Urethral injury aetiology and management

1. MANAGEMENT OF URETHRAL
INJURY
Dr I.O. Akinwande

2. OUTLINE
• Introduction
• Relevant Anatomy
• Classification
• Aetiology
• Clinical Features
• Management
• Complications
• Conclusion

3. INTRODUCTION
• Urethral injury is a relatively uncommon
urological condition
• The management could be challenging to both
the urologist and patient
• It could affect all age groups but more
commonly males
• It is usually associated with pelvic fractures
and multiple organ injuries

4. RELEVANT ANATOMY
• Male Urethra is divided
into: Anterior and
Posterior Urethra
• Female Urethra is only
Posterior
• Blood Supply
• Nerve Supply

5. CLASSIFICATION
• ANATOMICAL CLASSIFICATION
Anterior Urethral Injury
Posterior Urethral Injury
• MECHANISM OF INJURY
Blunt – 90%
Penetrating

6. ANTERIOR URETHRAL INJURY
Blunt trauma
• Vehicular accidents
• Fall astride
• Kicks in the perineum
• Blows in the perineum from
bicycle handlebars, tops of
fences, etc.
Sexual intercourse
• Penile fractures
• Urethral intraluminal
stimulation
• Constriction bands
Penetrating trauma
• Gunshot wounds
• Stab wounds
• Dog bites
• External impalement
• Penile amputations
Constriction bands
• Paraplegia
Iatrogenic injuries
• Endoscopic
instrumentations
• Urethral catheters, dilators

7. CLINICAL FEATURES
• History of perineal or
penile trauma
• Blood at meatus
• Inability to void
• Suprapubic fullness
• Haematuria
• Haematoma
• Other associated
injuries

8. MANAGEMENT
• BRIEF HISTORY
• GENERAL EXAMINATION
• RESUSCITATION
• SUPRAPUBIC CYSTOSTOMY / URETHRAL
CATHETERIZATION
• ANTIBIOTICS
• ANALGESICS
• INVESTIGATION
Retrograde urethrogram

9. MANAGEMENT
• RUCG FINDINGS
1.Urethral contusion
2.Incomplete urethral
rupture
3.Complete urethral
rupture
• FACTORS AFFECTING
INITIAL MANAGEMENT
1.Mechanism of injury
2.Extent of injury
3.Co-injuries
4.Surgeon’s familiarity
with proposed
procedure

10. MANAGEMENT
• Urethral Contusion – Maintain suprapubic
catheter or gentle urethral catheterization for
2 weeks and remove subsequently
• Incomplete Urethral Rupture – Blunt or
Penetrating
• Complete Urethral Rupture – Blunt or
Penetrating
(McAninch and Armenakas)

11. MANAGEMENT
• BLUNT
• Maintain Suprapubic or
Urethral catheter for 3-4
wks to allow for urethral
healing
• Do a MCUG + RUG to assess
for any stricture and
manage accordingly
• For Complete Disruption,
MCUG + RUG after 3-6
months and manage the
stricture
• PENETRATING
• For incomplete rupture,
Primary urethral suturing
with creation of a water-
tight, tension-free repair
• For complete rupture,
repair over a urethral stent
if possible
• Repeat MCUG after 2 weeks
• If defect is large, two stage
urethral repair after at least
3 months

12. COMPLICATIONS
• BLOOD/URINE EXRAVASATION
• PERI URETHRAL ABSCESS
• NECROTIZING FASCITIS
• GRAM –VE UROSEPSIS
• URETHRO-CUTANEOUS FISTULA
• PERIURETHRAL DIVERTICULUM
• URETHRAL STRICTURE

13. POSTERIOR URETHRAL INJURY
• Posterior urethra =
Membranous + Prostatic
urethra
• The apex of the prostate is
anchored to the pubic
symphysis by the pubo-
prostatic ligament anteriorly
• Membranous urethra is
fixed to the ischiopubic rami
by the urogenital diaphragm
• Blunt injuries >90%
RTA,Industrial accident,
Construction site accident,
Falling from height
• Penetrating
injuries;uncommon
• Approx 100% of
membranous urethra injury
following blunt trauma have
associated pelvic fracture.
• 5-10% of pelvic fracture
have associated urethral
injury

14. MECHANISM OF INJURY
• Upward displacement of the hemipelvis & pubic
symphysis
• Bilateral superior & inferior rami # with a displaced
central floating segment
• Pubic symphysis diastasis with rupture of
puboprostatic ligament
• Direct laceration by a sharp bony spicule

16. CLINICAL FEATURES
• Meatal bleeding / Blood at introitus (37-93%)
• Inability to void
• Distended bladder
• High riding prostate (not a reliable indicator)
• Perineal/Vulva haematoma
• Inability to walk
• Features of shock

17. CLINICAL FEATURES
• BRIEF HISTORY
• GENERAL EXAMINATION
• RESUSCITATION
• SUPRAPUBIC CYSTOSTOMY / URETHRAL
CATHETERIZATION
• ANTIBIOTICS
• ANALGESICS
• INVESTIGATION
Retrograde urethrogram +/- mcug

18. • OTHER INVESTIGATIONS
• ABDOMINOPELVIC USS
• COMPUTED TOMOGRAPHY (CT)
• MAGNETIC RESONANCE IMAGING (MRI)
• URETHROSCOPY esp female urethral injuries

19. COLAPINTO & McCALLUM
• Type 1: Rupture of the puboprostatic ligaments and surrounding
periprostatic hematoma stretch the membranous urethra without
rupture
• Type 2: Partial or complete rupture of the membranous urethra
above the urogenital diaphragm or perineal membrane. On
urethrography, contrast material is seen extravasating above the
perineal membrane into the pelvis
• Type 3: Partial or complete rupture of the membranous urethra
with disruption of the urogenital diaphragm. Contrast extravasates
both into the pelvis and out into the perineum
• Type 4: Bladder neck injury with extension into the urethra.
• Type 4a: Extraperitoneal bladder rupture at the bladder base with
periurethral extravasation, simulating a Type 4 injury.
• Type 5: Pure anterior urethral injury

20. AMERICAN ASSOCIATION FOR
SURGEON OF TRAUMA (AAST)
• GRADE 1 - CONTUSION
NORMAL RUCG
• GRADE II - STRETCH INJURY
URETHRAL ELONGATION,NO EXTRAVASATION
• GRADE III - PARTIAL DISTRUPTION
EXTRAVASATION + CONTRAST IN BLADDER
• GRADE IV - COMPLETE DISTRUPTION
NO CONTRAST IN BLADDER, URETHRAL SEPARATION <2cm
• GRADE V - COMPLETE DISTRUPTION
URETHRAL SEPARATION >2cm or EXTENSION INTO THE PROSTATE,
BLADDER NECK, OR VAGINA

21. MANAGEMENT
• Partial tears of the posterior urethra can be
managed in most cases with a suprapubic or
urethral catheter
• Repeat retrograde urethrography at 2-week
intervals until healing has occurred
• They may heal without significant scarring or
obstruction if managed by diversion alone
• Any residual or subsequent stricture can be
managed with urethral dilation or optical
urethrotomy, if short and flimsy, or by
anastomotic urethroplasty if denser

22. COMPLETE TEAR
• Primary Realignment – Open or Endoscopic
• Immediate Open Urethroplasty (< 48hours)
• Delayed Primary Urethroplasty (2 – 14 days)
• Delayed Urethroplasty (3 – 6 months)
• Delayed Endoscopic Incision (Cut-to-the-light
technique)

23. PRIMARY REALIGNMENT
• RATIONALE
1. Injury may heal without stricture at all
2. Injury may heal with mild stricture treatable
by DVIU or bouginage
3. Eases the difficulty of urethroplasty later

24. PRIMARY REALIGNMENT
• OPEN – for concomitant bladder neck or rectal injuries
• ENDOSCOPIC – Opions are
 Simple passage of a catheter across the defect
 Endoscopically assisted catheter realignment using flexible,
rigid endoscopes and biplanar fluoroscopy
 Use of interlocking sounds (“railroading”) or magnetic
catheters to place the catheter
 Pelvic hematoma evacuation and dissection of the prostatic
apex (with or without suture anastomosis) over a catheter
 Catheter traction or perineal traction sutures to pull the
prostate back to its normal location

25. COMPLICATIONS
• IMPOTENCE
• URINARY INCONTINENCE
• URETHRAL STRICTURE

26. CONCLUSION
• Urethral injury still remain of the most
commonly mismanaged urological condition
• Constant reminder to colleagues about the
presentation
• Need for initial proper assessment and
subsequent management

27. THANKS FOR LISTENING