The document discusses urethral injuries, including their classification, causes, clinical features, investigations, and management approaches. It covers injuries to both the posterior urethra from pelvic fractures or trauma, and anterior urethra from straddle injuries or trauma. For posterior injuries, early management includes suprapubic cystostomy while late management involves anastomotic urethroplasty techniques like the Webster or Waterhouse procedure. Anterior injuries are often managed with delayed repair or dilation depending on the severity of stricture formation.

1. URETHRAL INJURIES
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D.Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2

3. INTRODUCTION
 Urethral injury is a breach in the
structural integrity of the urethra
resulting from trauma
 Caused by Blunt injury , Penetrating injury
& Iatrogenic injury
 Leads to strictures , impotence &
incontinence
Dept Of Urology, KMC and GRH, Chennai 3

4. CLASSIFICATION
 SITE
 Posterior Urethral
injury
Prostatic,Membraneous
urethra
 Anterior Urethral
injury
- Bulbar & Penile
urethra
Dept Of Urology, KMC and GRH, Chennai 4

5. ETIOLOGY
POSTERIOR URETHRAL INJURY
Pelvic fracture- PFUDD
 10% Pelvic fracture associated with urethral injury
following RTA / BLUNTTRAUMA
 Site of injury – PROSTO MEMBRANOUS
 All membranous urethral disruptions due to blunt
trauma have associated pelvic fracture
IATROGENIC
 Catheter related
 Post surgery – Endoscopy, Radical Prostatectomy
Dept Of Urology, KMC and GRH, Chennai 5

6. ETIOLOGY
ANTERIOR URETHRAL INJURY
 STRADDLE INJURY
 IATROGENIC- Catheter related , Post surgery
– Endoscopy, Radical Prostatectomy.
 PENETRATING INJURY
 SELF MUTILATION – Mentally ill
Dept Of Urology, KMC and GRH, Chennai 6

7. PFUDD
 Mechanism - Shearing force
avulses the apex of the prostate
from the membranous urethra
 90 % involve the posterior
urethra
 Bulbomembranous
junction is more vulnerable
to injury than the
prostatomembranous
junction
Dept Of Urology, KMC and GRH, Chennai 7

8. Pelvic Fracture - Classifications
TILE’S CLASSIFICATION
Based on
- Stability of the pelvic ring
- Integrity of the posterior sacroiliac complex
TYPE A – Stable
A1 - Fractures of the pelvis not involving the ring
A2 - Stable, minimally displaced fractures of the ring
Dept Of Urology, KMC and GRH, Chennai 8

9. TYPE B - Rotationally unstable, vertically
stable
( S.I. joint not disrupted)
 B1- Open book
 B2- Lateral compression : Ipsilateral
 B3- Lateral compression : Contralateral (Bucket-
handle)
Dept Of Urology, KMC and GRH, Chennai 9

10. Urethral injury mechanisms
Dept Of Urology, KMC and GRH, Chennai 10

11. Urethral injury mechanisms
Dept Of Urology, KMC and GRH, Chennai 11

12. TYPE C - Rotationally and vertically
unstable
( Disruption of S.I. joint)
 C1 - Unilateral
 C2 - Bilateral
 C3 - Associated with an acetabular fracture
Dept Of Urology, KMC and GRH, Chennai 12

13. Urethral injury mechanisms
 Vertical shear fractures
 Injury due to traction distraction mechanism
Dept Of Urology, KMC and GRH, Chennai 13

14. Young & Burgess Classification
 Based on mechanism and direction of force of injury
 Three vectors of force and how this disrupts the pelvic
ring
- Lateral Compression (LC)
- Anterior posterior compression
(APC)
-Vertical shear (VC)
Dept Of Urology, KMC and GRH, Chennai 14

15. OPEN BOOK FRACTURE
 Caused by A.P.
compression
 Diastasis of pubic
symphysis
 May be associated with
ipsilateral S.I. joint
disruption
Dept Of Urology, KMC and GRH, Chennai 15

16. BUTTERFLY FRACTURE
 STRADDLE Fracture
 A.P. compression
 Fracture of bilateral
superior and inferior
pubic rami
 Butterfly shaped intact
pubic symphysis
16

17. MALGAIGNE’S FRACTURE
 Vertical shear fracture
 Ipsilateral fracture of both
superior and inferior
pubic rami
 Ipsilateral fracture of S.I.
joint
17

18. BUCKET HANDLE FRACTURE
 Fracture of anterior
arch and contralateral
posterior arch
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19. STRADDLE INJURIES
 Most common cause -
ANTERIOR URETHRAL
INJURY
 Person falls astride over BLUNT
OBJECT
 Mechanism: Bulbar urethra
crushed aganist inferior aspect of
Pubis bone
 Eg
1. Handlebar of Bicycle
2.Top of Fence
3. rung of a Ladder
Dept Of Urology, KMC and GRH, Chennai 19

20. CLINICAL FEATURES
POSTERIOR URETHRAL INJURY
 TRAID OF URETHRAL
INJURY – Pelvic frature
1. Blood at the meatus.
2. Inability to urinate
3.Palpably full bladder
Other- may have
DRE- High-riding prostate.
bony spicules
Dept Of Urology, KMC and GRH, Chennai 20

21. CLINICAL FEATURES
ANTERIOR URETHRAL INJURY
 IFTHE INJURY WITHIN
BUCK’S FACIA
Edema /
Discolouration of Penile
shaft
 IFTHE INJURY BEYOND
BUCK’S FACIA
Butterfly Hematoma
Swelling , discolouration
& enlargement of scrotum
Dept Of Urology, KMC and GRH, Chennai 21

22. CLINICAL FEATURES
Butterfly Hematoma
Dept Of Urology, KMC and GRH, Chennai 22

23. INVESTIGATION
 DYNAMIC AUG
Assess traumatic
urethral injuries
Ideally should be
done under
Fluoroscopy
Dept Of Urology, KMC and GRH, Chennai 23

24. GOLDMAN’S MODIFICATION
(1997) OF COLOPINTO AND
MACALLUM’S
CLASSIFICATION
Dept Of Urology, KMC and GRH, Chennai 24

25. Type I
 Puboprostatic ligament is ruptured, and the prostate
is allowed to move superiorly.
 Membranous urethra only severely stretched
 No extravasation of contrast material is seen
Dept Of Urology, KMC and GRH, Chennai 25

26. Type II
 Urethra is torn superior to the urogenital diaphragm
 Contrast extravasation is seen within the
extraperitoneal pelvis
Dept Of Urology, KMC and GRH, Chennai 26

27. Type III
 Most common
 Extends through the urogenital diaphragm and
includes the proximal bulbous urethra.
 Extravasation can be found within the extraperitoneal
pelvis and within the perineum.
Dept Of Urology, KMC and GRH, Chennai 27

28. Type IV
 Injury involving the bladder neck that extends into the
proximal urethra.
 Contrast-agent extravasation is seen in the extraperitoneal
pelvis around the proximal urethra
Dept Of Urology, KMC and GRH, Chennai 28

29. TypeV
Pure Anterior Urethral injury
Dept Of Urology, KMC and GRH, Chennai 29

30. POSTERIOR URETHRALTRAUMA -
Rx
Emergency - SPC , Endoscopic alignment
( Immediate)
7 days - Endoscopic realignment
(Delayed)
May avoid urethroplasty
3 months - Anastomotic urethroplasty
( Late)
Dept Of Urology, KMC and GRH, Chennai 30

31. Indications for early intervention
 Rectal tear
 Associated bladder neck injury
 Degloving perineal injury
 Penetrating injuries
 SPC + Open surgical repair at 4-6months – GOLD
STANDARD
Dept Of Urology, KMC and GRH, Chennai 31

32. Immediate urethral realignment
 Injury explored at time of presentation
 Evacuation of pelvic hematoma
 Realignment of urethra over a stenting catheter
 Flexible endoscopic catheter placement
 RAIL-ROADING technique - obsolete
 Disadvantages :
Incontinence
Bleeding
Impotency
Dept Of Urology, KMC and GRH, Chennai 32

33. Primary repair -Technique
1.Open rail-roading
2.Endoscopic realignment
3.Blind realignment procedures
-davis inter-locking sounds
-magnetic tip catheters
Dept Of Urology, KMC and GRH, Chennai 33

34. Open ‘railroading’/realignment
 Prevesical space is explored and
the haematoma and debris are
evacuated
 Cystotomy made and foley
catheter passed antegradely.
 Retrogradely another catheter is
passed and tied to the previous
one.
 Catheter is brought in and bulb
inflated
Disadvantage:
1.Tamponade effect of haematoma
lost and bleeding may occur
2.Planes not well defined and high
chance of injury to neurovascular
structures leading to impotence
and incontinence
Dept Of Urology, KMC and GRH, Chennai 34

35. Endoscopic realignment
Step 1: antegrade flexible
cystoscope
Step 2: ategrade and
retrograde flexible
cystoscope
Step 3: fluoroscopic
guidance
Dept Of Urology, KMC and GRH, Chennai 35

36. Delayed Primary Repair
 SPC at time of injury
 7-10 days later
 After stabilisation of patient GC
 Endoscopic realignment over a stenting catheter
Dept Of Urology, KMC and GRH, Chennai 36

37. Late endoscopic management
( secondary repair )
 Non-obliterative memb.
Urethralstrictures/partial
tear → OIU / Dilatation
 Obliterative memb.
urethral defects → OIU
‘Cut for Light’ technique
Dept Of Urology, KMC and GRH, Chennai 37

38. PFUDD- LATE MANAGEMENT
 Repair determined by the type and
extent of associated injuries.
 Desirable to proceed within 4 to 6
months after trauma
 Primary anastomosis – Gold
standard
Dept Of Urology, KMC and GRH, Chennai 38

39. Late surgical repair of PFUDD
 Gold standard
 Two common approaches
Perineal ( WEBSTER) - upto 8 cm.
Abdomino-perineal ( WATERHOUSE) ->8 cm
 Procedure selection depends upon
- Nature of defect
- Length of defect
- Presence of complicating factors
Dept Of Urology, KMC and GRH, Chennai 39

40. Principles of open repair
 Reconstruction after min. 4 months after the event
 Exact delineation of the defect
 Status of bladder neck
 Status of erectile function
 Complete excision of all scar tissue
 Tension free & water-tight anastomosis
 Asepsis
Dept Of Urology, KMC and GRH, Chennai 40

41. PFUDD - OPPOSING
URETHEROGRAM
Dept Of Urology, KMC and GRH, Chennai 41

42. Dept Of Urology, KMC and GRH, Chennai 42

43. Predictors for repair of PFUDD repair
 Urethrometry index –
Urethral gap length / Length of bulbar
urethra
< 0.35 = simple perineal operation- End to End
Anastomosis
> 0.35 = Webster / Waterhouse
 Urethral gap length
 Prostatic displacement
Dept Of Urology, KMC and GRH, Chennai 43

44. Progressive Perineal Urethroplasty
(Webster’s procedure)
EXAGGERATED LITHOTOMY POSITION
Dept Of Urology, KMC and GRH, Chennai 44

45. PPU= WEBSTER
( Cardinal steps)
1. Bulbar urethra mobilisation
2. Corporal/crural separation
3. Inferior pubectomy
4. Corporal rerouting
Dept Of Urology, KMC and GRH, Chennai 45

46. Dept Of Urology, KMC and GRH, Chennai 46

47. InvertedY incision and exposure of Midline fusion of
Bulbospongiosus muscle
Dept Of Urology, KMC and GRH, Chennai 47

48. Division of fusion of Bulbospongiosus muscle
Dept Of Urology, KMC and GRH, Chennai 48

49. Exposure of full length of bulb
Dept Of Urology, KMC and GRH, Chennai 49

50. Incision of fibrosed urethra- freeing of bulb
Dept Of Urology, KMC and GRH, Chennai 50

51. Opening of the anterior urethra
Dept Of Urology, KMC and GRH, Chennai 51

52. Incision of fibrotic defect and antegrade passage of
Haygrove staff 52

53. Incision and seperation of triangular ligament
53

54. PFUDD
Step 1- Bulbar
urethral mobilization
Dept Of Urology, KMC and GRH, Chennai 54

55. Crural separation
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56. Inferior pubectomy
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57. Supracrural Re-routing
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58. End to end anastomosis
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59. Perineo-Abdominal Progression-
Approach (PAPA)
INDICATIONS:
 Long distraction defects > 8cms
 To allow a tension free anastomosis in long
distraction defects
 To aid in excision of fistulas and cavities
Dept Of Urology, KMC and GRH, Chennai 59

60. Perineo-Abdominal Progression-
Approach (PAPA)
1. Bulbar urethra mobilisation
2. Corporal separation
3. Inferior pubectomy
4. Supracrural rerouting
5. Total pubectomy
6. Omental wrapping Midline infraumblical
incision
Dept Of Urology, KMC and GRH, Chennai 60

61. Waterhouse procedure
Dept Of Urology, KMC and GRH, Chennai 61

62. Waterhouse procedure
Dept Of Urology, KMC and GRH, Chennai 62

63. PFUDD
 Omental wrapping
Dept Of Urology, KMC and GRH, Chennai 63

64. Post-operative Management
 Silicon catheter – plugged- only used as a stent
 Urine diverted by SPC
 Bed rest – 24 to 48 hours
 3 rd day – drain removed
 Discharged with SPC and urocath
 21- 28 days – pericatheteric study
 If study normal – SPC clamping for 5-7 days & urethral
voiding
 SPC removal
 Flexible endoscopy after 6 months and 1 year
Dept Of Urology, KMC and GRH, Chennai 64

65. Postoperative Complications
 Incontinence
 Anastomotic stenosis
 Impotence
 Nerve injury - superficial peroneal nerve
neuropraxia
Dept Of Urology, KMC and GRH, Chennai 65

66. ANTERIOR URETHRAL INJURY -
MANAGEMENT
 Mc Aninch classified
Contusion Treated with
Incomplete Distruption Catheterization
complete Distruption
 Primary surgical repair
Gunshot injuries
Penetrating injuries
 Initial Suprapubic Urinary diversion +
Delayed reconstruction
Dept Of Urology, KMC and GRH, Chennai 66

67.  Anastomotic urethroplasty –GOLD
STANDARD
Procedure of choice in obliterated
bulbar urethra after straddle injury
 DEFECT 1.5 to 2 cm long - Scar
completely excised.
 The proximal and distal urethra can be
mobilized for a tension-free, end-to-end
Anastomosis.
 High succes rare - 95%
Dept Of Urology, KMC and GRH, Chennai 67

68. Female urethral injuries
 Less commonly associated with pelvic fractures ( < 1 %)
-short ,mobile
-no significant attachment to pelvis
 Injury is most commonly due to sharp bone spikes
 Associted with rectal & vaginal injury
 Urethroscopy is the investigation of choice
 Managed by primary repair over a
catheter and suturing of vagina
 SPC diversion and delayed management
high incidence of fistula.
Dept Of Urology, KMC and GRH, Chennai 68

69. Injuries in children
 Bladder neck injuries & Prostatic
urethral and are more common due to
rudimentary nature of prostate.
 Mechanism of injury is same,
 High incidence of incontinence and impotence
Dept Of Urology, KMC and GRH, Chennai 69

70. THANKYOU
Dept Of Urology, KMC and GRH, Chennai 70