed but reopened later, and in due
course a moderate-sized diverticulum developed. Of 4 other cases of fistula and stricture
at the peno-scrotal junction who were operated upon, 2 were failures due to recurrence
of the urethral stricture. These difficulties with the surgical repair of fistulae associated
with urethral stricture were also encountered by other workers in this field. Diversion of
the urinary flow by suprapubic drainage in these cases does not, as a rule, guarantee a
successful primary closure of a fistula as this diversional procedure does not prevent
detrusor action and thus voiding through the urethra occurs, and in the experience of
Griffiths & Walsh, Comarr (1959), Bors & Comarr (1971) and others, repeated trials
were necessary to close the fistula. Therefore this diversionary procedure, let alone that
by perineal urethrostomy, has been abandoned.
The key to the solution of this difficult problem is prevention and there cannot be any
doubt that with the adoption of a meticulous technique of urethral catheterization as
proved by the non-touch technique, the incidence of urethral fistulae will profoundly
decline.
(3) Urethral diverticula
Urethral diverticula which are of different shape and size are not infrequent results of
long-standing indwelling catheter drainage, especially with larger size of catheters
