Urethra Trauma

Urethra Trauma

David Ray Velez, MD

Table of Contents

Background
Diagnosis
Treatment

This Article Primarily Discusses Urethral Injury from Trauma – Iatrogenic Injury from Urethral Catheterization Should Be Considered Separate

Background

Classification

  • Anterior Injury: Bulbar or Penile Urethra
    • Most Common from Direct/Straddle Injury
  • Posterior Injury: Prostatic or Membranous Urethra
    • Most Common from Pelvic Fracture

Often Associated with Pubic Rami Fractures

  • Associated with 10% of Male Patients with Pelvic Fractures
  • Associated with 6% of Female Patients with Pelvic Fractures

Nearly 10x More Common in Males (Due to the Shorted and More Mobile Urethra in Females)

AAST Urethra Injury Grade

Complications

  • Infection
  • Urethral Structure
  • Incontinence
  • Erectile Dysfunction

Urethra Anatomy

Diagnosis

Presentation

  • Blood at Urethral Meatus – 98% Sensitivity
  • “Butterfly” Perineal Hematoma/Ecchymosis
  • High Riding Prostate on Digital Rectal Exam (DRE)
  • Unable to Void
  • Unable to Pass Foley

Diagnosis

  • Retrograde Urethrogram (“RUG”)
  • 30 mL of Contrast Instilled with a Catheter Just Inside the Urethral Meatus Before a Plain Film Radiograph is Performed
  • Normal Findings:
    • Contrast Filling of the Entire Urethra without Defects
    • No Contrast Extravasation
    • Contrast Entering into the Bladder

Butterfly Perineal Hematoma 1

Urethral Injury on Retrograde Urethrogram: Partial (Left) and Complete (Right) 2

Treatment

Bladder Drainage

  • It May Be Appropriate to Allow a Single Attempt at Foley Catheterization
    • There is No Strong Evidence that a Single Attempt will Convert a Partial Tear into a Complete Disruption
    • Do Not Force or Apply Pressure if Meeting Resistance or Having Difficulty
  • Avoid Repeated Attempts at Foley Catheterization if Unsuccessful
  • May Also Consider Urologist Endoscopic-Guided Foley Placement Under Direct Visualization
  • May Require a Suprapubic Cystotomy if Unable to Place a Foley Catheter

Anterior Injury

  • Blunt Trauma:
    • Incomplete Injury: Foley Catheter 2-3 Weeks
    • Complete Injury: Suprapubic Cystostomy and Delayed Repair After 3-6 Months – Immediate Repair for Crush Injury Makes It Difficult to Determine the Exact Demarcation for Resection with Tension-Free Repair
  • Penetrating Trauma: Urethroplasty (Primary Repair) with Foley Catheter
    • Use Absorbable Suture
    • May Consider Suprapubic Cystostomy for Damage Control

Posterior Injury

  • Traditional Management of Posterior Injuries is by Suprapubic Cystostomy and Delayed Repair in 3-6 Months
  • Delayed Repair Allows Pelvic Hematoma to Resolve and the Defect to Shorten – Possibly Preventing Early Stricture, Infection, or Impotence
  • May Consider Endoscopic Bridging Foley Catheter for Incomplete Defects – May Be Able to Heal Over the Catheter without Need for Delayed Surgery
  • Indications for Immediate Repair (Never in Penetrating Injury):
    • Bladder Neck Injury
    • Rectal Injury

References

  1. Hajji F, Ameur A. Butterfly hematoma after traumatic intercourse. Pan Afr Med J. 2015 Apr 1;20:317. (License: CC BY-2.0)
  2. Seo IY, Lee JW, Park SC, Rim JS. Long-term outcome of primary endoscopic realignment for bulbous urethral injuries: risk factors of urethral stricture. Int Neurourol J. 2012 Dec;16(4):196-200. (License: CC BY-NC-3.0)