health

1. URETHRAL TRAUMA
(Brown & Martindale, Jou of Trauma, 2008)
SUB BAGIAN UROLOGI
BAGIAN / SMF BEDAH
FK UNS/RSUD Dr. MOEWARDI

2. POSTERIOR URETHRAL INJURY
 Is not common  associated with pelvic fracture
 Most patients best treated by SPC for 3 month, then end to
end anastomotic urethroplasty
Mechanism of injury :
 Fracture pelvic 90 %, 5 – 10 % associated urethral injury
 60 % posterior urethral injury are complete rupture, 40 %
incomplete
 Impotence occurs 10 – 20 % of pelvic fracture injury, and
about half with urethral rupture
Diagnosis and imaging :
 Blood at the external urethral meatus
 Imaging : urethrography

3. MANAGEMENT
 Immediate management in pelvic
fracture and injuries to the posterior
urethra is controversy
◦ Primary realignment, primary repair
◦ Delayed primary repair a few days later
◦ Delayed primary realignment a few days later
◦ Suprapubic catheterization, repair 3 month or so
later

4. Early surgery for ruptured posterior urethra :
 Traditional treatment “railroading” (open
surgical procedure, endoscopically)
 Stricture rate 70 %
 Open railroading complication :
 Impotence, incontinence, infection,
bleeding
 Primary repair by end to end anastomosis
Delayed primary repair and realignment for
rupture posterior :
 Indication for the distracted “pie-in-the-sky”
bladder
 Evacuation of the haematoma
 Open or endoscopic realignment

5. Delayed surgery for rupture posterior
urethra :
 Suprapubic catheterization for 3
month is the GOLD STANDARD of
treatment follow by end to end
anastomosis
 Suprapubic catheterization and
delayed uretheoplasty cause the least
harm
 10 - year stricture-free survival 90 %

6. Complication
Impotence
 2.6 to 75 % after pelvic fracture
 42 % with urethral injury, 5 % withouth urethral
injury
 22.5 % after suprapubic inwelling catheterization
 42 % after railroading procedure
 Cause damage the neurovascular bundle (80-85
% vascular)
Incontinence
 Mechanism : destroyed or non function of the
urethral sphincter

7. ANTERIOR URETHRAL INJURY
 The incidence is relatively low compare to
the posterior urethra
Mechanism of injury :
 Due to instrumentation iatrogenic, self-
inflected, contusion
 Blunt trauma : straddle- type injury
 Gunshout, stab wounds

8. Mechanism and Imaging
 History presence urethral injury
 Present the blood at the meatus (OUE)
 Inability to void
 Dysuria
 Hematuria
 Butterfly hematoma 

9.  Butterfly
hematoma
(Sullivan & Morgan, 2004)

10. Retrograde Urethrography :
 Normal urethrography  diagnosis
contusion
 Contrast extravasation and some contrast
reaching the bladder  partial disruption
 Contrast extravasation without contrast
reaching the bladder  complete
disruption

11. Management
 Catheterization  the protocol in severely injury
patient by the trauma team during primary resuscitation
 Not catheterization  partial tear covert to complete
 Initial management :
1. Adequate drainage of urin
2. Minimize potential complication (stricture, fistula,
infection)
 Stable patient  retrograde urethrogram
 Unstable patient  pass catheter can be made,
suprapubic catheterization  stable retrograde study

12.  Partial tear  suprapubic or urethral
catheterization, 2 weekly interval
urethrogram
 Stricture  manage direct visual
uretrotomy
 Blunt trauma complete disruption 
suprapubic catheterization 
urethroplasty 3-6 months

13. SCROTAL EMERGENCY
(Zomorrodi et al, Int. Med J Vol. 6, 2007)

14. Etiology Acute
Scrotal
(Sullivan & Morgan, 2004)

15.  Torsion of the testicle is a urological
emergency  the risk testiculer loss
 Can occur at any age, most common
during adolescent (12 – 18; peak 14 – 16
years old)
 In adult the torsion is intravaginal, in
neonates is extravaginal
 Left testes more frequently than the right
( 6 : 4 ), bilateral < 1 %

16.  Common in cold weather  due to
cremasteric contraction
 When torsion occurs  venous blood
supply obstruction  secondary edema
and hemorrhage subsequent arterial
obstruction  testicular necrosis
 Degree and duration of torsion affect the
severity ischemic damage

17. Extravaginal Torsion
 First describe by Tailor (1897) , can occur pre-
postnatally
 75 % prenatally and 25 % postnatally within 30
days of birth
 Present hard scrotal mass at time delivery
 Some infants have oedematous, erythematous
scrotum, inflammatory reaction surrounding area
 The diagnosis depend on physical examination
 Rarely neonates with normal postnatal
examination then found swollen tender testes in 1
month of life

18. Management
 The management is controversial
 Some surgeons no exploration
 Exploration and fix the contralateral
testes
 Methode of on fixation of the
contralateral testes debatable
 The three – points fixation using
monofilamentous non-absorbable has
been recomended

19. Terima kasih