Muhammad Azmi Hakim - 1102012170

LI 1. Memahami dan menjelaskan trauma urethra

LO 1.1. Definisi

LO 1.2. Etiologi
As with many traumatic events, the etiology of a urethral injury can be classified as blunt or penetrating. In the posterior
urethra, blunt injuries are almost always related to massive deceleration events such as falls from some distance or vehicular
collisions. These patients most often have a pelvic fracture involving the anterior pelvis.[2] Blunt injury to the anterior
urethra most often results from a blow to the bulbar segment such as occurs when straddling an object or from direct strikes
or kicks to the perineum. Blunt anterior urethral trauma is sometimes observed in the penile urethra in the setting of penile
fracture.

Penetrating trauma most often occurs to the penile urethra. Etiologies include gunshot and stab wounds. Iatrogenic injuries
to the urethra occur when difficult urethral catheterization leads to mucosal injury with subsequent scarring and stricture
formation. Transurethral procedures such as prostate and tumor resections and ureteroscopy can also lead to urethral injury.
(http://emedicine.medscape.com/)

LO 1.3. Epidemiologi
Frequency
Posterior urethral injuries are most commonly associated with pelvic fracture, with an incidence of 5%-10%. With an
annual rate of 20 pelvic fractures per 100,000 population, these injuries are not uncommon. Anterior urethral injuries are
less commonly diagnosed emergently; thus, the actual incidence is difficult to determine. However, many men with bulbar
urethral strictures recall an antecedent perineal blunt injury or straddle injury, making the true frequency of anterior urethral
injury much higher. Penetrating injury to the urethra is rare, with major trauma centers reporting only a few per year.
(http://emedicine.medscape.com/)

LO 1.4. Klasifikasi

LI 2. Memahmi dan menjelaskan trauma urethra anterior

LO 2.1. Patofisiologi
Anterior urethral injury most often results from a blunt force blow to the perineum, producing a crushing effect on the
tissues of the urethra. The initial injuries are often ignored by the patient, and urethral injury manifests years later as a
stricture. The stricture results from scarring induced by ischemia at the site of the injury. Penetrating injuries also occur in
the anterior urethra as a result of external violence.
(http://emedicine.medscape.com/)

LO 2.2. Manifestasi Klinis

Diagnosis of urethral injuries requires a reasonably high index of suspicion. Urethral injury should be suspected in the
setting of pelvic fracture, traumatic catheterization, straddle injuries, or any penetrating injury near the urethra. Symptoms
include hematuria or inability to void. Physical examination may reveal blood at the meatus or a high-riding prostate gland
upon rectal examination. Extravasation of blood along the fascial planes of the perineum is another indication of injury to
the urethra. "Pie in the sky" findings revealed by cystography usually indicate urethral disruption.

The diagnosis of urethral trauma is made by with retrograde urethrography, which must be performed prior to insertion of
a urethral catheter to avoid further injury to the urethra. Extravasation of contrast demonstrates the location of the tear.
Further management is predicated on the findings of urethrography in combination with the patient's overall condition.

1
Muhammad Azmi Hakim - 1102012170

Urethrogram demonstrating partial urethral disruption.

Urethrogram demonstrating complete urethral disruption.

(http://emedicine.medscape.com/)

LO 2.3. Diagnosis
Cystoscopy can be a valuable adjunct in the evaluation of a male urethral injury. In the acute setting, the feasibility of early
endoscopic realignment can be determined (see Treatment). In the delayed setting, the quality of the urethra can be
evaluated for surgical repair. When cystoscopy is combined with retrograde urethrography and cystography, a more
accurate estimation of stricture length can be made, facilitating decisions in operative strategy.

These studies have become even more important as trauma services rely more on initial CT scanning as the major imaging
modality. The "trauma" CT may well miss lower urinary tract injuries to the urethra and bladder and thus any suspicion for
urethral injury should lead one to perform these studies in addition to any others.[5]

Retrograde urethrography
The retrograde urethrography is the standard imaging study for the diagnosis of urethral injury. It is performed using gentle
injection of 20-30 mL of contrast into the urethra. Examination is made for extravasation, which pinpoints the existence
and location of the urethral tear.

2
Muhammad Azmi Hakim - 1102012170

Cystography
The static cystography allows for concurrent bladder injury to be excluded in the acute setting. When a delayed repair is
being considered, voiding cystography (performed through the suprapubic catheter) demonstrates the bladder neck and
prostatic urethral anatomy and allows for proper surgical planning.
(http://emedicine.medscape.com/)

LO 2.4. Diagnosis Banding

LO 2.5. Penatalaksanaan
When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient
stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually
trauma, critical care, and orthopedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm.[6]

The traditional intervention for men with posterior urethral injury secondary to pelvic fracture is placement of a suprapubic
catheter for bladder drainage and subsequent delayed repair. This is the safest approach because it establishes urinary
drainage and does not require either urethral manipulation or entrance into the hematoma caused by the fracture of the
pelvis. This allows a formal repair to be carried out several weeks later under controlled circumstances and after resolution
of the hematoma. The suprapubic catheter can be safely placed either percutaneously or via an open approach with a small
incision. Ultrasound guidance can aid in the percutaneous approach. Some advocate immediate realignment through a
number of different techniques, although much controversy exists on this topic.

Ultimate repair of the posterior urethral injury can be performed 6-12 weeks after the event, after the pelvic hematoma has
resolved and the patient's orthopedic injuries have stabilized. It is often carried out via a perineal approach, and repair
consists of mobilizing the urethra distally to allow a direct anastomosis after excision of the stricture. To prevent tension
on the anastomosis, the distal urethra can be mobilized to the penoscrotal junction. Further length can be achieved with
division of the septum between the corpora cavernosa and with inferior pubectomy. A urethral catheter is left indwelling
to stent the repair, and the suprapubic catheter may be removed. Transpubic approaches for this repair have also been
described and may be useful in men with fistulous tracts complicating a membranous urethral injury. Combining a perineal
and abdominal approach with pubectomy provides maximum exposure of the prostatic apex.[7, 8, 9, 10]

Early realignment of posterior urethral injuries is also a treatment option. This has been performed at the time of injury,
using interlocking sounds or by passage of catheters from both retrograde and antegrade approaches. Also, direct suture
repair has been attempted in the immediate postinjury period. Another approach could be careful insertion of a urethral
catheter under fluoroscopic guidance by a urologist experienced in that approach. These approaches have the disadvantage
of possible entrance into and contamination of the pelvic hematoma with ensuing hemorrhage and sepsis.

Early endoscopic realignment (within 1 week postinjury) using a combined transurethral and percutaneous transvesical
approach may be safer. If performed 5-7 days postinjury, the pelvic hematoma has stabilized and hemorrhage is less of a
concern. The patient's overall condition has usually improved by this time, and sepsis is less of a concern. Ultimate
outcomes and benefits of this approach remain controversial.

Bulbar urethral injuries often manifest months to years following blunt perineal trauma. The presentation for these injuries
is often that of decreased stream and voiding symptoms. The diagnosis of urethral stricture is then made with urethrography
and cystoscopy. These strictures may be managed with excision of the stricture and end-to-end anastomosis via a perineal
approach. Most are short (< 2 cm). Longer strictures may require flaps (penile fasciocutaneous) or grafts (buccal mucosa)
to achieve a tensionless anastomosis.

Penetrating anterior urethral injuries should be explored. The area of injury should be examined, and devitalized tissue
should be debrided carefully to minimize tissue loss. Defects of up to 2 cm in the bulbar urethra and up to 1.5 cm in the
penile urethra can be repaired primarily via a direct anastomosis over a catheter with fine absorbable suture. This is the
preferred method of repair for these injuries. Longer defects should never be repaired emergently; they should be
reconstructed at an interval following the injury to allow for resolution of other injuries and proper planning of the tissue
transfers required for the repair. Urinary diversion can be accomplished with a suprapubic catheter during this interval.

Female urethral injuries are uncommon but deserve special consideration. The mechanism involves shearing of the urethra
away from the pubic symphysis by the pelvic fracture and can be associated with significant vaginal and bladder injury.

Blood is often found in the vaginal vault on pelvic examination, and passage of a urethral catheter is impossible or yields
no urine. Urethrography is difficult to obtain; the diagnosis is often clinical. Concomitant bladder injury must often be

3
Muhammad Azmi Hakim - 1102012170

ruled out with CT cystography. These women commonly have multiple injuries, and the management approach must reflect
this.

Bladder drainage must be established; the easiest and fastest method is placement of a suprapubic catheter followed by
delayed evaluation and reconstruction. If the patient is being explored for other injuries or if a percutaneous suprapubic
catheter cannot be safely placed, cystotomy with antegrade urethral catheter may provide for early definitive repair and
minimize further morbidity. Careful follow-up is needed to manage any resulting incontinence or gynecologic disturbance.
(http://emedicine.medscape.com/)

LO 2.6. Komplikasi

LO 2.7. Prognosis
Men with urethral injuries have an excellent prognosis when managed correctly. Problems arise if a urethral injury is
unrecognized and the urethra is further damaged by attempts at blind catheterization. In those instances, future
reconstruction may be compromised and recurrent stricture rates rise. When managed well, these men have an excellent
chance of becoming totally rehabilitated from a urinary standpoint.
(http://emedicine.medscape.com/)

LO 2.8. Pencegahan

LI 3. Memahami dan menjelaskan trauma urethra posterior

LO 3.1. Patofisiologi
Injury to the posterior urethra occurs when a shearing force is applied at the prostatomembranous junction in blunt pelvic
trauma. The prostatic urethra is fixed in position because of the attachments of the puboprostatic ligaments. Displacement
of the bony pelvis from a fracture type injury thus leads to either tearing or stretching of the membranous urethra.
(http://emedicine.medscape.com/)

LO 3.2. Manifestasi Klinis

Diagnosis of urethral injuries requires a reasonably high index of suspicion. Urethral injury should be suspected in the
setting of pelvic fracture, traumatic catheterization, straddle injuries, or any penetrating injury near the urethra. Symptoms
include hematuria or inability to void. Physical examination may reveal blood at the meatus or a high-riding prostate gland
upon rectal examination. Extravasation of blood along the fascial planes of the perineum is another indication of injury to
the urethra. "Pie in the sky" findings revealed by cystography usually indicate urethral disruption.

The diagnosis of urethral trauma is made by with retrograde urethrography, which must be performed prior to insertion of
a urethral catheter to avoid further injury to the urethra. Extravasation of contrast demonstrates the location of the tear.
Further management is predicated on the findings of urethrography in combination with the patient's overall condition. See
the images below.

Urethrogram demonstrating partial urethral disruption.

4
Muhammad Azmi Hakim - 1102012170

Urethrogram demonstrating complete urethral disruption.

(http://emedicine.medscape.com/)

LO 3.3. Diagnosis
Cystoscopy can be a valuable adjunct in the evaluation of a male urethral injury. In the acute setting, the feasibility of early
endoscopic realignment can be determined (see Treatment). In the delayed setting, the quality of the urethra can be
evaluated for surgical repair. When cystoscopy is combined with retrograde urethrography and cystography, a more
accurate estimation of stricture length can be made, facilitating decisions in operative strategy.

These studies have become even more important as trauma services rely more on initial CT scanning as the major imaging
modality. The "trauma" CT may well miss lower urinary tract injuries to the urethra and bladder and thus any suspicion for
urethral injury should lead one to perform these studies in addition to any others.[5]

Retrograde urethrography
The retrograde urethrography is the standard imaging study for the diagnosis of urethral injury. It is performed using gentle
injection of 20-30 mL of contrast into the urethra. Examination is made for extravasation, which pinpoints the existence
and location of the urethral tear.

Cystography
The static cystography allows for concurrent bladder injury to be excluded in the acute setting. When a delayed repair is
being considered, voiding cystography (performed through the suprapubic catheter) demonstrates the bladder neck and
prostatic urethral anatomy and allows for proper surgical planning.
(http://emedicine.medscape.com/)

LO 3.4. Diagnosis Banding

LO 3.5. Penatalaksanaan
When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient
stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually
trauma, critical care, and orthopedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm.[6]

The traditional intervention for men with posterior urethral injury secondary to pelvic fracture is placement of a suprapubic
catheter for bladder drainage and subsequent delayed repair. This is the safest approach because it establishes urinary
drainage and does not require either urethral manipulation or entrance into the hematoma caused by the fracture of the
pelvis. This allows a formal repair to be carried out several weeks later under controlled circumstances and after resolution
of the hematoma. The suprapubic catheter can be safely placed either percutaneously or via an open approach with a small

5
Muhammad Azmi Hakim - 1102012170

incision. Ultrasound guidance can aid in the percutaneous approach. Some advocate immediate realignment through a
number of different techniques, although much controversy exists on this topic.

Ultimate repair of the posterior urethral injury can be performed 6-12 weeks after the event, after the pelvic hematoma has
resolved and the patient's orthopedic injuries have stabilized. It is often carried out via a perineal approach, and repair
consists of mobilizing the urethra distally to allow a direct anastomosis after excision of the stricture. To prevent tension
on the anastomosis, the distal urethra can be mobilized to the penoscrotal junction. Further length can be achieved with
division of the septum between the corpora cavernosa and with inferior pubectomy. A urethral catheter is left indwelling
to stent the repair, and the suprapubic catheter may be removed. Transpubic approaches for this repair have also been
described and may be useful in men with fistulous tracts complicating a membranous urethral injury. Combining a perineal
and abdominal approach with pubectomy provides maximum exposure of the prostatic apex.

Early realignment of posterior urethral injuries is also a treatment option. This has been performed at the time of injury,
using interlocking sounds or by passage of catheters from both retrograde and antegrade approaches. Also, direct suture
repair has been attempted in the immediate postinjury period. Another approach could be careful insertion of a urethral
catheter under fluoroscopic guidance by a urologist experienced in that approach. These approaches have the disadvantage
of possible entrance into and contamination of the pelvic hematoma with ensuing hemorrhage and sepsis.

Early endoscopic realignment (within 1 week postinjury) using a combined transurethral and percutaneous transvesical
approach may be safer. If performed 5-7 days postinjury, the pelvic hematoma has stabilized and hemorrhage is less of a
concern. The patient's overall condition has usually improved by this time, and sepsis is less of a concern. Ultimate
outcomes and benefits of this approach remain controversial.

Bulbar urethral injuries often manifest months to years following blunt perineal trauma. The presentation for these injuries
is often that of decreased stream and voiding symptoms. The diagnosis of urethral stricture is then made with urethrography
and cystoscopy. These strictures may be managed with excision of the stricture and end-to-end anastomosis via a perineal
approach. Most are short (< 2 cm). Longer strictures may require flaps (penile fasciocutaneous) or grafts (buccal mucosa)
to achieve a tensionless anastomosis.

Penetrating anterior urethral injuries should be explored. The area of injury should be examined, and devitalized tissue
should be debrided carefully to minimize tissue loss. Defects of up to 2 cm in the bulbar urethra and up to 1.5 cm in the
penile urethra can be repaired primarily via a direct anastomosis over a catheter with fine absorbable suture. This is the
preferred method of repair for these injuries. Longer defects should never be repaired emergently; they should be
reconstructed at an interval following the injury to allow for resolution of other injuries and proper planning of the tissue
transfers required for the repair. Urinary diversion can be accomplished with a suprapubic catheter during this interval.

Female urethral injuries are uncommon but deserve special consideration. The mechanism involves shearing of the urethra
away from the pubic symphysis by the pelvic fracture and can be associated with significant vaginal and bladder injury.

Blood is often found in the vaginal vault on pelvic examination, and passage of a urethral catheter is impossible or yields
no urine. Urethrography is difficult to obtain; the diagnosis is often clinical. Concomitant bladder injury must often be
ruled out with CT cystography. These women commonly have multiple injuries, and the management approach must reflect
this.

Bladder drainage must be established; the easiest and fastest method is placement of a suprapubic catheter followed by
delayed evaluation and reconstruction. If the patient is being explored for other injuries or if a percutaneous suprapubic
catheter cannot be safely placed, cystotomy with antegrade urethral catheter may provide for early definitive repair and
minimize further morbidity. Careful follow-up is needed to manage any resulting incontinence or gynecologic disturbance.
(http://emedicine.medscape.com/)

LO 3.6. Komplikasi

LO 3.7. Prognosis
Men with urethral injuries have an excellent prognosis when managed correctly. Problems arise if a urethral injury is
unrecognized and the urethra is further damaged by attempts at blind catheterization. In those instances, future
reconstruction may be compromised and recurrent stricture rates rise. When managed well, these men have an excellent
chance of becoming totally rehabilitated from a urinary standpoint.
(http://emedicine.medscape.com/)

LO 3.8. Pencegahan

6
Muhammad Azmi Hakim - 1102012170

Gambar. Mekanisme cedera urethra pada laki-laki

7
Muhammad Azmi Hakim - 1102012170

Gambar. Jenis-jenis cedera urethra pada laki-laki

(Hansen, J.T. Netters Clinical Anatomy 2th Ed. Saunders Elsevier. 2010)