Severe burn trauma from deliberate self-harm: the Sokoto experience.

BACKGROUND: Burn injury is one of the most severe forms of trauma that can afflict mankind. Although several forms of suicide and para suicide have been reported worldwide, severe burn injuries from deliberate self-harm have been poorly documented in Africa. AIM: To evaluate the pattern of deliberate self-harm by burning in our environment. METHOD: This is a 5-year retrospective analysis of all patients who sustained burns from deliberate self-harm (DSH) seen at the Usmanu Danfodiyo University Teaching Hospital, Sokoto from June 1998 to May 2003. The patients' data and other necessary information were extracted from the case notes. RESULTS: Seven patients were seen over the study period. There were six females and one male, giving a female to male ratio of 6:1. All the injuries occurred at home from kerosene flame burns. In all cases, the intent was to take the patient's own life. The triggering factors were mainly psychosocio-economic. Six patients had up to secondary education while one patient had a degree certificate. None of the patients was gainfully employed at the time of incidence. Two patients had previously attempted suicide. Only one patient had a history of psychiatric illness. All sustained severe flame burns ranging from 45% - 98% body surface area (BSA). Compliance to treatment was generally poor. All patients were managed at the intensive care unit (ICU) of the hospital.. Five patients died, while the remaining two signed against medical advice (SAMA) during the course of management. The duration of hospital stay ranged from 2 - 10 days. CONCLUSION: Severe burn injury from DSH, although previously poorly documented in Africa, is not uncommon in our environment. The morbidity and mortality are high, not only because of the nature of injury, but probably because of poor compliance to treatment. We advocate community based studies and routine screening of adolescents to identify those at risk. The need for the establishment suicide information, intervention and prevention centre in Nigeria cannot be overemphasised.

Management of "watering-can" perineum.

OBJECTIVES: To review the management of watering-can perineum (WCP) in a Nigerian centre and to outline challenges of its management. DESIGN: A retrospective review of cases of watering-can perineum over a seven-year period. SETTING: Usmanu Danfodiyo University Teaching Hospital, Sokoto, a Nigerian tertiary health centre. SUBJECTS: Forty one patients with the diagnosis of watering-can perineum managed from January 1997 to December, 2003. RESULTS: There were 41 cases of watering-can perineum. The mean age at presentation was 46.0 years (range: 7 to 80). Characteristically, all the patients had long standing neglected urethral stricture. Eighteen (43.9%) presented with single active fistulae while eight (19.5%) had more than four (9.8%) active external openings. Fistulae were located in the perineum (58.5%), scrotum (41.6%), penis (14.6%), penoscrotal junction (9.8%) and thigh (49%). The strictures were post inflammatory in 73% of patients. Bulbar strictures constituted 63.4% of cases. At presentation, patients were in general planned for initial suprapubic cystostomy (SPC) followed by assessment of stricture and finally urethroplasty in six months. Patients who could not afford urethroplasty were offered dilatation. The immediate outcome of urethroplasty was satisfactory in 70.6% of patients. CONCLUSION: Watering-can perineum was a common sequel of long standing neglected inflammatory urethral stricture. SPC followed by urethroplasty gave the best results. Prevention and adequate treatment of urethritis, prompt treatment of urethral stricture, and affordable and accessible reconstructive urologic service are recommended to reduce the incidence of WCP and suffering of the patients.

Paediatric urolithiasis in northern Nigeria

Background. The incidence of paediatric urolithiasis varies according to geographic areas. In Nigeria, there is paucity of literature on urinary stone diseases in childhood. Materials and Methods. In the period between January 1993 and December 2003, 67 Nigerian children with urinary stones were retrospectively reviewed. Results. There were 63 (94.0%) boys and 4 (6.0%) girls. The mean age at presentation was 6.9 years. Thirty one (46.3%) were in the age group less than 5 years. The commonest presenting symptoms were dysuria 42 (62.7%) and abdominal pain in 30 (44.8%). Pulling on the penis is characteristically present in 26 (38.8%) patients. The stones were located in the lower tract in 57 (85.1%) cases. Anatomic obstruction along the urinary tract was responsible for stone formation in 12 (17.9%) patients. Sixteen (23.9%) patients had associated urinary tract infection. All the stones analyzed were mixed and 75% contained urate. In 7 (10.4%) patients the stones were passed spontaneously. Open surgical technique was employed in the remaining 60 patients. There was no death recorded. Post-operative complications occurred in 15 (25.0%) of the operated patients. The commonest complications were wound infection 3 (5.0%) and vesicocutaneous fistula in 3 (5.0%) patients. The average duration of hospital stay was 16.0 days. Conclusion. In our practice lower tract stones are common and congenital urinary tract obstruction is the commonest identifiable cause for stones. The age and sex distribution and chemical composition are in keeping with historic and endemic stones. Early detection and treatment of urinary tract obstruction will further reduce the durden of stones disease

Bowel prolapse through perforated uterus following induced abortion.

Between 1991 and 1998, there were nine cases of uterine perforation following induced abortion with prolapse of the bowel out of the introitus, managed at Usmanu Danfodiyo University Teaching Hospital, Sokoto. Non-physicians caused the injury in six cases. Interval between instrumentation and presentation ranged from 5 to 14 days. In all the cases, there was already necrosis of the involved bowel. The ileum was the most commonly involved bowel (6 cases; 67%) while the uterine injury was on the fundus most of the time (7 cases; 78%). Resection and anastomosis with uterine repair was the surgical procedure in all the cases. There were 3 cases of anastomotic leakage but no mortality. We do encounter major complications of induced abortion in our center. Apart from preventive measures against unwanted pregnancies, access to safe abortions by trained personnel might minimize this type of complication.

Excretory urography before prostatectomy.

A study of the pre-operative excretory urograms of 205 patients who had prostatectomy for benign prostatic hyperplasia, over a 5-years period is presented. Seventy-four per cent (74.1%) of the urographic abnormalities were a direct result of prostatic enlargement found on clinical examination. The significant upper tract abnormalities found in 11.0% of the cases were duplex kidneys (3.4%), poor renal excretion (3.8%) and small kidneys (3.8%). None of these was a contraindication to prostatectomy when the blood urea and creatinine levels became normal. No upper tract tumour nor calculus was found in these patients. We conclude that, for the management of patients presenting with urinary retention from BPH, routine pre-operative excretory urography has little or no value and is not worth the expense and delay.

One-stage urethroplasty for complicated urethral strictures using axial penile skin island flap.

Surgical repair of urethral strictures complicated by multiple scrotal/perineal urethrocutaneous fistulae (watering-can perineum) can be very problematic. The perineal/scrotal skin is either not available or is riddled with infection, fibrosis or granulomata and therefore unsuitable as a graft source. The presence of infection makes free grafts from other sites unlikely to survive. Furthermore, extensive fibrosis may prevent excision and re-anastomosis as well as internal urethrotomy. The absence of preputial skin in circumcised patients compounds these problems. We have used a one-stage, transverse vascularized cutaneous penile flap to repair 20 cases of these complicated strictures. The graft took in 100% and no absolute repair failure was registered. In spite of obvious pre-operative infection, the result of repair was judged excellent in 17 patients (85%) and very fair in 3 (15%).

True hermaphroditism in older patients: problems of diagnosis and management.

Four new cases of true hermaphroditism in older patients are herein presented. The diagnosis was delayed in all 4 patients and not made in 3 until feminization had occurred. The clinical features, the sex of rearing, gonadal locations, sex chromosomes, treatment and fertility potentials of these patients are discussed. Problems encountered in the management of these older patients underscores the need to exclude at birth bisexuality in any patient with perineal hypospadias and crytorchidism.

One-stage penile cutaneous island flap repair for hypospadias in circumcized patients.

Routine circumcision of infants, even those with congenital hypospadias, still takes place in some parts of the world. Hypospadias repair in such patients is difficult. We describe our recent experience with a one-stage transverse penile cutaneous island flap repair of congenital hypospadias in 16 circumcized patients. In all patients the graft took. There were only 2 cases of urethrocutaneous fistulae and these were easily closed with rotation flap. Functional and cosmetic results were judged as good in 81% and fair in the rest. There were no repair failures.

Synchronous suprapubic prostatectomy and inguinal herniorrhaphy.

Synchronous suprapubic prostatectomy and inguinal herniorrhaphy were performed on 12 patients who presented with benign prostatic hypertrophy and concurrent inguinal hernia(s). The results of these were compared with those of 12 other (control) patients, matched for age, who presented with benign prostatic hypertrophy only and who had suprapubic prostatectomy by the same surgical team under similar operative conditions. The results showed that while the additional herniorrhaphy increased the operating time by 30 min and increased the mean blood loss by 250 ml, it did not carry any other significant morbidity. This approach eliminates multiple hospitalisation and operations, multiple anaesthesia and prolonged catheterisation, and lowers the high cost of hospitalisation.