The 5 Minute Urology Consult 3rd Ed.

URETHRAL TRAUMA (ANTERIOR AND POSTERIOR)

Lee C. Zhao, MD, MS

Allen F. Morey, MD, FACS

 BASICS

DESCRIPTION

• Injury that disrupts the watertight integrity of the urethra, typically in male patients.

• Injury to the urethra in women is less common.

EPIDEMIOLOGY

Incidence

• Occurs in 10% of pelvic fractures

• Estimate 10–20% of anterior urethral stricture from external trauma

Prevalence

N/A

RISK FACTORS

• Pelvic fracture

• Perineal straddle injury

• Urethral instrumentation

PATHOPHYSIOLOGY

• Anterior urethra injuries

– Less common due to mobility of anterior urethra and protection of the bulbospongiosus

– Penile fracture (often intercourse related) can cause anterior urethral injury

– Penile constriction bands

– Penetrating trauma (gunshot, stabbing)

• Posterior urethra

– More common due to fixed location of urethra within urogenital diaphragm; the combination of straddle fractures with diastasis of the sacroiliac joint has the highest risk of urethral injury

– Pelvic fracture

– Straddle injuries

• Penetrating can injure both anterior and posterior urethra

– Gunshot wound, stab

• Iatrogenic

– False passage: instrument or catheter

– Catheter placement in patient with urethral stricture

– Chronic indwelling catheters

– Transurethral surgery using oversized resectoscopes

ASSOCIATED CONDITIONS

• Pelvic fracture

• Pelvic hematoma

• Bladder injury

• Vaginal injury

GENERAL PREVENTION

• Seat belts

• Careful instrumentation of the urethra to prevent iatrogenic injury

ALERT

• The amount of urethral bleeding does not correlate with the degree of injury.

• Pain with urination or inability to void is highly suggestive of urethral disruption in the trauma patient.

 DIAGNOSIS

HISTORY

• Description of trauma and mechanism of injury

• Voiding history

– Retention

– Hematuria

PHYSICAL EXAM

• Classic clinical triad:

– Bloody urethral discharge

– Inability to urinate

– Palpably full bladder

• Blood at meatus:

– 37–93% of patients with posterior urethral injury

– Greater than 75% of patients with anterior urethral (AU) injury.

• Ecchymosis and swelling limited to penile shaft

– Anterior urethral injury confined by Buck fascia

• Butterfly hematoma

– Violation of Buck fascia, hematoma confined by Colles fascia

• DRE: High riding prostate may be hard to detect due to associated pelvic hematoma and may not be reliable for urethral disruption

• Vaginal laceration is often associated with urethral injury

• Vaginal introitus blood is present in more than 80% of pelvic fractures and coexisting urethral injury (1).

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• CBC, electrolytes, BUN, creatinine

• Urinalysis

Imaging

• Retrograde urethrography

– 30-degree oblique position with bottom leg flexed at knee and top leg straight.

– Place Foley catheter into fossa navicularis, inflate balloon with 2–3 mL

– Injection of ∼25 mL of contrast into urethra

– Extravasation of contrast indicates the location of the tear

– Complete injury usually has no contrast flow into the bladder

• CT is inadequate to evaluate urethral trauma

– Generally obtained for staging of associated injuries

Diagnostic Procedures/Surgery

Flexible cystoscopy

DIFFERENTIAL DIAGNOSIS

• Urethral injury: contusion, complete, partial

• Injury to bladder neck, ureter

• Penile corporal injury

• Labial/vaginal injury

 TREATMENT

GENERAL MEASURES

• Perform retrograde urethrogram (RUG) prior to placement of Foley catheter; avoid urethral instrumentation until urethral imaging if the patient is stable.

• If catheter has already been placed, do not remove it. Perform pericatheter RUG with pediatric feeding tube or angiocatheter

• Establish prompt urinary drainage in patients with pelvic fracture associated urethral injury as typically unable to void and undergo aggressive resuscitation

• Urethral injury confirmed by:

– Extravasation on RUG or VCUG

– Cystoscopy

• Classification of urethral injury can guide treatment decisions

– EAU Classification of blunt urethral injury (1)[C]:

 Grade I: stretch injury

 Grade II: contusion

 Grade III: partial disruption

 Grade IV: complete disruption

 Grade V: complete or partial disruption of posterior urethra with associated tear of the bladder neck, rectum or vagina

MEDICATION

First Line

• Analgesics as needed

• Antibiotics

Second Line

N/A

SURGERY/OTHER PROCEDURES

• Pelvic fracture and posterior urethral injury

– Place large bore suprapubic catheter (16-Fr Foley) using percutaneous peel-away sheath

– We advise against using small pigtail suprapubic catheters

– For complex injuries with associated bladder trauma, open suprapubic tube placement with bladder inspection is suggested. Place suprapubic tube (SPT) in patients undergoing ORIF for pelvic fracture (24 Fr, high on bladder and tunneled through skin away from hardware)

– Open surgical realignment should be avoided due to high risk of erectile dysfunction, incontinence

– Primary endoscopic realignment may be attempted but has a success rate of 25% (2)[B], but may delay the ultimate curative therapy for this condition. In our experience, traumatic strictures tend to be short and dense, and refractory to endoscopic treatment. Success rates for open anastomotic urethroplasty are greater than 90%.

– In women, primary open repair is recommended for disruption of the urethra with associated tear of bladder neck and vagina (3)[C] due to risk of incontinence and vesicovaginal fistula

• Penetrating trauma

– Immediate reconstruction is highly successful

 High velocity projectile creates blast effect, making immediate reconstruction less reliable

• Iatrogenic urethral injury: Place indwelling Foley for 7 days, followed by voiding cystourethrogram

ADDITIONAL TREATMENT

Radiation Therapy

N/A

Additional Therapies

• Repeated endoscopic treatment of traumatic urethral strictures may lead to longer strictures (4)[B].

• In an unstable trauma patient, a cautious attempt can be made to pass a urethral catheter.

– If there is any a difficulty a suprapubic catheter can be placed and a retrograde urethrogram performed later (1).

Complementary & Alternative Therapies

N/A

 ONGOING CARE

PROGNOSIS

• Posterior urethral injury:

– Low rate of incontinence in patients with competent bladder neck

• Anterior urethral injury: Good prognosis after primary repair

COMPLICATIONS

• Urethral stricture

• Fistulas

• Incontinence

• Erectile dysfunction

FOLLOW-UP

Patient Monitoring

• Recovery often complicated by other orthopedic and neurologic injuries

• Anterior urethral injury:

– If primary repair has been performed, catheter should be kept in place for 2–3 wk with follow-up VCUG

• Posterior urethral injury:

– If endoscopic alignment has been performed, the suprapubic tube should be kept in place for at least one week after removal of urethral Foley. Most endoscopic alignment will fail at 1 wk

– Perform reconstructive procedures at 4–6 mo

Patient Resources

Urology Care Foundation: Urethral trauma. http://www.urologyhealth.org/urology/index.cfm?article=44

REFERENCES

1. Martinez-Pineiro L, Djakovic N, Plas E, et al. EAU guidelines on urethral trauma. Eur Urol. 2010;57:791–803.

2. Leddy LS, Vanni AJ, Wessells H, et al. Outcomes of endoscopic realignment of pelvic fracture associated urethral injuries at a level 1 trauma center. J Urol. 2012;188:174–178.

3. Black PC, Miller EA, Porter JR, et al. Urethral and bladder neck injury associated with pelvic fracture in 25 female patients. J Urol. 2006;175:2140–2145.

4. Hudak SJ, Atkinson TH, Morey AF, et al. Repeat transurethral manipulation of bulbar urethral strictures is associated with increased stricture complexity and prolonged disease duration. J Urol. 2012;187:1691–1695.

ADDITIONAL READING

• Rosenstein DI, Alsikafi NF. Diagnosis and classification of urethral injuries. Urol Clin N Am. 2006;33:73–85.

• Morey AF, Brandes S, Dugi DD, et al. Urotrauma: AUA Guideline (https://www.auanet.org/common/pdf/education/clinical-guidance/Urotrauma.pdf Accessed August 21, 2014)

See Also (Topic, Algorithm, Media)

• Bladder Trauma

• Penis, Trauma

• Urethra, Strictures, Male

• Urethra, Trauma (Anterior and Posterior) Images 

 CODES

ICD9

• 599.70 Hematuria, unspecified

• 867.0 Injury to bladder and urethra, without mention of open wound into cavity

• 867.1 Injury to bladder and urethra, with open wound into cavity

ICD10

• R31.9 Hematuria, unspecified

• S37.30XA Unspecified injury of urethra, initial encounter

• S37.33XA Laceration of urethra, initial encounter

 CLINICAL/SURGICAL PEARLS

• Retrograde urethrography is considered the gold standard for evaluating urethral injury.

• Most pelvic fracture associated injuries occur in the posterior urethra.

• Posterior urethral injury should be managed with suprapubic catheter and delayed definitive repair.

• When placing a suprapubic catheter, should use a large bore Foley catheter placed via a peel away sheath.

• Urethral injury in women associated with bladder neck or vaginal injury should be repaired primarily.

• Anastomotic repair of traumatic strictures has a high success rate.



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