Urethral Injuries

Ahmed S. Zugail
Urology House Officer
Case:

• 26 year old .
• Medically free.
• Sudanese.
• MVC (pedestrian).
• ER 16/11.
• Urethral meatus bleeding.
• Lower abdominal pain.
• Acute urinary retention.
• No past medical or surgical history.
• Smoker.
• Jeddah.
• ABCDE.
• Surgical and orthopedic consultation.
• O/E
• Vitally normal.
• Blood at meatus.
• Suprapubic tenderness.
• CXR, Pelvic X-ray & CT.
• Retrograde urethrogram.
• Suprapubic catheter.
• Admission on 16/10.
• Passed clots with small amount
of urine 17/10.
• CT 19/10:
• Cystogram.
• Arterial phase.
• Delayed phase.
• Flexible cystoscopy with urethral
catheter insertion.
• Dischared Home 22/10
• F/U Retrograde urethrogram 22/11.
• Remove catheter in OR then
cystoscopy 3/1/2012.
 Etiology:

• Well-defined events.
• Major blunt trauma 90%.1
• Penetrating injuries.
• Straddle injuries.
• Iatrogenic injury.

1Dixon CM. Diagnosis and acute management of posterior urethral disruptions. In: McAninch JW, ed. Traumatic
and Reconstructive Urology. Philadelphia, Pa: WB Saunders; 1996:347-55.
• The Bulbomembranous junction is more
vulnerable to injury during pelvic fracture
than is the prostatomembranous junction
(Colapinto and McCallum, 1977; Brandes
and Borelli, 2001).
• In children, injuries are more likely to
extend proximally to the bladder neck
because of the rudimentary nature of the
prostate (Devine et al, 1989; Al-Rifaei et
al, 1991; Boone et al, 1992).
 Iatrogenic injury to the urethra:

• The majority of iatrogenic lesions

are the result of improper or
prolonged catheterization.
• They are surprisingly common and
account for 32% of urethral
strictures. Of these, 52% affect the
bulbar and/or prostatic urethra.2
2 FentonAS, Morey AF, Aviles R, Garcia CR. Anterior urethral stricture: etiology and characteristics. Urology 2005
Jun;65(6):1055-8 (level of evidence 3).
• Iatrogenic urethral trauma caused by
transurethral surgery Transurethral
procedures, especially transurethral
resection of the prostate (TUR-P), are
the second most common cause of
iatrogenic urethral lesions.3

3 VicenteJ, Rosales A, Montlleó M, Caffaratti J. Value of electrical dispersion as a cause of urethral stenosis
after endoscopic surgery. Eur Urol 1992;21(4):280-3.
Frequency:

• Posterior urethral injuries’ incidence is 5-

10% associated with pelvic fracture with an
annual rate of 20:100000.4

4Dixon CM. Diagnosis and acute management of posterior urethral disruptions. In: McAninch JW, ed. Traumatic
and Reconstructive Urology. Philadelphia, Pa: WB Saunders; 1996:347-55.
• The male posterior urethra is injured
in 4-19% and the female urethra in
0-6% of all pelvic fractures.5

5 Koraitim MM, Marzouk ME, Atta MA, Orabi SS. Risk factors and mechanism of urethral injury in
pelvic fractures. Br J Urol 1996 Jun;77(6):876-80 (level of evidence: 2b).
• Anterior urethral injuries actual
incidence is difficult to determine
because they are seldom diagnosed
emergently.
• Penetrating injury to the urethra is
rare.
Presentation:
• Blood at the meatus.
• Inability to urinate.
• Palpably full bladder.
• High-riding prostate.
• Perineal hematoma.
• Vulvar edema.
• Blood at the vaginal introitus.
• Failure to pass a foley catheter.
• Blood at the meatus is present in 37-93%
of patients with posterior urethral injury6,
and in at least 75% of patients with
anterior urethral injury.7

6 Lim PH, Chng HC. Initial management of acute urethral injuries. Br J Urol 1989 Aug;64(2):165-8 (level
of evidence: 3).
7 McAninch JW. Traumatic injuries to the urethra. J Trauma 1981 Apr;21(4):291-7 (level of evidence: 3).
• Blood at the vaginal introitus is
present in more than 80% of
female patients with pelvic
fractures and co-existing urethral
injuries.8
• The symptoms of urethral injury
caused by improper catheterisation
or use of instruments are:
• Penile and/or perineal pain
(100%)
• Urethral bleeding (86%).8

8 PerryMO, Husmann DA. Urethral injuries in female subjects

following pelvic fractures. J Urol 1992 Jan;147(1):139-43 (level of
evidence 2b).
Imaging Studies:
1 - Retrograde urethrography: 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.
• Direct inspection by urethroscopy is
suggested in lieu of urethrography in
females with suspected urethral injury
(Perry and Husmann, 1992; Koraitim,
1999).
2 - Cystography:

• Exclude bladder injury in the acute

setting (static cystography).
• Voiding cystography (performed
through the suprapubic catheter)
demonstrates the bladder neck and
prostatic urethral anatomy when a
delayed repair is being considered
and for surgical planning.
3 - Computerized tomography: may
miss lower urinary tract injuries and
thus missing the suspicion for further
evaluating studies of urethral injuries.9

9Lawson CM, Daley BJ, Ormsby CD, Enderson B. Missed injuries in the era of the
trauma scan. J Trauma. Feb, 2011;70:452-6.
4 - Magnetic Resonance Imaging: has been
used successfully to define defect length
and to determine the extent and direction
of urethral dislocation and the extent of
prostatic displacement, and it may help in
planning the surgical approach. (Dixon et
al, 1992) and (Koraitim and Reda, 2007).
Diagnostic Procedure:

Cystoscopy:
• A valuable tool in the evaluation of
a male urethral injury.
• The feasibility of early endoscopic
realignment can be determined
especially in the acute setting.
• The combination of the imaging
studies “up and down-o-gram” and
cystoscopy gives a more accurate
estimation of the stricture length
which facilitates decisions in
operative strategy.
Management
Management of posterior urethral injuries in men
Management of anterior urethral injuries in men
Management of urethral injuries in women
• In cases of female urethral disruption
related to pelvic fracture, most
authorities suggest immediate primary
repair, or at least urethral realignment
over a catheter, to avoid subsequent
urethrovaginal fistulas or urethral
obliteration (Koraitim et al, 1996;
Dorairajan et al, 2004, Black et al,
2006).
• Incomplete urethral tears are best
treated by stenting with a urethral
catheter. The authors and others
(Al-Ali and Husain, 1983; Mundy,
1991; Kotkin and Koch, 1996)
have not seen any evidence that a
gentle attempt to place a urethral
catheter can convert an
incomplete into a complete
transection.
Complications:

• Erectile Dysfunction.
• Recurrent Stenosis/Stricture.
• Incontinence.
• Some degree of impotence is noted in up to
82% of patients with pelvic fracture and
urethral distraction injury (Flynn et al,
2003).
• Although the average reported rate is
approximately 50% (Corriere et al, 1994;
Routt et al, 1996; Elliott and Barrett, 1997;
Asci et al, 1999; Koraitim, 2005).
• The etiology is multifactorial and
variably attributed to cavernous nerve
injury, arterial insufficiency, venous
leak, and direct corporeal injury
(Narumi et al, 1993; Munarriz et al,
1995; Shenfeld et al, 2003).
• The risk of impotence caused by
delayed urethroplasty is about 5%
and the rate of incontinence is
about 4%.
?
Thank you