Urethral injury

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Trauma to the male urethra must be quickly diagnosed and promptly treated to prevent serious long-term complications. Patients who develop urethral stricture from poorly-managed traumatic injury are likely to have significant voiding problems and continuing need for further medical/surgical interventions.

Most urethral injuries are associated with well-defined events, including major blunt trauma (MVC, motorcycle accidents, falls). Penetrating injuries in the general anatomic area of the urethra may also cause urethral trauma. Straddle injuries may cause both short- and long-term problems. Iatrogenic injury to the urethra from traumatic catheter placement, transurethral procedures, or dilation is seen all to commonly.

Many patients with urethral injuries also have significant orthopedic and neurologic injuries. Effective rehabilitation requires reconstruction of the urinary tract in a manner that does not interfere with the healing process.

When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient stability.

Types of urethral injury

Urethral injuries can be classified into two broad groups based on the anatomical site of the trauma. Posterior urethral injuries are located in the membranous and prostatic urethra. These injuries most commonly result from major blunt trauma (MVC, motorcycle accident, falls). These injuries are most frequently associated with pelvic fractures.

Injuries to the anterior urethra are located distal to the membranous urethra. Most anterior urethral injuries come from blunt trauma to the perineum (straddle injuries), and may present in a delayed fashion, appearing years after the original trauma as a stricture.

External penetrating trauma to the urethra is rare, but iatrogenic injuries are quite common in both segments of the urethra. Most are related to difficult urethral catheterizations.

Treatment of urethral injury

Patients with urethral injuries often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopedic specialists. Life-threatening injuries must be addressed first.

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.

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 (5-7 days postinjury) using a combined transurethral and percutaneous transvesical approach may be safer. At this time, 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.

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 in length). 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.

Urethral injuries in women

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. Not infrequently, the passage of a urethral catheter is impossible or yields no urine. Urethrography is difficult to obtain, and the diagnosis is often made based om clinical grounds. Concomitant bladder injury must often be ruled out with CT cystography. Women with urethral injuries commonly have multiple injuries, and the management approach must address other life-threatening injuries first.

Bladder drainage must be established in these cases. The easiest and fastest method is placement of a suprapubic catheter, followed by delayed anatomic evaluation and reconstruction. If the patient is undergoing surgical exploration 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 sequelae.

Notes & References

[1] Jepson BR, Boullier JA, Moore RG, Parra RO. Traumatic posterior urethral injury and early primary endoscopic realignment: evaluation of long-term follow-up. Urology. Jun 1999;53(6):1205-1210.

[2] Webster GD, Mathes GL, Selli C. Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management. J Urol. Nov 1983;130(5):898-902.

[3] Mayher BE, Guyton JL, Gingrich JR. Impact of urethral injury management on the treatment and outcome of concurrent pelvic fractures. Urology. Mar 2001;57(3):439-42.

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Stawicki SP

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