Urethral Injuries

Ahmed S. ZugailUrology 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.

1 Dixon 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 Fenton AS, 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 Vicente J, 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

4 Dixon CM. Diagnosis and acute management of posterior urethral disruptions. In: McAninch JW, ed. Traumatic and Reconstructive Urology. Philadelphia, Pa: WB Saunders; 1996:347-55.

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).

• The male posterior urethra is injured in 4-19% and the female urethra in 0-6% of all pelvic fractures.5

• 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 (levelof 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 Perry MO, 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 lengthand 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%.

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Thank you