Therapeutic strategy for taking care of perineal pressure ulcers in spinal cord injury (SCI) patients
Dr Marie THOMAS-POHLa, Dr Caroline HUGERONa, Prof Emmanuel CHARTIER-KASTLERb, Prof Pierre DENYSc, Dr Célia RECHa, Dr Haude CHAUSSARDd, Prof Djamel BEN SMAILa
a Service de MPR, Widal 1, Hôpital Raymond Poincaré, Garches, b Service d’urologie, Hôpital de la Pitié Salpétrière, 75013 Paris, c Service de neuro-urologie, Hôpital Raymond Poincaré, Garches, d Service d’orthopédie, Hôpital Raymond Poincaré, Garches
Objective: The perineal pressure ulcer is, from the outset, a serious bedsore as it exposes the patient to the risk of fistula in addition to the regular complications associated with bedsores. Treatments reported in the literature couple recovery by musculocutaneous flap combined either with urethroplasty or urinary diversion , without decision-making criteria. The objective of this study is to analyze the management of perineal pressure ulcers in SCI patients and suggest a suitable therapeutic strategy.
Materials and Methods: Retrospective, observational study of a group of SCI patients picked up at the Garches hospital and in the urology department at the Pitié Salpêtrière, between 2002 and 2014.
Results: The study includes 20 patients, of which 15 show urethrocutaneous fistula. Following a musculocutaneous flap combined or not with an urethroplasty, but without joint urological care, no patient recovered. None of the two urethral reconstructions have helped to heal the bedsores or enabled the reuse of urethra for self-catheterization. After cystoprostatectomy and Bricker, only 2 out of 15 patients relapsed, given a follow-up period between 1 and 6 years.
Discussion: Like any pressure ulcer, the treatment of perineal pressure ulcer requires a careful evaluation of the circumstances of occurrence and risk factors (history of ischiectomy, proximal hip removal, prolonged indwelling catheter), and a neuroperineal (bladder balance and voiding mode), skin, nutrition, neuro-orthopedic, seat, and socio-psychological assessment.
In the presence of urethrocutaneous fistula, a urinary diversion seems absolutely necessary: usually a non-continent bypass with cystoprostatectomy and Bricker which remains surgically heavy and may negatively affects self-image; exceptionally, a continent diversion may be considered with closure of the bladder neck. The urethroplasty by experienced urologists associated with bedsores surgery could have been discussed but was not be performed for technical reasons (surgeries on 2 different hospitals). In the absence of fistula, but the presence of chronic perineal maceration with bad management of bladder, trans-ileal cutaneous ureterostomy with cystoprostatectomy ensures the complete drying of the perineum.
References: 1.Secrest CL et al. Urethral reconstruction in spinal cord injury patients. J Urol 2003;170:1217-1221.
Keywords : spinal cord injury, perineal pressure ulcer, urethrocutaneous fistula, urethroplasty, urinary diversion